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We report a case of a 67-year-old woman who underwent an aortic valve replacement with a 23-mm Trifecta prosthesis (St. Jude Medical, St. Paul, MN, USA). We implanted Perceval S (LenoNova, London, UK) after resecting the degenerated leaflets three years later after the first operation. This strategy enabled us to reduce the ischemic time and hence simplify the surgical procedure in addition to providing excellent postoperative hemodynamics.

Background Long-term prognosis of patients with bicuspid aortic valve (BAV) disease and poor left ventricular ejection fraction (LVEF) who underwent aortic valve replacement (AVR) is unknown. We aimed to analyze the recovery of LVEF and incidence of adverse events after AVR in patients with BAV and poor LVEF. Materials and Methods A total of 90 consecutive BAV patients (mean age 57 ± 10 years, 89% male) with baseline LVEF ≤40% underwent an isolated AVR between January 1, 1995, and June 30, 2008, and served as our study population. Follow-up data (800 patient-years) were obtained for all 90 hospital survivors. A subgroup of patients who underwent AVR for BAV stenosis (Group aortic stenosis [AS], n = 70) was compared with those who underwent AVR for BAV regurgitation (Group aortic regurgitation [AR], n = 20). Primary end point was the recovery of LVEF in AS Group versus AR Group. Secondary end points were survival and freedom from adverse cardiac events (i.e., cardiac-related death and need for reinterventions due to persisting heart failure). Results There was a significant increase in LVEF (mean follow-up 9.0 ± 5 years) in AS versus AR Group (i.e., 32 ± 7% [baseline] and 53 ± 9% [follow-up], p

Carcinoid tumor is a slow-growing type of neuroendocrine tumor, originating from enterochromaffin cells and secreting mainly serotonin. The diagnosis is based on clinical symptoms, hormone blood levels, radiological and nuclear imaging, and histological confirmation. However, most patients have metastases at the time of diagnosis because the clinical signs often remain unnoticed or are attributed to other abdominal conditions. In up to 50% of patients the endocardium is affected due to a hormonally active tumor profile. The study aim was to report the outcome of surgical treatment in patients with carcinoid heart disease, including the data of radiological and nuclear imaging, histological diagnosis, and follow up information.Between 2008 and 2014, a total of 39 consecutive patients (28 males, 11 females; mean age 66 years; range: 28-84 years) with carcinoid heart syndrome were operated on at the authors' institution. Valvular heart disease was diagnosed with two-dimensional echocardiography. The study population included 26 patients (67%) with severe metastatic disease, who underwent radiotherapy preoperatively, and 13 patients (33%) who were metastasis-free and did not receive preoperative systemic therapy. Follow up was available for all hospital survivors, all of whom underwent serial echocardiographic follow up postoperatively. Adverse cardiac events were defined as cardiac-related death, a need for valvular reintervention, the occurrence of valve prosthesis-related complications, or echocardiographic evidence of new, high-degree valvular dysfunction during follow up.The majority of patients (n = 34; 87%) underwent isolated tricuspid valve replacement, while simultaneous pulmonary valve replacement was performed in five patients (13%). Postoperative complications included reoperation for bleeding in five patients (13%) and new heart block requiring pacemaker implantation in 10 (25%). The in-hospital mortality was 5% (n = 2). The overall survival was 43% at six years postoperatively. At the latest follow up, 12 of the 17 survivors were in NYHA class I, and five in NYHA class II. The adverse cardiac event rate was 71%. Echocardiographically, 46% of patients (6/13) showed at least stationary or mild improvement in the right ventricular ejection fraction at follow up, with no evidence of paravalvular leak, infective endocarditis, or progressive other native valvular carcinoid affection. Postoperatively, the right atrial dimensions were preserved as normal in 23 patients (59%), mildly dilated in six (15%), moderately dilated in three (8%), and severely dilated in seven (18%). Valve-in-valve transcatheter aortic valve implantation was performed in two patients (12%) due to structural degeneration of the valve bioprosthesis and native valve disease progression.Despite advanced systemic disease, the surgical treatment of patients with carcinoid heart syndrome is associated with an acceptable perioperative risk and satisfactory mid-term survival. Those patients who survived valve surgery benefited from a significant improvement in their functional capacity. Percutaneous procedures may represent a useful tool to reduce the risk of late valvular reinterventions.

