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Reduced conduit arteries flow-dependent dilatation and altered compliance have been described during heart failure. However, the role of shear stress, the relation between endothelial dysfunction and mechanics, and the effect of chronic ACE inhibition on this relationship have not been investigated. The present study was designed to evaluate in heart failure patients the relationship between flow-dependent dilatation and radial artery mechanics at known shear stress levels and to assess the effect of chronic ACE inhibition. Sixteen stable congestive heart failure patients, who had never been treated with ACE inhibitors, participated in the study. Arterial pressure, cardiac output (bioimpedance), radial artery diameter (echo tracking) and flow (Doppler), total blood viscosity, and mean artery wall shear stress were assessed before and during a gradual increase in the forearm blood flow in response to gradual distal hand skin heating. Cross-sectional radial artery compliance and distensibility indexes were calculated at 34 degrees C, 40 degrees C, and 44 degrees C. The endothelium-independent vasodilatation was evaluated by use of glyceryl trinitrate. All parameters were assessed before and 24 hours after the last administration of perindopril (4 mg once daily) or placebo in a 2-month double-blind randomized study. Before treatment, there was no difference between the 2 groups for all parameters. After chronic ACE inhibition, systolic arterial pressure decreased at baseline from 126+/-11 to 118+/-10 mm Hg (P<0.05). During heating, the increase in diameter in response to shear stress was higher after ACE inhibition than after placebo (time/treatment interaction, P<0.05). Moreover, in contrast to placebo, at the same shear stress, there was a significant increase in compliance (3.23+/-0.79 x 10(-7) to 6.82+/-2.47 x 10(-7) m(2)/kPa, P<0.05) and distensibility (5.71+/-1.35 x 10(-3) to 8.87+/-1.88 x 10(-3)/kPa, P<0.05) during heating after ACE inhibition. The effect of glyceryl trinitrate did not change. The present study demonstrates that chronic administration of the ACE inhibitor perindopril increases the magnitude of the flow-dependent dilatation and restores the flow-dependent increase in compliance and distensibility of the radial artery evaluated at stable shear stress. In addition, the decrease in baseline systolic arterial pressure after ACE inhibitor suggests an associated increase in the distensibility of the proximal elastic conduit arteries.

The value of measuring the velocities of myocardial motion in the analysis of regional contractility has been demonstrated. The effects of changes in load on myocardial velocities has not been extensively studied. The aim of this study was to increase the change in myocardial velocities during haemodialysis. The velocities of longitudinal myocardial motion of the posterior wall and mitral annulus were measured by Doppler tissue imaging in 33 chronic haemodialysis patients (16 men: ages 64 +/- 14 years). Using the apical 2 chamber view: systolic (S), diastolic (D) and late (A) velocities were measured before and immediately after haemodialysis. The weight loss and decrease in mean blood pressure was 2.6 +/- 1.2 Kg and 10 +/- 17% respectively. Before dialysis, the systolic and diastolic velocities were maximal at the mitral annulus and decreased from the base to the apical region of the posterior wall. After dialysis, the velocities of the basal, median and apical segments of the posterior wall increased in systole but decreased in early diastole. Conversely, diastolic velocities of the mitral annulus did not change after dialysis. The authors conclude that the systolic and diastolic velocities of myocardial motion are affected by acute changes in left ventricular load induced by haemodialysis whereas those of the mitral annulus are little affected.

Objectives: The aim of our study was to assess the value of transesophageal echocardiography (TEE) in predicting embolic events (EEs) in a large group of patients with definite endocarditis according to the Duke criteria, including silent embolism., Background: The value of echocardiography in predicting embolism in patients with endocarditis remains controversial. Some studies reported an increased risk of embolism in patients with large and mobile vegetations, whereas other studies failed to demonstrate such a relationship., Methods: Multiplane transesophageal echocardiograms of 178 consecutive patients with definite infective endocarditis (IE) were analyzed. The incidence of embolism was compared with the echocardiographic characteristics (localization, size and mobility) of the vegetations. To detect silent embolism, cerebral and thoraco-abdominal scans were performed in 95% of patients., Results: Among 178 patients, 66 (37%) had one or more EEs. There was no difference between patients with and without embolism in terms of age, gender and left valve involved. On univariate analysis, Staphylococcus infection, right-side valve endocarditis and vegetation length and mobility were significantly related to EEs. A significant higher incidence of embolism was present in patients with vegetation length >10 mm (60%, p < 0.001) and in patients with mobile vegetations (62%, p < 0.001). Embolism was particularly frequent among 30 patients with both severely mobile and large vegetations (> 15 mm) (83%, p < 0.001). On multivariate analysis, the only predictors of embolism were vegetation length (p = 0.03) and mobility (p = 0.01)., Conclusions: Our study shows that the presence of vegetations on TEE is predictive of embolism and that the morphologic characteristics of vegetations are helpful in predicting EEs in both mitral and aortic valve IE. It also suggests that early operation may be recommended in patients with vegetations > 15 mm and high mobility, irrespective of the degree of valve destruction, heart failure and response to antibiotic therapy.

Background: A combination of low-dose aspirin with anticoagulants may provide better protection against thromboembolic events compared to anticoagulants alone in high-risk patients with atrial fibrillation., Objective: Evaluation of the preventive efficacy against nonfatal thromboembolic events and vascular deaths of the combination of the oral anticoagulant fluindione and aspirin (100 mg) in patients with high-risk atrial fibrillation., Methods: A multicenter, placebo-controlled, double-blind, randomized trial was conducted at 49 investigating centers in France. Atrial fibrillation patients with a previous thromboembolic event or older than 65 years and with either a history of hypertension, a recent episode of heart failure or decreased left ventricular function were included in the study. Patients were treated with fluindione plus placebo (i.e. anticoagulant alone) or fluindione plus aspirin (i.e. combination therapy), with an international normalized ratio target of between 2 and 2.6. The combined primary endpoint was stroke (ischemic or hemorrhagic), myocardial infarction, systemic arterial emboli or vascular death. The secondary endpoint was the incidence of hemorrhagic complications., Results: The 157 participants (average age 74 years; 52% women; 42% with paroxysmal atrial fibrillation) were followed for an average of 0.84 years. Three nonfatal thromboembolic events were observed (1 in the anticoagulation group, 2 in the combination group) and 6 patients died (3 in the anticoagulation group, 3 in the combination group), none of them from a thromboembolic complication. However, 3 deaths were secondary to severe hemorrhagic complications (1 in the anticoagulation group, 2 in the combination group). Nonfatal hemorrhagic complications occurred more often in the combination group (n = 10, 13.1%) compared to the anticoagulation group (n = 1, 1.2%) (p = 0.003)., Conclusion: The combination of aspirin with anticoagulant is associated with increased bleeding in elderly atrial fibrillation patients. The effect on thromboembolism and the overall balance of benefit to risk could not be accurately assessed in this study due to the limited number of ischemic events., (Copyright 2001 S. Karger AG, Basel)

Background: A combination of low-dose aspirin (A) and anticoagulation (AC) may provide better protection against thromboembolic events compared with AC alone in high-risk patients with atrial fibrillation (AF)., Methods: We performed a multicentric placebo-controlled double blind-trial to test the preventive efficacy against thromboembolic events of the addition of aspirin (A) (100 mg) or placebo (P) to anticoagulant treatment in patients with high-risk atrial fibrillation. A total of 157 patients were included, with atrial fibrillation and previous thromboembolic event or older than 65 years with either a history of hypertension, a recent episode of heart failure or a left ventricular dysfunction. All patients received fluindione (F) and P or F and A, with an INR target between 2 and 2.6. The primary endpoint was a combined endpoint of stroke (ischaemic or haemorrhagic), myocardial infarction, systemic arterial emboli or vascular death., Results: The study had to be stopped prematurely owing to a too low recruitment rate. During follow-up (0.84 years) 3 non-fatal thromboembolic events were recorded (1P, 2A) and 6 patients died (3P, 3A), none of them from a thromboembolic complication. However, 3 deaths were secondary to severe haemorrhagic complications (1P, 2A). Non-fatal haemorrhagic complications occurred more often in group A (n = 10, 13.1 pour cent) compared with group P (n = 1, 1.2 pour cent), p = 0.003., Conclusion: The FFAACS study was not able to show any therapeutic benefit from the addition of aspirin to anticoagulant in patients with high-risk AF. Such a combination increased the incidence rate of bleeding complications, which therefore greatly reduces its potential overall benefit.

