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Aim: To study recent experience and safety of ergonovine stress echocardiography in our centre., Methods: In this study we collected the clinical variables of patients referred since 2002 for ergonovine stress echocardiography, in addition to indications, the results of this test, complications, blood pressure and heart rate values during the test and the number and results of tests requested before this technique., Results: We performed 40 tests in 38 patients, 2 tests were carried out to verify therapy efficacy. The prevalence of classic cardiovascular risk factors was low and the most frequent indication was chest pain (57.5%). Coronary angiography was performed in 32 patients, and showed normal coronary arteries in 27 patients and non-significant stenosis in 5 cases. In 16 patients, coronary angiography was carried out after a positive or inconclusive ischemia test. Another 6 patients had a normal stress test (5 exercise electrocardiography tests and 1 nuclear imaging test). Of the 40 ergonovine stress echocardiography tests, 6 were positive (4 in the right coronary artery territory and 2 in the circumflex coronary artery territory), all of them by echocardiographic criteria, and by electrocardiographic criteria in only 3 (50%). The presence of non-significant coronary artery stenosis was more frequent in patients with positive ergonovine stress echocardiography (50% vs 6%, P = 0.038), and were related to ischemic territory. During the maximum stress stage, there was a higher systolic (130.26 ± 19.17 mmHg vs 136.58 ± 27.27 mmHg, 95% CI: -12.77 to 0.14 mmHg, P = 0.055) and diastolic blood pressure (77.89 ± 13.49 mmHg vs 83.95 ± 15.73 mmHg, 95% CI: -10.41 to -1.69 mmHg, P = 0.008) than at the baseline stage, and the same was registered with heart rate (73 ± 10.96 beats/min vs 79.79 ± 11.72 beats/min, 95% CI: -9.46 to -4.11 beats/min, P < 0.01). Nevertheless, there were only 2 hypertensive reactions during the last stage, which did not force a premature end to the test, without sustained tachy or bradyarrhythmias, and the technique was well tolerated in 58% of cases. A unique complication (2.5%) of this test was a prolonged vasospasm with a slight increase in necrosis biomarkers, however, this was without repercussion., Conclusion: Ergonovine stress echocardiography can be performed with safety, is well tolerated in the majority of cases, and is useful for determining the ischemia mechanism in selected cases.

Background: High blood pressure increases left ventricular (LV) after-load. Furthermore, LV response to that high blood pressure varies among different subjects. Nevertheless, myocardial deformation behavior in these different adaptative responses has not been analyzed until now., Methods: Prospective study in which 66 consecutive hypertensive patients were enrolled in between May and August 2009. Every patient underwent a standard echocardiographic study and a three-dimensional-wall motion tracking (3D-WMT) study. The patients were classified according to parameters derived from echocardiography in four different groups: normal geometry, concentric remodelling, concentric hypertrophy, and eccentric hypertrophy., Results: Mean age was 68 years (57-74.25; 51.5% male). Comparing the four groups, significant differences were found for the five 3D-WMT-derived parameters. When patients were compared with hypertensive patients with normal geometry, our finding show that: (a) LV average torsion is the only impaired parameter that is found in the LV concentric remodelling group (P < 0.05 vs. group 1); (b) there is a trend for an increase (P = 0.055) in LV average radial strain in the group with concentric hypertrophy and this increase is accompanied by a significant decrease in the remaining studied parameters (P < 0.05); and (c) in the LV eccentric hypertrophy group, there is a significant impairment in all the studied parameters (P < 0.05)., Conclusions: LV adaptative response to hypertension is accompanied by a modification or even impairment, in LV myocardial deformation evaluated by 3D-WMT. This assessment might be useful to detect early and subtle deformation impairments in hypertensive patients and it could help optimize their clinical management., (© 2010, Wiley Periodicals, Inc.)