BACKGROUND: There is growing evidence for the association between physical activity and systemic inflammatory markers in healthy individuals and populations with a low prevalence of coronary artery disease (CAD). However, the association between fitness and CRP in patients with stable CAD treated with medications known to influence the inflammatory response, such as statins and aspirin, is not well known. METHODS: We prospectively enrolled 209 patients with angiographically documented CAD (161 men; age 63 +/- 10 years; 1-/2-/3-vessel disease in 42%, 34%, and 24% of patients, respectively; left ventricular ejection fraction 60% +/- 13%). Fitness level was assessed by maximal exercise testing. CRP was measured in all patients using high-sensitivity immunoassay. RESULTS: Fitness level was inversely correlated with natural log-transformed CRP level (r = -0.28, P < .001). After multivariate linear regression adjustment for age, sex, body mass index, waist circumference, smoking status, educational level, diabetes, hypertension, modality of exercise testing, exercise-induced ischemia, extent of CAD, medication use, leukocyte count, hemoglobin, renal function, glucose level, and cholesterol level, exercise capacity remained inversely correlated with CRP level (beta = -.226, P = .001). Other covariates associated with CRP remaining in the final model were leukocyte count (beta = .348), pack-years of smoking (beta = .185), diabetes status (beta = -.201), hemoglobin concentration (beta = -.187), and high-density lipoprotein cholesterol level (beta = -.149). CONCLUSIONS: These results indicate that exercise capacity is inversely correlated with CRP level in patients with known stable CAD irrespective of extent of CAD and standard medication for secondary prevention.

OBJECTIVES: Bicuspid aortic valve (BAV)-associated aortopathy has been proposed to progress after isolated aortic valve replacement (AVR) surgery, which has been traditionally used as an argument against a TAVR procedure in this clinical subset. Still, more than half of BAV patients have a normal-sized proximal aorta at the time of AVR surgery. We aimed to analyse the long-term risk of adverse aortic events after isolated conventional AVR surgery for BAV and normal-sized proximal aorta. METHODS: A total of 200 consecutive patients (mean age 56 ± 13 years, 73% men) with BAV disease and ascending aortic diameter of

OBJECTIVES: The optimal surgical treatment of patients with bicuspid aortic valve (BAV) disease and ascending aortic aneurysm is controversial. The aim of this study was to evaluate the risk of late aortic events after an isolated aortic valve replacement (AVR) for BAV stenosis with concomitant mild-to-moderate proximal aortic dilation. METHODS: A review of our institutional BAV database identified a subgroup of 153 consecutive BAV patients (mean age 54.2 ± 10.5 years, 73% men) with BAV stenosis and concomitant ascending aortic dilation of 40–50 mm who underwent an isolated AVR from 1995 to 2000. All cases of simultaneous aortic surgery (i.e. ascending aorta with a diameter of >50 mm) were excluded. The follow-up (1759 patient-years) was 100% complete. The mean follow-up was 11.5 ± 3.2 years. Adverse aortic events were defined as the need for proximal aortic surgery, the occurrence of aortic dissection/rupture or sudden death during the follow-up. RESULTS: Actuarial survival rates of our study population were 86 and 78% at 10 and 15 years, respectively. Ascending aortic surgery was required in five patients (3%) for progressive ascending aortic aneurysm. Freedom from aortic interventions at 10 and 15 years was 97 and 94%, respectively. No documented aortic dissection or rupture occurred. Freedom from adverse aortic events was 95% at 10 years and 93% at 15 years postoperatively. In a separate group of patients presenting with aortic insufficiency (i.e. root phenotype), freedom from adverse aortic events was significantly lower (88 and 70% at 10 and 15 years, P = 0.009). CONCLUSIONS: BAV patients with aortic valve stenosis and concomitant mild-to-moderate ascending aortic dilation are at a considerably low risk of adverse aortic events at 15 years after an isolated AVR. The BAV phenotype should be considered when determining the risk of subsequent adverse aortic events and the need for concomitant aortic replacement.