Myocardial ischemia is usually responsible for alterations of regional left ventricular function which are not quantified by routine echocardiography. We used tissue Doppler echocardiography to quantitate the three main components (radial, longitudinal and angular) of left ventricular function, and their alterations after acute anterior myocardial infarction. Radial function was assessed by the myocardial velocity gradient derived from M-mode color tissue Doppler echocardiography, and longitudinal function by the pulsed wave tissue Doppler echocardiography, in 26 patients who experienced a first acute anterior myocardial infarction and in 11 matched healthy subjects. We describe a new tissue Doppler method for the measurement of septal angular deformation during cardiac contraction. In healthy subjects, our results showed heterogeneous regional myocardial contraction. Septal angular deformation occurred in the same direction and was of the same order as predicted by previous MRI studies. After anterior infarction, systolic and diastolic myocardial velocity gradients were dramatically decreased in the anterior wall when compared with controls (p < 0.01), whereas the systolic velocity gradient was significantly higher in the opposite wall (p < 0.05). Pulsed wave tissue Doppler echocardiography revealed significant alterations of longitudinal left ventricular function. Septal angular deformation was decreased after anterior infarct, and a good correlation was found between the angle of rotation and the left ventricular ejection fraction by cineangiography. These results indicate that tissue Doppler echocardiography has the potential for measuring the three main components of regional left ventricular function, and for quantitatively assessing their functional alterations induced by acute myocardial ischemia.

A clinical investigation has been conducted since January 1996 with a new valve dilator for percutaneous treatment of mitral stenosis: metallic commissurotome. This new technique is based on the principle of surgical commissurotome but, in its mechanism of action, differs from the usual techniques with balloon catheters. It also offers the unique possibility for multiple utilizations of the same device after resterilization. This article reports a multicenter international investigation involving 500 patients, mean age of 34 +/- 13 years, with a isolated mitral stenosis and an echography score of 7.7 +/- 1.9. Our technique has been feasible in 489 cases (98%) with a success rate (mitral area > 1.5 cm2 without MR > grade 2) of 93%. The transmitral gradient has diminished from 20 +/- 8 mmHg to 4 +/- 3 mm Hg and the mitral area (assessed by planimetry at 24 hrs) has increased from 0.91 +/- 0.20 to 2.12 +/- 0.34 cm2. Complications were uncommon (13 patients: 2.6%) and consisted in 6 tamponades, 5 mitral insufficiencies (one patient required an emergency valve replacement) and 2 neurological transient accidents. The outcomes of this clinical investigation appear most encouraging and at least comparable to those being reported with the commonly used techniques. The most serious complications appear to be closely related to the level of experience with this technique. Considering the possibility to reutilize the metal segments of the apparatus, this technique notably reduces the cost of the procedure per patient and it represents a significant benefit in countries with limited resources.

Background: Transmural myocardial contractile performance is nonuniform across the different layers of the left ventricular wall. We evaluated the accuracy of color M-mode tissue Doppler imaging (TDI) to assess the transmural distribution of myocardial velocities and to quantify the severity of dysfunction induced by acute ischemia and reperfusion in the inner and outer myocardial layers., Methods and Results: Thirteen open-chest dogs underwent 15 minutes of left anterior descending coronary artery occlusion followed by 120 minutes of reperfusion. M-mode TDI was obtained from an epicardial short-axis view. Systolic velocities were calculated within endocardium and epicardium of the anterior and posterior walls. Regional myocardial blood flow was assessed by radioactive microspheres. Segment shortening was measured by sonomicrometry in endocardium and epicardium of both the anterior and posterior walls. At baseline, endocardial velocities were higher than epicardial velocities, resulting in an inner/outer myocardial velocity gradient. Ischemia caused a significant and comparable reduction in endocardial and epicardial systolic velocities in the anterior wall with the disappearance of the velocity gradient. Systolic velocities significantly correlated with segment shortening in both endocardium and epicardium during ischemia and reperfusion. In the first minutes after reflow, endocardial velocities showed a greater improvement than epicardial velocities, and the velocity gradient resumed although to a limited extent, indicative of stunning., Conclusions: TDI is an accurate method to assess the nonuniformity of transmural velocities and may be a promising new tool for quantifying ischemia-induced regional myocardial dysfunction.

Power motion imaging (PMI) is a new Doppler imaging technology that can enhance contrast agent visualization. We hypothesized that PMI combined with Albunex injection (CPMI) could provide new insights into myocardial contractility and perfusion. In a first step, PMI signal was studied with an in vitro phantom. In a second step, PMI signal was studied in 10 rabbits at different workloads. In a third step, 10 rabbits were studied before and after ischemia produced by coronary ligation and finally during reperfusion. During the latter protocol, epicardial echocardiography analyzed by PMI and fundamental mode was performed before and after Albunex injection. PMI signal was well correlated with phantom velocity. PMI signal and myocardial wall thickening were well correlated, particularly in the septal area. On the coronary occlusion model, ischemia was associated with a significant decrease in PMI and CPMI signals, whereas reperfusion was associated with a significant decrease in PMI signals only, indicating stunning. We conclude that PMI combined with CPMI is a powerful tool to assess myocardial contractility and perfusion.

Objectives: The purpose of this study was to assess the value and limitations of Duke criteria for the diagnosis of infective endocarditis (IE)., Background: Duke criteria have been shown to be more sensitive in diagnosing IE than the von Reyn criteria, but the diagnosis of IE remains difficult in some patients., Methods: Both classifications were applied in 93 consecutive patients with pathologically proven IE. Blood cultures, and transthoracic and transesophageal echocardiography were performed in all patients., Results: Sensitivities for the diagnosis of IE were 56% and 76% for von Reyn and Duke criteria, respectively. Fifty-two patients were correctly classified as "probable IE" by von Reyn and "definite IE" by Duke criteria (group 1). However, discrepancies were observed in 41 patients. Eleven patients (group 2) were misclassified as "rejected" by von Reyn, but were "definite IE" by Duke criteria; this difference could be explained by negative blood cultures and positive echocardiogram in all patients. In eight patients (group 3), the diagnosis of IE was "possible" by von Reyn but "definite" by Duke criteria. This difference was essentially explained by the failure of the von Reyn classification to consider echocardiographic abnormalities as major criteria. Twenty-two patients (group 4) were misclassified as possible IE using Duke criteria, being false negative of this classification. Echocardiographic major criteria were present in 19 patients, but blood cultures were negative in 21 patients. The cause of negative blood cultures was prior antibiotic therapy in 11 patients and Q-fever endocarditis diagnosed by positive serology in three cases., Conclusions: Twenty-four percent of patients with proved IE remain misclassified as "possible IE" despite the use of Duke criteria, especially in cases of culture-negative and Q-fever IE. Increasing the diagnostic value of echographic criteria in patients with prior antibiotic therapy and typical echocardiographic findings and considering the serologic diagnosis of Q fever as a major criterion would further improve the clinical diagnosis of IE.