BACKGROUND: Left-ventricular ejection fraction (LVEF), the most frequently used parameter to evaluate left ventricular (LV) systolic function, depends not only on LV contractility, but also on different variables such as pre-load and after-load. Three-dimensional wall motion tracking echocardiography (3D-WMT) is a new technique that provides information regarding different new parameters of LV systolic function. Our aim was to evaluate whether the new 3D-WMT-derived LV systolic function parameters are less dependent on load conditions than LVEF. METHODS: In order to modify the load conditions to study the dependence of the different LV systolic function parameters on them, a group of renal failure patients under chronic hemodialysis treatment was selected. The echocardiographic studies, including the 3D-WMT analysis, were performed immediately before and immediately after the hemodialysis session. RESULTS: Thirty-one consecutive patients were enrolled (mean age 65.5 ± 17.0 years; 74.2% men). There was a statistically significant change in predialysis and postdialysis, pre-load and after-load conditions (E/È ratio and systolic blood pressure) and in the LV end-diastolic volume and LVEF. Nevertheless, the findings did not show any significant change before and after dialysis in the 3D-WMT-derived parameters. CONCLUSIONS: LV 3D-wall motion tracking-derived systolic function parameters are less dependent on load conditions than LVEF. They might measure myocardial contractility in a more direct way than LVEF. Thus, hypothetically, they might be useful to detect early and subtle contractility impairments in a wide number of cardiac patients and they could help to optimize the clinical management of such patients.

Transcatheter aortic valve implantation (TAVI) by percutaneous or transapical approach has emerged as an effective and less-invasive treatment for patients with severe symptomatic aortic valve stenosis and high surgical risk. Echocardiography is a fundamental tool in patients' selection for TAVI, for guiding the intervention as well as evaluating the position, deployment and function of the prosthesis. This review describes the role of echocardiography during the intervention, in procedure guidance and in the assessment of complications.

Coronary artery bypass grafting (CABG) is the most effective revascularisation treatment for advanced coronary heart disease. Atherosclerotic disease may compromise graft patency in the follow-up. As a result, it is not unusual for patients to present with angina requiring evaluation. When present, graft disease or progression of the disease in native vessels can be treated by means of percutaneous coronary intervention (PCI) or by repeated bypass surgery. The utility of modern helical ultrafast multidetector computed tomography (MDCT) in the evaluation of the patency of arterial or vein coronary grafts and thereby avoiding the need of a coronary angiography (CA) in the majority of patients is well established using 16 or 64-slice scanners. Although the accuracy of MDCT in the study of native coronary vessels in operated patients is more challenging, modern multislice computed tomography technology (64-slice) is especially useful in the non-invasive evaluation of patients with previous CABG with chest pain or equivalent symptoms, but with inconclusive or contradictory results in exercise or pharmacological stress tests. MDCT emerges as an attractive imaging technique, not only in the study of symptomatic patients with previous CABG, but also in the planning of secondary revascularisation procedures, either percutaneous, surgical or hybrid procedures.

Background: Two-dimensional (2D) wall motion-tracking echocardiography (WMT) is a useful method to measure myocardial strain, but it is very limited because acquisition and analysis are time consuming. Three-dimensional (3D) WMT is a new method that might improve diagnostic usefulness and reduce study times. The aims of this study were to compare results on 2D and 3D WMT and to compare the times for the acquisition and analysis of regional myocardial strain between the two methods., Methods: Measurements of the radial and longitudinal strain of every left ventricular (LV) segment and the time for acquisition and analysis were obtained using 3D and 2D WMT., Results: Thirty patients were enrolled (mean age, 57.2 +/- 19.6 years; 60% men). Three-dimensional WMT provided complete radial and longitudinal LV strain information, similar to 2D WMT (P = NS), but it was less time consuming: the times for acquisition and analysis were 14.0 +/- 1.9 minutes with 2D WMT and 5.1 +/- 1.1 minutes with 3D WMT (P < .001). Furthermore, in the same analysis, a greater number of segments could be analyzed using 3D WMT (72.4%) compared with 2D WMT (52.0%)., Conclusions: Three-dimensional WMT provides a faster, more complete, and similar analysis to assess LV longitudinal and radial strain compared with 2D WMT. Thus, 3D WMT is a potential clinical bedside tool for quantifying myocardial strain.

We present the case of a rare echocardiographic image of a giant cavitated myxoma and the pathologic findings of the cystic mass. The new echocardiographic equipment not only has improved the sensitivity for diagnosis of different pathologies but also has redefined its visual and morphologic characteristics. Although most myxomas are solid masses and some cystic myxomas have been reported, the presence of multiple cavities on echocardiographic exam has exceptionally been described. While cystic changes have been described at autopsy in 14% of cardiac myxomas, its identification with echocardiography is rare. Nowadays, the new echocardiographic equipment has improved the quality and the accuracy to detect and describe intracardiac masses, showing myxomas with cystic cavities in vivo that in the past was a pathologic finding.