Although there is adequate evidence that bicuspid aortic valve (BAV) is an inheritable disorder, there is a great controversy regarding the pathogenesis of dilatation of the proximal aorta. The hemodynamic theory was the first explanation for BAV aortopathy. The genetic theory, however, has become increasingly popular over the last decade and can now be viewed as the clearly dominant one. The widespread belief that BAV disease is a congenital disorder of vascular connective tissue has led to more aggressive treatment recommendations of the proximal aorta in such patients, approaching aortic management recommendations for patients with Marfan syndrome. There is emerging evidence that the 'clinically normal' BAV is associated with abnormal flow patterns and asymmetrically increased wall stress in the proximal aorta. Recent in vitro and in vivo studies on BAV function provide a unique hemodynamic insight into the different phenotypes of BAV disease and asymmetry of corresponding aortopathy even in the presence of a 'clinically normal' BAV. On the other hand, there is a subgroup of young male patients with BAV and a root dilatation phenotype, who may present the predominantly genetic form of BAV disease. In the face of these important findings, we feel that a critical review of this clinical problem is timely and appropriate, as the prevailing BAV-aortopathy theory undoubtedly affects the surgical approach to this common clinical entity. Thorough analysis of the recent literature shows a growing amount of evidence supporting the hemodynamic theory of aortopathy in patients with BAV disease. Data from recent studies requires a reevaluation of our overwhelming support of the genetic theory, and obliges us to acknowledge that hemodynamics plays an important role in the development of this disease process. Given the marked heterogeneity of BAV disease, further studies are required in order to more precisely determine which theory is the 'correct' one for explaining the obviously different types of BAV-associated aortopathy.

Background Arteriovenous fistulas (AVF) and arterial pseudoaneurysms (PSA) are potentially harmful complications of diagnostic and interventional cardiac catheterisation. Incidence, risk factors and clinical outcome are not well defined yet, although important for stratification and treatment. Methods A total of 18,165 consecutive patients undergoing cardiac catheterisation were enrolled in our prospective registry. For the diagnosis of AVF and PSA a clinical examination was performed in every patient followed by a Duplex examination in case of clinical suspicion of AVF/PSA. The impact of the following risk factors was assessed: age, body mass index, puncture of left vs. right groin, gender, hypertension, sheath size, peripheral artery disease, coumadin therapy, glycoprotein IIb/IIIa-inhibitors, pre-treatment with thrombolytics, and emergency procedures. Results Within 3 years a total of 334 complications were found (1.8%). The incidence of AVF and PSA was 0.6% ( n =107) and 1.2% ( n =227), respectively. The following significant independent risk factors were identified: arterial hypertension (odds ratio [OR])=1.86, female gender (OR=1.65), and emergency procedures (OR=2.13). During follow-up (mean 48±10 months) only 11% of all AVF underwent operative repair due to symptoms. All PSA could be treated successfully either by manual compression, thrombin injection, or surgery. The overall mortality was 0.8%. Conclusion Almost 2% of patients undergoing cardiac catheterisation acquire femoral AVF or PSA, for which patient- or procedure-related risk factors could be identified. Most of AVF and PSA could be managed conservatively or without any treatment, the overall mortality is low.