Aims: The aim of this study was to determine whether myocardial velocity gradients assessed by M-mode colour Doppler tissue imaging could be of clinical relevance and represent reliable indicators of regional left ventricular function after acute myocardial infarction., Methods and Results: Among 64 consecutive patients with a first acute myocardial infarction, in 50 who had a marked asynergy in the parasternal short-axis view at the mid-papillary muscle level, myocardial velocities and velocity gradients were assessed in the anteroseptum and posterior wall by M-mode Doppler tissue imaging. Similar measurements were obtained in 11 matched healthy volunteers who served as a control group. In patients with anterior myocardial infarction, the peak myocardial velocity gradient in the anteroseptum was significantly lower when compared with controls (mean +/- [SD] 0.0 +/- 0.5 vs 1.1 +/- 0.7 s-1 during systole, P < 0.01; and 0.3 +/- 0.6 vs 2.0 +/- 0.5 s-1 during diastole, P < 0.01). Conversely, the peak systolic myocardial velocity gradient in the posterior wall was significantly higher than in controls (2.6 +/- 1.2 vs 1.8 +/- 1.2 s-1, P < 0.05). In patients with inferior myocardial infarction, the peak velocity gradient in the posterior wall was significantly lower when compared with healthy subjects (0.9 +/- 0.6 vs 1.8 +/- 1.2 s-1 during systole and 1.4 +/- 1.4 vs 4.9 +/- 1.2 s-1 during diastole, both P < 0.01). The peak systolic tissue velocity gradient in the anteroseptum was significantly higher than in controls (2.1 +/- 1.0 vs 1.1 +/- 0.7 s-1, P < 0.01)., Conclusion: The present study indicates that myocardial velocity gradients assessed by M-mode Doppler tissue imaging are of clinical relevance for the characterization of ischaemic myocardial dysfunction after infarction and may provide quantitative assessment of segmental left ventricular function in this clinical setting.

The authors compared the results of conventional 2D echocardiography and those of Doppler tissue imaging in 30 patients in the intensive care unit for acute pulmonary myocardial infarction and 10 normal control subjects, to assess the longitudinal contraction of the left ventricle. Echocardiography was performed in the apical 2 and 4 chamber views to analyse the septal, lateral, posterior and anterior left ventricular walls. Each wall was divided into 3 segments: basal, median and apical. Each segment was scored: 1-normo or hyperkinetic, 2-hypokinetic, 3-akinetic and 4-dyskinetic. Doppler tissue imaging provided the maximum instantaneous velocities in systole and diastole in each segment. In control subjects, the myocardial velocities decreased significantly from the base to the apex, resulting in a systolic and diastolic pressure gradient with each wall between the base and the apex. In patients with myocardial infarction, the myocardial velocities were decreased compared with the control group. Moreover, the myocardial velocity gradient between the base and apex was significantly reduced in the hypo and akinetic walls, both in systole and diastole. These results show that, in myocardial infarction, the longitudinal left ventricular contraction is abnormal and may be analysed and quantified by new indices of myocardial systolic and diastolic function, provided by Doppler tissue imaging.

Background: Percutaneous balloon valvotomy has become a common treatment of mitral stenosis, but the cost of the procedure remains a limitation in countries with restricted financial resources, leading to a frequent reuse of the disposable catheters. To overcome this limitation, a reusable metallic valvotomy device has been developed with the goals of both improving the mitral valvotomy results and decreasing the cost of the procedure., Methods and Results: The device consists of a detachable metallic cylinder with 2 articulated bars screwed onto the distal end of a disposable catheter whose proximal end is connected to an activating pliers. By the transseptal route, the device is advanced across the valve over a traction guidewire. Squeezing the pliers opens the bars up to a maximum extent of 40 mm. The clinical experience consisted of 153 patients with a broad spectrum of mitral valve deformities. The procedure was successful in 92% of cases and resulted in a significant increase in mitral valve area, from 0.95+/-0.2 to 2. 16+/-0.4 cm2. No increase in mitral regurgitation was noted in 80% of cases. Bilateral splitting of the commissures was observed in 87%. Complications were 2 cases of severe mitral regurgitation (1 requiring surgery), 1 pericardial tamponade, and 1 transient cerebrovascular embolic event. In this series, the maximum number of consecutive patients treated with the same device was 35., Conclusions: The results obtained with this new device are encouraging and at least comparable to those of current balloon techniques. Multiple uses after sterilization should markedly decrease the procedural cost, a major advantage in countries with limited resources and high incidence of mitral stenosis.

In order to assess the value of Doppler tissue imaging (DTI) in the differentiation of physiological hypertrophy of athletes from primary hypertrophic cardiomyopathy (HCM), the authors compared a group of 20 normal, non-athletic subjects, a group of 43 competitive athletes and a group of 20 patients with mild HCM. In addition to the conventional echocardiographic criteria, the velocity of wall motion at the endocardium and epicardium of the interventricular septum and the posterior wall as well as their gradients, were measured throughout the cardiac cycle. No significant difference was observed between normal subjects and the athletes with respect to velocities and the gradients of velocity. Early diastolic velocities of the posterior wall and interventricular septum were significantly lower than those of normal subjects and athletes. The systolic and early diastolic gradients of velocity of the posterior wall were significantly lower in HCM compared with the normal subjects and athletes. The gradient of velocity between the endocardium and epicardium of the interventricular septum was significantly lower in HCM compared with normal subjects in early diastole and with athletes in systole and early diastole. The best Doppler tissue imaging parameter to differentiate pathological hypertrophy of HCM from physiological hypertrophy of athletes was analysis of the gradient of velocity in early diastole of the posterior wall. A value of 0.7 sec-1 differentiated HCM with a sensitivity of 89%, a specificity of 95% and a diagnostic accuracy of 94%. Doppler tissue imaging is a more sensitive and specific technique than conventional Doppler echocardiography for detecting moderate forms of HCM.

M-mode color Doppler imaging of the myocardium affords a greater sampling rate and signal-to-noise (S/N) ratio than 2-dimensional (2D) imaging. In this study, we compared myocardial velocities assessed by 2D and M-mode Doppler tissue imaging (DTI) at the same site and evaluated the influence of the S/N ratio on velocity estimates of the currently used DTI systems. In patients with and without impaired regional left ventricular function, myocardial velocities assessed by 2D DTI were lower than those obtained with M-mode DTI. The difference between regional velocities derived from both imaging techniques was positively correlated with the extent of the "black zone," which could be considered as indirectly reflecting the S/N ratio for each frame. Thus in the clinical setting and on currently used echocardiographs, 2D DTI may provide underestimated regional myocardial velocities when compared with M-mode, mainly because of the influence of the lower sampling rate and S/N ratio on velocity estimators of the imaging system.