Loeffler endocarditis, eosinophilic endomyocardial disease or fibroplastic endocarditis appears to be a subcategory of the Hypereosinophilic syndrome in which the heart is predominantly involved. It is an uncommon myocardial disease, thought to be secondary to eosinophils damage, characterized by fibrous thickening of the endocardium of one or both ventricles, leading to apical obliteration and multiple cardiovascular complications. Despite all the efforts, the ultimate responsible mechanisms of this entity remain unresolved. Many theories have been raised trying to explain this phenomenon, but nowadays the enigma in relation to the different patterns of evolution continues. In this concise review we discuss the different pathophysiologic theories postulated and the management of the cardiovascular complications. Perhaps it will serve to assist in recognition of patients with the same condition around the world.

A 67 year-old asymptomatic patient was referred to our echo-lab because of hypertension. Transthoracic 2D-echocardiogram showed a non-prolapsing ovoid mass attached to the left side of the interatrial septum. Transesophageal echocardiography evidenced an ovoid cavitated mass with internal areas of calcification. Color Doppler revealed flow inside the cavities. At surgery, a multicavitated mass was observed attached to interatrial septum. Macroscopically revealed cavities filled with blood, as well as partially calcified areas. Microscopically there were collections of "lipidic" cells embedded in the myxoid matrix, typical of cardiac myxoma. Cardiac hydatid cysts usually have a rounded shape. Most myxomas are solid masses without a cystic architecture or cavitations. Calcification is usually identified at a microscopic level. The combination of a polycystic appearance of the mass and macroscopic areas of calcification is more frequently observed in hydatid cysts than in cardiac myxomas. This appearance of the mass leads us to consider a cardiac echinococcal cyst as the first diagnostic possibility. This peculiar structure of cardiac myxoma, to the best of our knowledge, has never been documented. Transthoracic echocardiography and particularly transesophageal imaging, enable us to delineate this kind of tumors. Surgical resection is the appropriate treatment for these tumors, even in asymptomatic patients.

An 82-year-old female was admitted to the coronary care unit with an anterior wall myocardial infarction and cardiogenic shock. She was in chronic atrial fibrillation without oral anticoagulation. Coronary angiography showed occlusion of the left main coronary artery which originated together with a normal right coronary artery from the right sinus of Valsalva. The advanced age, the presence of chronic atrial fibrillation not anticoagulated and the normal appearance of the remaining coronary arteries suggested a thromboembolic origin. Transthoracic echocardiography showed an abrupt interruption of the myocardial wall, in the apical portion of the interventricular septum, not communicating with the pericardial sac or right ventricular cavity suggesting the presence of an incomplete contained rupture of the myocardial wall at this location. She died in cardiogenic shock due to the extensive left ventricular damage.

Granulocytic sarcoma, or chloroma, is an uncommon presentation of acute leukemia. Cardiac involvement is very rare and usually diagnosed at autopsy. We present a case that discloses the essential role of transesophageal echocardiography for its in vivo diagnosis. The principal features with this imaging technique are finely described.

Introduction and Objectives: Tako-tsubo-like transient left ventricular apical ballooning has been described in Japan, but few cases have been reported in Western countries. We report one of the first series outside Japan, which provides new information on the coronary anatomy of this disorder., Patients and Methods: From January 1998 to February 2003 we observed 11 patients with a clinical suspicion of acute myocardial infarction, normal coronary arteries, and transient tako-tsubo-like systolic left ventricular apical ballooning. We compared the coronary artery anatomy in these 11 patients with that in 44 controls matched for age and sex: 22 with normal coronary arteries and 22 with acute myocardial infarction related with an obstructive thrombus in the left anterior descending coronary artery., Results: As in Japanese patients, tako-tsubo syndrome in Caucasian patients frequently occurs in women in their seventh or eighth decades of life, and is usually preceded by emotional or physical stress. The left anterior descending in our patients with tako-tsubo syndrome was longer overall, and its recurrent diaphragmatic segment was longer, than in controls. To compare these groups we designed a measure termed recurrent segment index (left anterior descending recurrent segment length/total left anterior descending length x 100). In tako-tsubo syndrome this index was 22.3 (1.5)%, vs 10.9 (6.7)% in normal controls (P<.001), and 11.3 (7.7)% in acute myocardial infarction patients (P<.001). Patients with acute myocardial infarction and a high recurrent segment index (> or =16%) had ventriculographic findings of systolic apical ballooning identical to those in patients with tako-tsubo syndrome., Conclusions: All our patients with tako-tsubo syndrome had a left anterior descending with a long recurrent segment. The identical ventriculographic findings in patients with tako-tsubo syndrome and those with acute myocardial infarction with a long recurrent segment may be due to a common etiology.