Kommunikation stellt einen zentralen Schritt des Interaktionsprozesses zwischen Arzt und Patient dar. 15 min nach Besprechung der Ergebnisse einer Linksherzkatheteruntersuchung wurden 288 konsekutiven Patienten folgende Fragen gestellt: 1. Wurden Ihnen die Ergebnisse der Herzkatheteruntersuchung erlautert? 2. Wie hies Ihr Untersucher? 3. Fanden sich an Ihren Herzkranzgefasen Engstellen? 4. Ist die Pumpkraft Ihres Herzens normal? 5. Welche Therapie ist notwendig? Mit 98,6% der befragten Patienten wurden die Ergebnisse der Herzkatheteruntersuchung besprochen, im Mittel wurden nur 53,4% der gestellten Fragen richtig beantwortet. 31,2% der Patienten konnten sich an den Namen des Untersuchers erinnern. 52,8% kannten ihren Koronarstatus, 36,8% die Pumpleistung ihres Herzens und 92,7% die abgegebene Therapieempfehlung. Ursachlich fur die falschen Antworten war in 85,4%, dass der Inhalt der Befundbesprechung vom Patienten nicht verstanden wurde, in 14,6% war eine Schwerhorigkeit des Patienten die Ursache. Eine hohere Rate an falschen Antworten zeigte sich bei komplexen angiographischen Befunden, sprachlicher Diskordanz zwischen Untersucher und Patient sowie Erlauterungen der Ergebnisse durch Nichtfacharzte (jeweils p < 0,001). Direkt nach Durchfuhrung einer Linksherzkatheteruntersuchung mundlich erlauterte Ergebnisse werden nur unzureichend von den Patienten verstanden. Hier sind insbesondere die kommunikativen Fahigkeiten der Arzte weiter verbesserungsbedurftig.

A congenital left ventricular aneurysm or diverticulum is a rare cardiac malformation described in 418 cases since the first description in 1816, being associated with other cardiac, vascular or thoracoabdominal abnormalities in about 75%. It appears to be a developmental anomaly, starting in the 4th embryonic week. Diagnosis can be made after exclusion of coronary artery disease, local or systemic inflammation or traumatic causes as well as cardiomyopathies. Clinically, most congenital left ventricular aneurysms and diverticula are asymptomatic, but some of them may cause systemic embolization, heart failure, valvular regurgitation, ventricular wall rupture, ventricular tachycardia, or sudden cardiac death. Diagnosis is established by imaging studies such as echocardiography, magnetic resonance imaging or left ventricular angiography, visualizing the structural changes and accompanying abnormalities. Mode of treatment has to be individually tailored and depends on clinical presentation, accompanying abnormalities and possible complications, options include surgical resection, especially in symptomatic patients, anticoagulation after systemic embolization, radiofrequency ablation or implantation of a cardioverter defibrillator in case of symptomatic ventricular tachycardias, occasionally combined with class I or III antiarrhythmic drugs. Because of the usually benign course of congenital left ventricular aneurysms and diverticula in the adulthood, most of them can be managed conservatively.

We report a rare case of late cardiac perforation after percutaneous closure of patent foramen ovale with the Cardia Star device (Cardia, Gent, Belgium), which presented as acute pericardial tamponade and was initially misdiagnosed as acute type A aortic dissection. The clinical course was dramatic in our patient and might have resulted in sudden death without prompt surgical treatment. The clinicians involved in treating a patient with acute, unexplained cardiac tamponade should be aware of late cardiac perforation occurring after percutaneous patent foramen ovale closure.

The minimally invasive procedure is a new surgical technique that uses a small sternal incision. Because of limited surgical exposure, removal of intracavitary air and visual assessment of cardiac function are not possible. We studied the utility of intraoperative transesophageal echocardiography (IOE) before and after cardiopulmonary bypass in 112 patients (mean age 53.1 ± 15.2 years, 74 males) who underwent minimally invasive valvular surgery. Surgical procedures included 52 isolated mitral valve procedures (49 repairs, 3 prostheses), 58 isolated aortic valve procedures (16 repairs, 26 prostheses, 16 homografts), and 2 combined aortic and mitral valve repairs. Prepump IOE was useful to confirm valve dysfunction and assist determination of arterial cannulation site. Postpump IOE identified intracardiac air in all patients, which was defined as extensive in 58 (52%) cases. Postoperatively, new left ventricular dysfunction was noted in 22 (20%) patients, more often in the group with extensive air by IOE (17 [30%] of 58 patients) compared with those without extensive air (5 [10%] of 54 patients, P = .01). Second pump runs were required in 7 (6%) of 112 patients: 3 cases of residual aortic regurgitation, 1 case of residual mitral regurgitation, and 3 cases with new ventricular dysfunction. No deaths occurred. We conclude that IOE is essential in minimally invasive valvular surgery because it detects problems that require immediate remedy. IOE allows real-time assessment of ventricular filling, ventricular and valvular function, and intracardiac air. (J Am Soc Echocardiogr 1999;12:231-6.)