Doppler tissue imaging is a new technique of measuring the velocities of myocardial wall motion. In order to assess its value in the diagnosis of acute rejection, the velocities of the interventricular septum and left ventricular posterior wall were measured in systole and early diastole in 34 cardiac transplant patients at the time of their endomyocardial biopsy, using an M mode left parasternal short axis view. During 40 episodes of acute rejection (26 mild and/or moderate, 10 sub-severe and 4 severe), the wall velocities decreased significantly (p < 0.001) both in the interventricular septum and endocardium of the posterior wall. Myocardial velocities were significantly slower in sub-severe or severe rejection than in mild or moderate rejection. The most sensitive criterion was the measurement of posterior wall endocardial velocity in early diastole, a decrease of 10% having a sensitivity of 92% whereas the sensitivity of usual Doppler echocardiographic parameters is only 73%. Acute rejection, even mild cases, can be diagnosed with excellent sensitivity by measuring myocardial velocities by Doppler tissue imaging. This technique has the advantage of being non-invasive, reproducible and reliable in the follow-up of cardiac transplant patients.

Background: Left ventricular (LV) dilation, which is a predictor of survival in humans with chronic heart failure (CHF), is limited by a mixed endothelin ETA-ETB antagonist. Whether selective ETA receptor blockade influences LV dilation is unknown. We determined, in a rat model of CHF, the effects of the ETA receptor blocker LU 135,252 on LV remodeling., Methods and Results: Rats were subjected to coronary artery ligation and treated for ten weeks with placebo or LU 135,252 (LU), at a dose of 10 or 30 mg kg-1 day-1. Systolic blood pressure and heart rate (plethysmography) were determined in conscious animals before and after four and ten weeks of treatment. At these time points, cardiac output and LV dimensions were measured in anesthetized rats by transthoracic echocardiography. LV hemodynamics were determined in anesthetized rats after ten weeks. Pressor responses to ET-1 (1 nmol/kg, i.v.) and sarafotoxin S6c (0.3 ng/kg, i.v.) were measured, to assess the efficacy of ET receptor antagonism and the lack of blockade of ETB receptor blockade, respectively. The pressor response to ET-1 was significantly reduced by LU (% change in systolic blood pressure: sham: 9 +/- 1; CHF: 5 +/- 1; CHF LU: 0 +/- 3 and -4 +/- 2% for the low and high dose, respectively). LU did not affect the response to sarafotoxin (CHF: -37 +/- 3; CHF LU: -29 +/- 3 and -28 +/- 2% for the low and high dose, respectively). Both doses of LU decreased systolic blood pressure, but only the high dose of LU reduced heart rate. Furthermore, LU restored cardiac output dose-dependently throughout the study. Both doses of LU limited LV dilatation and deterioration of LV fractional shortening to the same extent. After ten weeks, LU normalized LV end-diastolic- and central venous pressures, but did not affect LV dP/dtmax or dP/dtmin. LU did not prevent the development of cardiac hypertrophy, but reduced LV collagen density., Conclusions: In this rat model, the selective ETA receptor blocker LU, at the dose of 30 mg kg-1 day-1, reduced blood pressure and heart rate, limited progressive left ventricular remodeling and improved cardiac hemodynamics and function. These effects of LU might have important clinical relevance in the treatment of heart failure.

The aim of this study was to assess the value of low dose dobutamine (5 and 10 gammas/Kg/min) echocardiography for the detection of hibernating myocardium in an infarcted zone three weeks after the initial infarction. The authors studied 23 patients (18 men, 15 women) with an average age of 59 +/- 8 years before and 3 months after angioplasty of the culprit artery. Segmental wall motion was assessed semi-quantitatively by the criteria of the American Society of Echocardiography. All patients had regional contractile abnormalities under basal conditions and all underwent control coronary angiography at 3 months. Improvement of segmental wall motion with dobutamine predicted improvement after revascularisation with positive and negative predictive values of 95% and 85% respectively. The sensitivity and specificity of the test calculated in the usual manner were 83% and 96% respectively. In addition, assessment of diastolic function showed reduction of the isovolumic relaxation time with dobutamine only in patients with hibernating myocardium (120 +/- 30 ms decreasing to 114 +/- 29 ms with dobutamine, p < 0.02). Low dose dobutamine echocardiography therefore allows reliable non-invasive prediction of hibernating myocardium three weeks after infarction. The reduction of isovolumic relaxation time with dobutamine could be an additional argument in favour of the diagnosis.

The aim of this study was to assess a Doppler-echocardiographic parameter which has not been previously reported for the diagnosis of acute cardiac rejection. The parameter was left ventricular isovolumic relaxation blood flow. Eighty patients who had undergone orthoptic cardiac transplantation were followed up regularly with echocardiography for a period of 2 years. In all, 495 echocardiographic studies were performed and the results compared with those of endomyocardial biopsy performed on the same day (11.4 echocardiographic studies per patient). In the absence of cardiac rejection, isovolumic relaxation Doppler signal was recorded in all patients (364/387 echo studies). This was a positive signal directed towards the apex detected by continuous mode Doppler in the apical position, arising along the interventricular septum in the mid part of the left ventricle (82% of cases) or from the basal region of the septum (18% of cases) and lasting throughout the phase of isovolumic relaxation. The maximal velocity was 0.53 +/- 0.08 m/s (range 0.32 to 0.73 m/s) : the velocity-time integral was 34 +/- 33 cm. This signal was associated with medioventricular endosystolic acceleration of blood flow in 75% of cases. The incidence of the isovolumic relaxation flow signal decreased in cardiac rejection with no significant changes in the other usual Doppler-echocardiographic parameters except for a significant decrease in the ejection fraction in the group with severe rejection. In the group with mild rejection (n = 89) an isovolumic relaxation flow signal was only observed in 52 cases (including 29 in whom immunosuppressive treatment was not increased). In patients with moderate rejection (n = 12) there were only 5 cases in which a isovolumic relaxation flow signal was recorded, and in the group with severe rejection (n = 7), the signal could only be recorded in 1 case. The authors conclude that the absence of an isovolumic relaxation blood flow signal in a cardiac transplant patient is a reliable sign of cardiac rejection with an excellent specificity (94%). The absence of this signal is a sensitive indicator of severe rejection (86%) but less so for moderate (58%) or mild rejection (42%).

Background: Quantification of regional myocardial function is a major unresolved issue in cardiology. We evaluated the accuracy of pulsed Doppler tissue imaging (DTI), a new echocardiographic technique, to quantify regional myocardial dysfunction induced by acute ischemia and reperfusion., Methods and Results: In nine open-chest anesthetized pigs, various degrees of regional wall motion abnormalities were induced by graded reduction of left anterior descending coronary artery (LAD) blood flow. Pulsed Doppler tissue imaging was performed from an epicardial apical four-chamber view with the sample placed within the middle part of the septal wall. Peak septal velocities were calculated during systole, isovolumic relaxation, and early and late diastole. Regional myocardial blood flow and systolic and diastolic dysfunctions were assessed by radioactive microspheres and ultrasonic crystals, respectively. Ischemia resulted in a significant rapid reduction of systolic velocities and an early decrease in the ratio of early to late diastolic velocities. Both changes were detected by pulsed DTI within 5 seconds of coronary artery occlusion. The decrease in systolic velocity significantly correlated with both systolic shortening (r=.90, P<.0001) and regional myocardial blood flow (r=.96, P<.0001) during reduction of LAD blood flow., Conclusions: These results suggest that DTI may be a promising new tool for the quantification of ischemia-induced regional myocardial dysfunction.