This paper presents a methodology and a software package developed to quantify M-mode tissue Doppler imaging (TDI), defining a number of quantitative parameters drawn from velocity and gradient curves obtained after segmenting the myocardial wall into anatomical layers. The independent clinical predictive value of these parameters to detect motion abnormalities in the presence of ischaemia was evaluated in a comparative study between a group of 17 healthy volunteers and 18 ischaemic patients. Factor analysis and stepwise logistic regression were used to assess the independent predictive value of these parameters in detecting abnormal contractility of the basal posterior segment. The statistical analysis performed has proved that any single parameter related to the gradient intensity, particularly the maximum gradient at the moment of the "e" wave, provides meaningful clinical information, achieving a rate of correct classification of 79.1% on the same data set used for the analysis. Adding additional parameters does not improve the diagnostic performance. Further testing with different settings (stress studies, other pathologies or segments) is warranted.

Background: Preliminary experimental data have shown a nonuniform distribution of myocardial velocities (MVs) across the myocardial wall in normal conditions. However, after ischemic damage to the myocardium, a different pattern of reduction in the myocardial layers has been reported. The aim of this study is to analyze the spatial distribution of MVs and the resultant myocardial velocity gradients (MVGs) during the systolic and diastolic time periods. Doppler tissue imaging (DTI) in color M-mode was used to evaluate 3 different myocardial layers (endocardium, mesocardium, and epicardium) and their changes as a result of ischemia., Methods: Thirty-two consecutive patients were studied with DTI color M-mode: 18 patients with a history of previous or ongoing myocardial infarction and 14 healthy subjects. Postprocessing of images was accomplished with proprietary software. MV and MVG values of all layers along both systolic and diastolic time were calculated. For temporal analysis, systole was subdivided in 3 equal periods. Early- and late-diastolic times were also identified., Results: In ischemic patients, the mean MV and maximum MV throughout systole decreased significantly in the endocardium and mesocardium, whereas only slightly in the epicardium. The mean MVG was less in ischemic patients (0.66 +/- 0.11 vs 0.23 +/- 0.15, P <.03). Temporal analysis showed a decrease in the maximal MV and MVG in all layers over the 3 systolic periods. This decrease was the more consistent in mesocardium. In diastole, there was a decrease in maximal MV in all layers, being more pronounced in endocardium and mesocardium. Diastolic mean MVG was shown to be different between control and ischemic groups (-0.2 +/- 0.05 vs -0.10 +/- 0.04, P <.06). A significant decrease of the maximal MV in endocardium and mesocardium was reported in the temporal analysis during early diastole. No change was reported in the epicardium. The MVG value also showed a significant decrease (-2.69 +/- 0.29 vs -1.59 +/- 0.89, P <.02). In ischemic patients in late diastole, the maximum MV was increased in all layers of the myocardium, and this increase was observed mainly in the endocardium. An increase in the MVG (-0.78 +/- 0.18 vs -1.47 +/- 0.85, P = NS) was also reported during late diastole., Conclusion: There is a nonuniform distribution of velocities in the different myocardial layers under normal conditions. This distribution of velocities undergoes a significant change in patients with ischemic myocardial damage. Intramyocardial wall motion analysis could have clinical applications in both the early detection of ischemia and myocardial viability.

Aneurysm of the anterior mitral leaflet is a rare complication of infective aortic valve endocarditis, the natural evolution of which is generally its rupture, with subsequent acute and severe mitral regurgitation. Its presence cannot be recognized with transthoracic echocardiography and even in surgery. We describe a 78-year-old man with aortic valve endocarditis, in whom transesophageal echocardiography was essential for the diagnosis of this complication, its therapeutic management, and the postoperative follow-up after simple valve repair. In addition, the most appropriate surgical approach is discussed.