OBJECTIVES The aim of this study was to evaluate whether preoperative clinical and test data could be used to predict the effects of myocardial revascularization on functional status and quality of life in patients with heart failure and ischemic LV dysfunction. BACKGROUND Revascularization of viable myocardial segments has been shown to improve regional and global LV function. The effects of revascularization on exercise capacity and quality of life (QOL) are not well defined. METHODS Sixty three patients (51 men, age 66 ± 9 years) with moderate or worse LV dysfunction (LVEF 0.28 ± 0.07) and symptomatic heart failure were studied before and after coronary artery bypass surgery. All patients underwent preoperative positron emission tomography (PET) using FDG and Rb-82 before and after dipyridamole stress; the extent of viable myocardium by PET was defined by the number of segments with metabolism-perfusion mismatch or ischemia. Dobutamine echocardiography (DbE) was performed in 47 patients; viability was defined by augmentation at low dose or the development of new or worsening wall motion abnormalities. Functional class, exercise testing and a QOL score (Nottingham Health Profile) were obtained at baseline and follow-up. RESULTS Patients had wall motion abnormalities in 83 ± 18% of LV segments. A mismatch pattern was identified in 12 ± 15% of LV segments, and PET evidence of viability was detected in 30 ± 21% of the LV. Viability was reported in 43 ± 18% of the LV by DbE. The difference between pre- and postoperative exercise capacity ranged from a reduction of 2.8 to an augmentation of 5.2 METS. The degree of improvement of exercise capacity correlated with the extent of viability by PET (r = 0.54, p = 0.0001) but not the extent of viable myocardium by DbE (r = 0.02, p = 0.92). The area under the ROC curve for PET (0.76) exceeded that for DbE (0.66). In a multiple linear regression, the extent of viability by PET and nitrate use were the only independent predictors of improvement of exercise capacity (model r = 0.63, p = 0.0001). Change in Functional Class correlated weakly with the change in exercise capacity (r = 0.25), extent of viable myocardium by PET (r = 0.23) and extent of viability by DbE (r = 0.31). Four components of the quality of life score (energy, pain, emotion and mobility status) significantly improved over follow-up, but no correlations could be identified between quality of life scores and the results of preoperative testing or changes in exercise capacity. CONCLUSIONS In patients with LV dysfunction, improvement of exercise capacity correlates with the extent of viable myocardium. Quality of life improves in most patients undergoing revascularization. However, its measurement by this index does not correlate with changes in other parameters nor is it readily predictable.

Left ventricular (LV) cavity obliteration during dobutamine echocardiography (DE) indicates a vigorous inotropic response to stress. Such a response may suggest the absence of coronary artery disease (CAD), but a small LV cavity may also preclude recognition of wall motion abnormalities. We sought to determine the frequency, correlates, accuracy, and prognostic value of the LV cavity obliteration response in 336 consecutive patients who underwent coronary angiography within 1 year of DE. Cavity obliteration was defined by contact of the opposite walls in the apical views during DE, and ischemia by detection of a new or worsening wall motion abnormality. Sensitivity was based on comparison with coronary anatomy in 220 patients without prior revascularization. The prognostic implications of cavity obliteration were examined by follow-up of 324 patients (96%) over 23 +/- 9 months for death, myocardial infarction, and late revascularization. Cavity obliteration was present in 86 of the 336 DE studies (26%). Baseline and stress hemodynamics were not predictive of cavity obliteration, which was associated with LV hypertrophy and female gender (p