Background: After heart transplantation, accelerated coronary vasculopathy is a major factor that limits long-term survival and is usually detected by serial coronary angiography. The aim of this study was to determine whether dobutamine stress echocardiography could accurately identify the progression of cardiac allograft vasculopathy., Methods: Two sequential controls by dobutamine stress echocardiography were performed at an 18-month interval in 37 heart transplant recipients at the time of their routine coronary angiography. The first control (control 1) occurred 37+/-20 months after transplantation, and the second control (control 2) occurred after 56+/-21 months. Standard echocardiographic views were acquired at baseline and at incremental dobutamine infusion levels. Regional wall motion score was calculated in a 16-segment model, and each segment was graded from 1 (normal) to 4 (dyskinesia). Visual and quantitative coronary angiographic analysis were used to assess the severity of the coronary vasculopathy., Results: The incidence of coronary vasculopathy increased from 46% (17/37 patients, four of whom had stenoses > 50%) at control 1 fo 70% (26/37 patients, six of whom had stenoses > 50%) at control 2. Progression of coronary vasculopathy was diagnosed by coronary angiography in 25 patients (new abnormalities in 19 and worsening of previous abnormalities in 6). Dobutamine stress echocardiography correctly identified the progression of vasculopathy in 21 of these 25 patients (84%) with new abnormalities in 17 and worsening in four. In the four remaining patients with evidence of progression of vasculopathy on coronary angiography, the result of dobutamine stress echocardiography was abnormal in three patients and normal in only one. Therefore dobutamine stress echocardiography results were abnormal in 12 patients at control 1 (sensitivity: 65%, specificity: 95%) and in 27 at control 2 (92% sensitivity, 73% specificity)., Conclusion: Dobutamine stress echocardiography is a sensitive, noninvasive method to diagnose the progression of allograft vasculopathy, and a negative test result is a strong predictor of absence of allograft coronary vasculopathy. Therefore serial routine coronary angiography may be deferred when dobutamine stress echocardiography results are normal.

Background: Plasma levels of the vasoconstrictor peptide endothelin (ET) are increased in chronic heart failure (CHF), and ET levels are a major predictor of mortality in this disease. Thus, ET may play a deleterious role in CHF. The purpose of this study was to assess the effects of chronic treatment with the ET receptor antagonist bosentan in a rat model of CHF., Methods and Results: Rats were subjected to coronary artery ligation and were treated for 2 or 9 months with placebo or bosentan (30 or 100 mg x kg(-1) x d(-1)). Bosentan 100 mg x kg(-1) markedly increased survival (after 9 months: untreated, 47%; bosentan, 65%; P<.01). Throughout the 9-month treatment period, bosentan significantly reduced arterial pressure and heart rate. After 2 or 9 months of treatment, the ET antagonist reduced central venous pressure and left ventricular (LV) end-diastolic pressure as well as plasma catecholamines, urinary cGMP, and LV ventricular collagen density. Bosentan also reduced LV dilatation (evidenced at 2 months by a shift in the pressure/volume relationship ex vivo). Echocardiographic studies performed after 2 months showed that the ET antagonist reduced hypertrophy and increased contractility of the noninfarcted LV wall. The lower dose of bosentan (30 mg x kg(-1)), which had no major hemodynamic or structural effects, also had no effect on survival., Conclusions: Long-term treatment with an ET antagonist markedly increases survival in this rat model of CHF. This increase in survival is associated with decreases in both preload and afterload and an increase in cardiac output as well as decreased LV hypertrophy, LV dilatation, and cardiac fibrosis. Thus, chronic treatment with ET antagonists such as bosentan might be beneficial in human CHF and might increase long-term survival in this disease.

Left main coronary artery (LM) stenting has only been reported in bail-out situations or absolute contraindications so surgery. The authors report the immediate and midterm results of primary Palmaz-Schatz stent implantation in two young patients without contraindication to surgery. The first patient, 58 year-old, was admitted for unstable angina in October 1994. Coronary angiography showed an isolated severe ostial lesion of the LM. After conferring with the surgical team which remained on stand-by, angioplasty and stent implantation were performed with excellent results, no complications and no restenosis on angiographic controls at 3 and 12 months. The patient remained asymptomatic 24 months later. The second patient, 38 year-old, was admitted in June 1995 for unstable angina, and coronary angiography showed a severe isolated stenosis in the middle of a long and wide LM. Primary coronary stenting was also performed with excellent results, no complication and no restenosis on angiographic controls at 4 and 8 months. This patient was still asymptomatic 16 months after stenting. These excellent immediate and medium-term results are encouraging and suggest that this form of treatment might be extended to patients with an isolated whether primary LM stent implantation could become a suitable alternative to surgery in the future.

The authors studied 35 normal subjects (41 +/- 6 years) and 22 patients with idiopathic dilated cardiomyopathy 48 +/- 7 years; ejection fraction: 31 +/- 12%) in order to determine normal values of myocardial velocities and to demonstrate the sensitivity of Doppler tissue imaging in detecting a significant decrease in myocardial velocities in patients with abnormal left ventricular contractility. Interventricular septal and left ventricular posterior wall velocities were recorded by M mode long axis parasternal views. In normal subjects, a velocity gradient in the posterior wall was observed, higher in the endocardium than in epicardium, in systole (5.1 +/- 1.5 versus 2.8 +/- 1 cm/s, p < 0.01), and early diastole (13.7 +/- 3.5 versus 5.7 +/- 2 cm/s, p < 0.001) and late diastole at the time of atrial contraction (2.7 +/- 2.1 versus 1.8 +/- 1.7 cm/s, p < 0.01). Moreover, the velocities are higher in the posterior wall than in the interventricular septum throughout the cardiac cycle. Finally, the velocities are higher in early diastole than in systole, both in the interventricular septum and posterior wall. In the group of patients with idiopathic dilated cardiomyopathy, the intramyocardial velocities were lower than in normal subjects. In addition, the velocity gradient in the posterior wall was absent in 15 of the 22 patients. The authors conclude that Doppler tissue imaging provides new information in the analysis of myocardial function both in systole and diastole.

Background: Non-bacterial thrombotic endocarditis in patients with cancer can lead to ischemic stroke. Endocardial vegetations are usually small and may be missed at transthoracic echocardiography., Case Report: Disseminated intravascular coagulation developed in a woman with ischemic stroke. Transthoracic echocardiography was normal. Four days later, transesophageal echocardiography revealed a large mitral vegetation suggesting non-bacterial thrombotic endocarditis. The diagnosis was confirmed at pathology which reported carcinoma of the colon., Discussion: Transthoracic echocardiography is rarely contributed to the diagnosis of thrombotic endocarditis. In our patient transesophageal echocardiography grave the diagnosis before death instead of retrospectively at autopsy as usually occurs, demonstrating the value of transesophageal echocardiography for cancer patients who develop ischemic stroke.

It has been shown that brief episodes of myocardial ischemia can render the heart more resistant to a prolonged subsequent ischemic episode. This phenomenon, called "preconditioning," has been described in human beings during coronary angioplasty with the use of clinical, electrocardiographic (ECG), or metabolic parameters. The goal of this study was to assess this phenomenon further with the use of echocardiographic and metabolic parameters in addition to clinical and ECG parameters. Eighteen patients with isolated stenosis of the left anterior descending coronary artery and a normal left ventricular function were included. Angioplasty consisted of four consecutive balloon inflations. Sequential changes in clinical, ECG (intracoronary ECG), echocardiographic, and metabolic parameters of myocardial ischemia were compared between the first and the fourth balloon inflations. Improved tolerance to myocardial ischemia with repeated coronary occlusions was demonstrated by a significant reduction in the severity of angina, ST-segment elevation, wall motion abnormalities, and lactate production. This study confirms the adaptation of myocardial ischemia to repeated coronary occlusions through measurement of clinical, ECG, echocardiographic, and metabolic parameters.

The value of Dobutamine stress echocardiography in the detection of coronary artery disease in heart transplant patients was studied in 64 patients at control coronary angiography 39 +/- 14 months after transplantation. Dobutamine was infused at progressively increasing doses (5 to 40 micrograms/kg/min) at 5 minute intervals, in order to reach 85% of the theoretical maximal heart rate or an ischaemic event. Echocardiography was analysed in the 4 standard views which were digitised allowing calculation of a regional wall motion score under basal conditions and at peak dosage in 16 left ventricular segments. Coronary angiography identified three groups: group I: 29 patients with normal coronary arteries; group II: 17 patients with non-significant coronary disease (diffuse or localised stenosis < 50%); group III: 9 patients with significant (> 50%) coronary disease. Dobutamine stress echocardiography showed regional wall motion abnormalities in 2/29 patients in group I, 13/17 patients in group II and all patients in group III (global sensitivity: 85%; specificity: 97%). The contractility score was significantly higher under basal conditions in group III (1.45 +/- 0.54) than in group I (1) and group II (1.17 +/- 0.23). At peak dose, the contractility score was unchanged in group I and increased significantly (p < 0.01) in the other two groups. The authors conclude that Dobutamine echocardiography is a reliable, non-invasive method of detecting coronary disease in cardiac transplant patients, and is particularly valuable for demonstrating myocardial ischaemia related to coronary lesions judged to be not significant at coronary angiography.

Coronary angioplasty provides an ideal model for studying ischemic preconditioning in humans. Four coronary occlusions, each lasting 5.2 +/- 1.3 min, separated by 3 min of reperfusion, were performed during angioplasty of isolated stenosis of the left anterior descending artery of 18 patients with stable angina and normal left ventricular function. The ischaemia was evaluated and compared during the first and fourth coronary occlusion with the aid of clinical, electrocardiographic, echocardiographic and metabolic parameters. We analysed: 1) interval to chest pain and its intensity; 2) degree of ST change on the intracoronary electrocardiogram; 3) regional wall motion abnormalities on 2D echocardiography; 4) coefficient of myocardial lactate extraction. The results showed that during the fourth occlusion: chest pain occurred later (93 +/- 57 vs 60 +/- 49 s; p < 0.05) and ST elevation was less (0.69 +/- 0.5 vs 1.03 +/- 0.8; p < 0.05). During the fourth occlusion, there was a delay in appearance and a decrease in the regional wall motion abnormalities: anterior wall hypokinesia occurred later: 26 +/- 15 vs 19 +/- 19 s (p = 0.08). Akinesia observed in 10 patients out of 13 (77%) during the first occlusion, was only observed in 8 patients (62%) and dyskinesia, observed in 5 patients out of 13 (38%) during the first occlusion was not observed thereafter in any patient. The production lactate was less important during the fourth occlusion than during the first one: -3 +/- 17% vs -12 +/- 19% (p < 0.05). This study confirms that, in man, preconditioning allows myocardial adaptation to successive episodes of acute ischaemia.

Objective: This study concerns patients who underwent one or several aortic balloon valvuloplasties at our institution and subsequently required cardiac surgery, either on an emergency basis after aortic valvuloplasty or due to the development of aortic stenosis., Methods: Between February 1987 and December 1993, 137 patients (73 male, 64 female, mean age 72 +/- 9 years) underwent aortic valve replacement for calcified aortic stenosis after several percutaneous balloon aortic valvuloplasties. Thirty-one patients were in NYHA stage II, 70 in stage III and 36 in stage IV. Seventy patients had angina (23 stage I or II, 47 stage III or IV) and 24 patients presented syncope or lipothymia. Twenty-three percent had at least two of these three symptoms. The indications for balloon dilatation were non-definitive surgical contraindication or high surgical risk (73), personal choice (49), refusal of surgery (9) and emergency (5:2 massive aortic regurgitation, 1 left ventricle perforation, 1 cardiogenic shock, 1 endocarditis in cardiogenic shock). Seven patients received preoperative aortic valvuloplasty due to a very high operative risk. The average time between dilatation and surgery was 472 days and there was clinical improvement for an average period of 261 days. The aortic valve replacements consisted of 58 mechanical prostheses and 79 xenografts with 22 concomitant procedures., Results: Operative mortality was eight patients (5.8%). During the follow-up (17.4 +/- 9.2 months), four patients died (3.6%), 91.2% of the patients were in class I and II and 95% were without angina. The actuarial survival rate was 90.5 +/- 6.6% including hospital mortality., Conclusions: Both our experience and the literature show that balloon aortic valvuloplasty is followed by an immediate improvement in hemodynamic status with a decrease in valve gradient and an increase in valve area. However, the hemodynamic benefit is typically short-lived with a very high restenosis rate. Balloon aortic valvuloplasty is not an alternative to aortic valve replacement, which remains the best treatment for calcified aortic stenosis; the benefits and long-term results of aortic valve replacement are well established, even in the elderly.

Background: After standard orthotopic heart transplantation (Sd HT), the enlarged resultant atria may promote atrial thrombosis. The purpose of this study was to compare the incidence of spontaneous echo contrast and left atrial thrombosis after Sd HT and total orthotopic (Tot HT) heart transplantation., Methods and Results: Transesophageal echocardiography (TEE) was performed in 75 patients with Sd HT and in 20 patients with Tot HT. Despite the use of antiplatelet therapy, an acute arterial embolism occurred in 11 (15%) of the 75 patients with Sd HT but in none of the 20 Tot HT patients. All patients were in sinus rhythm. Left ventricular ejection fraction was similar in Sd HT and Tot HT patients. Left atrial diameter was smaller in Tot HT patients than in Sd HT patients (41 +/- 4 versus 58 +/- 6 mm, P < .001). In Sd HT patients, spontaneous echo contrast was present in 43 patients (57%) and was associated with left atrial thrombus in 20 patients (on the left atrial appendage in 12 patients, on the posterior wall in 6, and on the suture in 2). No thrombus was detected by transthoracic echocardiography; all thrombi were detected by TEE. On the other hand, no left atrial thrombus was observed in Tot HT patients, and only 1 patient had spontaneous echo contrast. Of the 11 Sd HT patients who experienced an arterial embolism, 5 had both spontaneous echo contrast and left atrial thrombus and 5 had only spontaneous echo contrast., Conclusions: This study demonstrates a high rate of left atrial thrombus after Sd HT and emphasizes the role of TEE in the follow-up of these patients. The therapeutic implications are the need for a preventive anticoagulant therapy in the high-risk population receiving Sd HT diagnosed with TEE and the consideration of Tot HT as a better surgical approach as far as thrombotic complications are concerned.

A 34-year old woman, with a 3 yr history of severe seropositive rheumatoid arthritis (RA) with lupus anticoagulant and anticardiolipin antibodies, developed a massive anterior myocardial infarction and ischemia of the lower extremities, with disseminated intravascular coagulation resulting from extensive tissue damage. Seven days after admission, she died of severe heart failure complicated by ventricular fibrillation. To our knowledge, this is the first documented case of fatal acute antiphospholipid syndrome in RA.