This study evaluated the prediction of cardiac events (cardiac death, myocardial infarction, unstable angina, or late myocardial revascularization) in patients with submaximum responses to dobutamine stress, defined by attainment of

Introduction. Left ventricular outflow obstruction might be part of the pathophysiological mechanism of Tako-tsubo cardiomyopathy. This obstruction can be masked by Tako-tsubo cardiomyopathy and diagnosed only by followup.Case Presentation. A 70-year-old female presented with Tako-tsubo cardiomyopathy and masked obstructive hypertrophic cardiomyopathy at presentation.Conclusion. Tako-tsubo cardiomyopathy typically presents like an acute MI and is characterized by severe, but transient, regional left ventricular systolic dysfunction. Prompt evaluation of the coronary status is, therefore, mandatory. The prognosis under medical treatment of heart failure symptoms and watchful waiting is favourable. Previous studies showed that LVOT obstruction might be part of the pathophysiological mechanism of TCM. This paper supports this theory. However, TCM may also mask any preexisting LVOT obstruction.

Communication between patient and physician remains a central step of interaction.15 min after receiving the results of their coronary angiography via a standard verbal report, a total of 288 patients were asked the following questions: (1) Were the results of coronary angiography explained to you? (2) Who performed your procedure? (3) Were there any narrowings in your coronary arteries? (4) Was your left ventricular ejection fraction normal? (5) What kind of therapy was recommended to you?98.6% of the patients were informed about the results of their coronary angiography. 31.2% were able to recall the name of the interventionalist. 52.8% knew about their coronary arteries, 36.8% knew their left ventricular function, and 92.7% were able to recall the recommendations for therapy (mean 53.4% correct answers). In 14.6%, the causes of incorrect answers were related to the patient, in 85.4% to the doctor. The number of incorrect answers increased significantly in patients with complex angiographic results, cultural discordance between physician and patient, and presentation of the results by noncardiologists (p0.001 for all).Communication of coronary angiography results to patients via standard verbal reports leads to frequent misunderstanding. To resolve communication problems in the cathlab as effective as possible, communication skills of physicians should be improved.

A congenital left ventricular aneurysm or diverticulum is a rare cardiac malformation described in 418 cases since the first description in 1816, being associated with other cardiac, vascular or thoracoabdominal abnormalities in about 75%. It appears to be a developmental anomaly, starting in the 4th embryonic week. Diagnosis can be made after exclusion of coronary artery disease, local or systemic inflammation or traumatic causes as well as cardiomyopathies. Clinically, most congenital left ventricular aneurysms and diverticula are asymptomatic, but some of them may cause systemic embolization, heart failure, valvular regurgitation, ventricular wall rupture, ventricular tachycardia, or sudden cardiac death. Diagnosis is established by imaging studies such as echocardiography, magnetic resonance imaging or left ventricular angiography, visualizing the structural changes and accompanying abnormalities. Mode of treatment has to be individually tailored and depends on clinical presentation, accompanying abnormalities and possible complications, options include surgical resection, especially in symptomatic patients, anticoagulation after systemic embolization, radiofrequency ablation or implantation of a cardioverter defibrillator in case of symptomatic ventricular tachycardias, occasionally combined with class I or III antiarrhythmic drugs. Because of the usually benign course of congenital left ventricular aneurysms and diverticula in the adulthood, most of them can be managed conservatively.

BACKGROUND: Important modern prognostic markers such as heart rate recovery (HRR), chronotropic index, delayed systolic blood pressure (SBP) response and Duke treadmill score (DTS) have been evaluated by treadmill exercise testing. Their value in bicycle exercise testing is unclear. METHODS: Patients (n=211, age 64+/-10; 75% male) with known or suspected coronary artery disease randomly underwent either bicycle (n=105) or treadmill (n=106) exercise electrocardiography. They were matched for age, gender, body mass index, hypertension, smoking, lipid status, prevalence of diabetes, medication, haemoglobin level, extent of coronary artery disease and left ventricular ejection fraction. RESULTS: Despite a higher peak heart rate (pHR) patients stressed by treadmill had a slower drop in HR during the early phase of recovery with a significantly higher rate of abnormal HRR (pHR; HR 1 min into recovery < or =12 bpm) with 37% in treadmill versus 19% in bicycle (P=0.004). Abnormally delayed SBP response [(SBP 1 min into recovery/SBP 3 min into recovery) >1.0] was also more common in treadmill (41%) compared to bicycle (12%, P

This issue is very important because it is still hard to predict these life-treatening arrhythmias in individual patients with myocardial infarction, especially if good reperfusion is acheived. It still remains uncertain, when considering the pathophysiology of these arrhythmias in patients with myocardial infarction, whether these are really caused by reperfusion (coronary intervention, medicamentous, spontaneous) or ischaemia?5 Further investigations should be directed towards discovering predictors of malignant ventricular arrhythmias after reperfusion in both NSTEMI and STEMI, as well as redefining VT/VF as reperfusion arrhythmias according to pathophysiological and clinical criteria. Finally, we agree that the problem of VT/VF in patients with myocardial infarction and mechanically achieved good reperfusion becomes of lesser significance after the first 24 h, which is important from an economic point of view.

Aims Previous studies have compared the accuracy of various tests of viability for the prediction of recovery of regional left ventricular function; global left ventricular recovery has been less well studied, although it has important prognostic and functional ramifications. We sought to identify the relative contribution of ischaemia, regional and global contractile reserve, perfusion and metabolic function to changes in left ventricular volumes and global function after coronary artery bypass surgery in patients with severe left ventricular dysfunction. Methods and Results Dipyridamole stress Rb-82, fluorodeoxyglucose positron emission tomography and low and high-dose dobutamine–atropine stress echocardiography were obtained in 66 patients with left ventricular impairment. Myocardial segments were considered viable if ischaemia or either metabolic or contractile reserve were present, on positron emission tomography or dobutamine echocardiography. Resting left ventricular function was reassessed after surgery (mean 10±3 weeks) in the 59 patients who had not suffered a major peri-operative event; functional improvement was defined by a 5% increment of ejection fraction. Myocardial viability was found in 37 (63%) patients using positron emission tomography and in 42 (71%) patients using dobutamine echocardiography; post-operative functional improvement was noted in 28 (47%) patients. In univariate analyses, predictors of global post-operative functional recovery included: the extent of viability according to positron emission tomography [OR (odds ratio): 2·08 for each additional viable segment, 95% CI (confidence interval): 1·33–3·25, P =0·001] or dobutamine echocardiography (OR: 2·06 for each additional viable segment, 95% CI: 1·28–3·30, P =0·003) and the increase in ejection fraction with low-dose dobutamine (OR: 1·9 for each 1% increase in ejection fraction with low dose dobutamine, 95% CI 1·39–2·61, P

Background Coronary disease is an important cause of long-term morbidity in patients needing major vascular surgery. We sought to assess the efficacy of preoperative clinical evaluation and the detection of inducible ischemia for prediction of immediate and long-term cardiac outcomes of patients undergoing vascular surgery. Methods In 233 patients undergoing vascular procedures, we assessed risk clinically on the basis of Eagle's criteria. Dobutamine echocardiography was performed with a standard protocol and results were classified as showing ischemia, scar, or a normal response. Patients were observed perioperatively, and late follow-up (28 ± 13 months) was completed in all surgical survivors. A composite end point of cardiac death, myocardial infarction, and unstable and progressive angina requiring late revascularization was used to judge event-free survival. Results Of 233 patients undergoing preoperative dobutamine echocardiography, 39 (17%) had inducible ischemia and 36 (15%) had scar. Perioperative events occurred in 8 patients (3%). None of the patients with ischemia had perioperative events, reflecting the effect of revascularization in 9 patients. Late events occurred in 36 patients; ischemia on preoperative stress testing was a predictor of these events even after adjusting for clinical variables and left ventricular dysfunction (relative risk=3.3; 95% confidence interval 1.6 to 6.8; P = .001). The association of ischemia with clinical predictors was associated with incrementally worse outcome. Conclusion In addition to perioperative assessment, the combined use of clinical and dobutamine echocardiographic evaluation may stratify the risk of late cardiac events. (Am Heart J 1999;137:469-75.)