Objectives: This study sought to determine whether dobutamine stress echocardiography could accurately identify coronary artery disease after heart transplantation., Background: After heart transplantation, coronary artery disease is related to either diffuse concentric intimal thickening or focal stenosis and may be underdiagnosed by coronary angiography., Methods: We enrolled 41 patients, a mean (+/- SD) of 40 +/- 20 months after heart transplantation, at the time of their routine control coronary angiogram. Three patients were excluded because of poor echogenicity on the angiogram and one because of ventricular premature beats. Standard echocardiographic views were acquired at baseline and at incremental dobutamine infusion levels (from 5 to a maximal dose of 40 micrograms/kg body weight per min at 3-min intervals). Regional wall motion score was calculated from a 16-segment model, and each segment was graded from 1 (normal) to 4 (dyskinesia). Coronary angiography was performed 24 h after dobutamine stress echocardiography, and angiograms were analyzed in blinded manner., Results: Twenty-three (62%) of 37 patients had normal coronary angiographic findings. Dobutamine stress echocardiography showed abnormalities in only 2 of 23 patients. Fourteen patients (38%) had abnormal angiographic findings, seven of whom had stenoses > 50%. Dobutamine stress echocardiography correctly identified the corresponding hypoperfused segments in these seven patients. More of interest were the other seven patients, of whom three had angiographic nonsignificant stenoses (< 50%), and four had minor diffuse coronary irregularities. Dobutamine stress echocardiography showed hypokinesia in five of these seven patients despite nonsignificant lesions at coronary angiography. The respective overall sensitivity and specificity of dobutamine stress echocardiography were 86% and 91%. At follow-up, 2 of the 37 patients had an acute myocardial infarction. Both had abnormal findings on dobutamine stress echocardiography: One had normal coronary angiographic results, and one had significant coronary lesions., Conclusions: Dobutamine stress echocardiography is a useful technique for the diagnosis of coronary artery disease after heart transplantation. These preliminary results indicate that dobutamine stress echocardiography may have a predictive value for further ischemic events in heart transplant recipients.

The authors report the case of a large right atrial thrombosis causing acute cardiac failure in an 18 year old patient with tricuspid atresia who had undergone 3 operations: Waterston shunt at 2 months of age, Fontan procedure at 3 years of age with reoperation at 13 years of age. The diagnosis was made at echocardiography and angiography. Surgical management comprised ablation of the thrombus and a tunneling of the right atrium between the inferior vena cava and the atriopulmonary conduit. The immediate postoperative course was complicated by a slowly regressive neurological deficit. The medium-term outcome (one year) is satisfactory with antiarrhythmic and anticoagulant therapy. A review of the literature showed that these thromboses are not exceptional in the early postoperative period for a variety of reasons. Secondary thrombosis is often related to arrhythmias, thus requiring clinical, electrocardiographic and echocardiographic follow-up of these patients and the prescription of antiarrhythmic and anticoagulant therapy. The diagnostic methods are discussed. Echocardiography may be sufficiently explicit to make potentially risky angiography unnecessary.

A new circulatory system, "physiologic anteroperfusion system", has been developed and tested in 6 patients with significant proximal coronary artery stenosis. Prolonged and safe balloon inflation was possible without any ischemic signs. The system consists of an electronic cardiac synchroperfusor which, by activating a pulsatile unit, permits increased diastolic anteroperfusion of autologous blood under physiologic pressure through low-profile standard angioplasty catheters. This study reports the results obtained in 6 patients during proximal prolonged percutaneous transluminal coronary angioplasty. Four men and two women suffering from severe exertional angina pectoris, with normal resting left ventricular function, no collaterals and excellent apical two-dimensional four-chamber echocardiographic views were studied. After a 90 +/- 10 seconds of control occlusion under continuous monitoring of hemodynamics, electrocardiograms (3 to 4 leads), two-dimensional echo and chest pain grading, a second balloon inflation protected by the physiologic anteroperfusion system at a flow rate of 44 +/- 12 ml/min was performed for fifteen minutes. The ischemic signs present in the myocardium depending on the occluded artery were totally abolished during prolonged inflation protected by physiologic anteroperfusion system. All the patients were successfully dilated and were discharged from hospital the following morning without cardiac enzyme elevation or signs of central or peripheral hemolysis. Conclusion, in 6 patients with severe proximal coronary artery stenosis, safe prolonged proximal angioplasty without signs of ischemia was performed using a new simple physiologic anteroperfusion system, which allows active diastolic flow-pressure controlled autologous arterial blood perfusion, through standard low profile catheters.

The aim of this study was to determine the prevalence of intra-atrial thrombi or spontaneous contrast by transoesophageal echocardiography in patients who underwent cardiac transplantation by Lower and Shumway's technique. Transoesophageal echocardiography was performed in 52 transplant patients (43 men, 9 women: average age 51 years) with a high frequency biplane transducer. After surgery, all patients received platelet antiaggregant therapy. Despite this treatment, 4 patients had a sudden systemic embolic episode and were then placed on oral anticoagulants. All patients were in sinus rhythm at the time of the examination and some had signs of acute rejection on endomyocardial biopsy performed the same day. Spontaneous contrast was observed in 27 patients (52%) and was associated with thrombosis in 15 patients (29%). These thrombi were located in the left atrial appendage in 8 cases, on the left atrial posterior wall in 5 cases and on the left atrial sutures in 2 cases. None of these thrombi had been detected by transthoracic echocardiography. No significant difference was observed between those with and those without thrombosis with respect to left atrial dimensions, left ventricular ejection fraction, cardiac index, pulmonary pressures and the number of episodes of acute rejection. The 4 patients with a history of arterial embolism all had an intra-atrial thrombus. This study demonstrates a high incidence of spontaneous contrast and intracardiac thrombi in the dilated left atrium of patients transplanted by Lower and Shumway's technique. It also underlines the value of transoesophageal echocardiography in the follow-up of transplant patients.(ABSTRACT TRUNCATED AT 250 WORDS)

Patients with mitral stenosis in Western countries are relatively old. It is anticipated that percutaneous transseptal mitral commissurotomy (PTMC) may have more complications and may not be as effective in this group of patient as in younger patients due to more calcification and fibrosis of the mitral valve. We analysed the clinical, hemodynamic, echocardiographic data in 296 consecutive patients divided prospectively into two groups; group 1 consisted of 184 patients > or = 40 years and group 2 of 112 patients < 40 years coming mostly from developing countries. The immediate gain in valve area was 2.18 +/- 0.61 cm2 in group 1 vs. 2.31 +/- 0.65 cm2 in group 2 (P = ns). The incidence of acute regurgitation requiring surgical intervention was similar in both groups. Follow-up data up to 5 years after PTMC was available in 170 patients (92.4%) in group 1 (mean 20 +/- 13 months) and 83 patients (74.1%) in group 2 (mean 29 +/- 17 months). Restenosis by Doppler method (valve area less than 1.5 cm2 with loss of at least 50% initial gain in valve area) was found in 33 patients in group 1 (29.2%) vs. 11 (14.9%) in group 2 (P < 0.05). Events free from death, need for mitral valve replacement or repeat PTMC at 5 year follow-up was 76% in group 1 vs. 87% in group 2 (P < 0.05). We conclude that the immediate effectiveness and acute complications of PTMC in patients 40 years and above are comparable to younger patients. Restenosis is clearly higher and there is a trend towards need for mitral valve replacement in patients 40 years and above at follow-up. However, the continuing benefit for the majority of the patients 40 years and above (76% free from adverse events) would suggest that PTMC is an appropriate treatment modality even in the older patients.