Dobutamine echocardiography (DE) has been shown to be safe, feasible, and accurate for identification of coronary artery disease (CAD) in mixed populations. The purpose of this study was to examine gender differences in physiologic response and accuracy of DE. We studied 2,886 consecutive DEs, performed in 2,748 patients, 1,209 of whom (44%) were women. A standard incremental protocol (5 to 40 μg/kg/min in 3-minute stages) was followed by atropine and/or an additional stage with 50 μg/kg/min, if the heart rate response was inadequate. Hemodynamic and echocardiographic findings were recorded at each stage. Three hundred sixty-nine patients without previous cardiac intervention (including 135 women) also underwent cardiac catheterization within 1 year of DE. Significant coronary stenoses (defined angiographically as >50% diameter) were present in 67% of women and 65% of men, of whom 55% and 65%, respectively, had multivessel disease. Women had a higher baseline heart rate (76 ± 13 vs 73 ± 14 beats/min, p

Objectives. This study sought to document the safety of dobutamine stress echocardiography as it has evolved at a single center and to define predictors of adverse events. Background. The indications and protocol for dobutamine stress testing have evolved over 5 years of clinical use, but the influence of these changes on the safety and side effects of the test is undefined. Methods. Over 5 years, 3,011 consecutive dobutamine stress studies were performed in 2,871 patients, using an incremental protocol from 5 to 40 μg/kg body weight per min in 3-min stages, followed by atropine or an additional stage with 50 μg/kg per min, if required. Clinical data were gathered prospectively, and hemodynamic and echocardiographic findings were recorded at each stage, including recovery. Dobutamine echocardiography was defined as positive for ischemia in the presence of new or worsening wall motion abnormalities; in the absence of ischemia, failure to attain 85% of age-predicted maximal heart rate was identified as a nondiagnostic result. Results. Studies were performed for risk assessment (70%) and symptom evaluation (30%); over the study period, there was an increment in the use of dobutamine echocardiography for preoperative evaluation. Most tests (n = 2,194 [73%]) were terminated due to attainment of peak dose with achievement of target heart rate (>85% maximal age-predicted heart rate); 455 patients (15%) failed to achieve >85% maximal predicted heart rate despite maximal doses of dobutamine and atropine. The protocol was stopped prematurely in 230 patients (7.6%) because of side effects, including ventricular (n = 27 [0.9%]) and supraventricular rhythm disorders (n = 22 [0.7%]), severe hypertension (n = 24 [0.8%]) and hypotension or left ventricular outflow tract obstruction (n = 112 [3.8%]). Noncardiac symptoms, such as headache, nausea or anxiety, caused early test termination in 45 patients (1.6%). The remaining tests were stopped because of severe chest pain (n = 106 [3.5%]) or severe ischemia by echocardiography (n = 26 [0.9%]). Serious complications occurred in nine patients, including sustained ventricular tachycardia in five, myocardial infarction in one and other conditions in three requiring hospital admission (sustained supraventricular tachycardia, hypotension, suspected myocardial infarction), but neither ventricular fibrillation nor death occurred. Independent predictors of serious complications could not be defined. Over 5 years, higher dose protocols and more frequent use of atropine have raised the number of diagnostic protocols from 59% to 80%, without increasing the incidence of major side effects. Conclusions. Despite the use of more aggressive protocols and alterations of the indications for testing to include sicker patients, major side effects are a rare complication of dobutamine echocardiography. (J Am Coll Cardiol 1997;29:1234–40)