In contrast with aortic valve replacement, the treatment of choice for severe aortic stenosis because of the better long-term results, percutaneous aortic valvuloplasty, has only limited indications, mainly because of the high rate of restenosis. However, in very elderly patients, the surgical risk is high, sometimes prohibitive. For this reason, the authors report their latest results with this technique in a series of octogenarians. Between January 1989 and December 1990, 70 aortic valvuloplasties were performed in octogenarians (average age 85 +/- 3 years). The indications were advanced age > or = 85 years (46%), poor left ventricular ejection fraction < 40% (20%), secere associated coronary artery disease (3%), associated extracardiac pathology (11%), poor general condition (11%) or refusal of surgery (4%). The great majority of these patients (83%) were very symptomatic: 70.5% had Grade III-IV dyspnoea, 20% had Grade III-IV angina and 20% had syncopal attacks. Valvuloplasty reduced the mean transvalvular pressure gradients from 61 +/- 23 to 30 +/- 11 mmHg (p < 0.01) and increased aortic valve surface area from 0.53 +/- 0.19 to 0.94 +/- 0.12 cm2 (p < 0.001). There were two deaths (2.9%) in the catheterization laboratory and 4 (5.7%) complications during the hospital period (myocardial infarction: 1, cerebrovascular accident: 1, severe aortic regurgitation: 1 and complete atrio-ventricular block: 1). There were no serious vascular complications. The average duration of the hospital period was 6 +/- 5 days. Clinical follow-up of 17 +/- 7 months was obtained in 97% of patients.(ABSTRACT TRUNCATED AT 250 WORDS)

The object of this study was to assess the accuracy of the simplified continuity equation (SCE) defined as the ratio of velocity time integrals (VTI) of the aortic or pulmonary to mitral orifice in the evaluation of severe mitral stenosis. The results of the continuity equation and VTI ratios were compared with the Gorlin catheter valve area in 70 patients with pure mitral stenosis in sinus rhythm. The continuity equation (CE) and SCE were significantly correlated (p < 0.01) with the Gorlin surface area with a better coefficient with the CE (r = 0.86) than with the VTI ratio (r = 0.74). The patient population was divided into two groups depending on the severity of mitral stenosis; Group I had catheter valve areas of less than 1.5 cm2: 38 patients had mean value of the CE of 1.11 +/- 0.22 cm2 and of the SCE of 0.32 +/- 0.09. In Group II (mitral valve area > or = 1.5 cm2), 32 patients had a mean CE value of 1.92 +/- 0.29 cm2 and a SCE value of 0.56 +/- 0.14. Only two patients in Group I had SCE values greater than 0.5. Conversely, no patients in Group II had a SCE value of less than 0.3. For a range of SCE values of 0.3 to 0.5, there was an important overlap between the two groups (19 patients of Group I and 9 patients of Group II).(ABSTRACT TRUNCATED AT 250 WORDS)

The authors report the case of a 64 year old man on chronic haemodialysis therapy in whom coronary angiography showed a right coronary artery aneurysm. This patient had undergone coronary angiography 4 years previously and no aneurysm had been found on that occasion. The aneurysm occurred in the context of coronary atherosclerosis, coronary angiography showing typical appearances of double vessel disease. There were several special features of this aneurysm which contribute to the originality of the case: its rapid development within 4 years, its large size and the fact that it was an isolated finding on the right coronary artery. Several aetiologies are discussed but none can be formally confirmed.

In order to assess the prevalence of cardiac involvement in the primary antiphospholipid syndrome (PAS), a syndrome which associates thromboembolism, recurrent abortion, the presence of antiphospholipid antibodies and thrombocytopenia, transthoracic (TTE) and trans-esophageal echocardiography (TEE) was performed in 15 patients, 10 women and 5 men with a mean age of 38.8 +/- 11 years, with the PAS but without systemic lupus erythematosus. The presentation of the PAS was a thrombotic event (6 arterial and 7 venous) in 13 cases, and recurrent abortion in 3 cases. Twelve patients had high anticardiolipin antibody levels (> or = 15 U GPL) and 12 had a raised anti-prothrombinase antibody title. Valvular heart disease was detected in 9 patients (60%) as a valve thickening (> or = 5 mm for the mitral and > or = 3 mm for the aortic valve) or nodule. Mitral regurgitation was observed in 4 cases both on TTE and TEE and was mild in 3 cases and severe in 1 case. Aortic regurgitation was diagnosed in 6 patients, in 3 cases by TTE and in 6 cases by TEE. It was mild in 5 cases and moderate in the other cases. Pericardial effusion was observed in 3 patients (20%), alone in 1 case and associated with valvular disease in the other two cases. No abnormality of left ventricular systolic or diastolic function could be demonstrated. In conclusion, cardiac involvement seems to be common in the PAS, and TEE is a sensitive and accurate method for describing the valvular, especially aortic valve, abnormalities.

The aim of this study was to evaluate the continuity equation in the quantification of mitral valve area in mitral stenosis, the area being considered as the product of the area of the left ventricular outflow tract multiplied by the ratio of the velocity time integrals of the aortic or pulmonary flow to that mitral flow. The continuity equation was compared to two other echocardiographic methods, planimetry and Hatle's method, and to the results obtained at catheterization using the Gorlin formula in a population of 44 patients with mitral stenosis. All were in sinus rhythm; twelve had Grade I mitral regurgitation and 9 patients had Grade I aortic regurgitation. Excellent correlation were observed between the values obtained by the continuity equation and planimetry (r = 0.91; SEE = 0.19 cm2; p less than 0.001) and Hatle's method (r = 0.87; SEE = 0.20 cm2, p less than 0.001). The correlation with the catheter values were also excellent (r = 0.83; SD = 0.22 cm2, p less than 0.001), better than those observed with Hatle's method (r = 0.73; SEE = 0.27 cm2, p less than 0.001) and very similar to those obtained with planimetry (r = 0.87; SEE = 0.23 cm2, p less than 0.001). The sensibility and specificity of the continuity equation for the diagnosis of severe mitral stenosis (surface less than 1.5 cm2) were 90% and 100% respectively, when those of Hatle's method were 88% and 91% respectively. The continuity equation in the evaluation of mitral valve area in mitral stenosis seems to be reliable and accurate compared with catheter data, and superior to Hatle's method.

Several attempts at circuit interruption of type 1 atrial flutter by means of surgical or catheter techniques have been published. We recently reported the results of a series of patients who underwent catheter fulguration of the low septal right atrium, with a mean follow-up of almost 3 years. True electrophysiological success was observed in 7/14 patients (50%). Clinical success, defined as absence of symptoms, was observed in 8 was observed in 8/14 (57%) in this patient population. No serious complications were encountered, but the potential risks of DC shock, and the experience that we gained in right atrial mapping using this approach, led us to reconsider the role of atrial DC ablation in these patients. Additional studies assessing the meaning of fragmented electrograms, and identification of one (or of several) slow conduction areas of the reentrant circuit are ongoing.

To evaluate the restenosis rate after successful balloon aortic valvuloplasty, clinical evaluation and repeat catheterization were performed in 96 patients who had undergone balloon dilatation 7 +/- 5 months earlier. Restenosis, defined as a loss of greater than 50% of the benefit in aortic valve area obtained after balloon valvuloplasty, was observed in 48% of the patients. Actuarial analysis showed that the restenosis rate was time dependent and was 80% at 15 months. However, functional improvement was observed in most of the patients with or without restenosis. The restenosis rate was not correlated with the degree of enlargement of the aortic orifice produced by the valvuloplasty procedure. Because of the high incidence of restenosis, balloon aortic valvuloplasty should be limited to patients who have a contraindication to surgery or are at high risk for surgery, or as a bridge to surgery.