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Echocardiography is the modality of choice for the noninvasive recognition of vegetations and abscesses that complicate endocarditis. Vegetation size is highly variable, and it has been suggested that large vegetations are related to a more complicated course. The case we present is unusual in that the echocardiographically detected vegetation was very large, highly mobile, and caused severe obstruction of the left ventricular outflow tract, which led to impaction and cardiac arrest.

Background: Primary graft failure from right or left ventricular insufficiency remains a serious cause of early death following heart transplantation. Inhaled nitric oxide (NO) is a potent pulmonary vasodilator that could decrease pulmonary pressure and improve right ventricular function. Methods Two cases of early graft failure following orthotopic heart transplantation were treated with NO inhalation. The treatment consisted of inhalation of 20 ppm of NO, introduced 4 to 6 hours following transplantation, in 2 patients supported with high doses of inotropic agents and vasopressors in addition to the intra-aortic balloon pump. Results In the first and second cases, NO inhalation resulted in a decrease in pulmonary artery pressure, in a decrease in pulmonary vascular resistance and in an increase in cardiac index. In the second patient, systemic oxygenation improved markedly 30 minutes after initiation of NO. In the 2 patients, NO inhalation, mechanical ventilation and the intra-aortic balloon pump were weaned 4 days following transplantation. Conclusion Primary graft failure from donor ischemic damage, reperfusion injury or pulmonary hypertension remains a serious complication. The use of an intra-aortic balloon pump, inotropic agents and of inhaled NO appears to offer the best support for recovery of donor heart function. Primary graft failure from right or left ventricular insufficiency remains a serious cause of early mortality following heart transplantation. 1 Ischemic damage of donor heart, reperfusion injury or pulmonary hypertension are the main causes of early graft failure. Although the cause is multifactorial, treatment of primary organ failure remains difficult with dismal results. The objective of the present study was to review the result of 2 patients with donor right heart failure following heart transplantation treated with inhaled nitric oxide (NO).

Objectives. The purpose of this study was to determine the impact of changes in flow on aortic valve area (AVA) as measured by the Gorlin formula and transesophageal echocardiographic (TEE) planimetry. Background. The meaning of flow-related changes in AVA calculations using the Gorlin formula in patients with aortic stenosis remains controversial. It has been suggested that flow dependence of the calculated area could be due to a true widening of the orifice as flow increases or to a disproportionate flow dependence of the formula itself. Alternatively, anatomic AVA can be measured by direct planimetry of the valve orifice with TEE. Methods. Simultaneous measurement of the planimetered and Gorlin valve area was performed intraoperatively under different hemodynamic conditions in 11 patients. Left ventricular and ascending aortic pressures were measured simultaneously after transventricular and aortic punctures. Changes in flow were induced by dobutamine infusion. Using multiplane TEE, AVA was planimetered at the level of the leaflet tips in the short-axis view. Results. Overall, cardiac output, stroke volume and transvalvular volume flow rate ranged from 2.5 to 7.3 liters/min, from 43 to 86 ml and from 102 to 306 ml/min, respectively. During dobutamine infusion, cardiac output increased by 42% and mean aortic valve gradient by 54%. When minimal flow was compared with maximal flow, the Gorlin area varied from (mean ± SD) 0.44 ± 0.12 to 0.60 ± 0.14 cm2(p Conclusions. By simultaneous determination of Gorlin formula and TEE planimetry valve areas, we showed that acute changes in transvalvular volume flow substantially altered valve area calculated by the Gorlin formula but did not result in significant alterations of the anatomic valve area in aortic stenosis. These results suggest that the flow-related variation in the Gorlin AVA is due to a disproportionate flow dependence of the formula itself and not a true change in valve area. (J Am Coll Cardiol 1997;29:1296–302)

Angiosarcoma of the heart is a rare tumor. This tumor is most frequently located in the right atrium and pericardium. Localization of a tumor in the interatrial septum usually suggests atrial myxoma. We report two cases of angiosarcoma originating from the interatrial septum, one extending into the right atrium and the other into the left atrium, mimicking atrial myxomas. Transesophageal echocardiography allowed the diagnosis and comprehensive assessment of compromised structures.

The purpose of this study was to describe the mechanism and determine predictive factors of mitral valve rupture requiring valve replacement following percutaneous mitral commissurotomy. Of the 350 consecutive patients treated by balloon mitral commissurotomy, the procedure was not completed in 16, and 11 developed acute severe mitral regurgitation requiring valve replacement: seven cases of anterior leaflet rupture, three cases of posterior leaflet rupture and one case of anterior chordal surface. These 27 group I patients were compared to the remaining 323 (group II) in whom the procedure was completed. The 11 excised valves were evaluated by an experienced pathologist. Eight of the 11 patients had an echocardiographic score < 8 (mean score 6.5 +/- 1), no valvular calcification at X-ray and double balloon percutaneous mitral commissurotomy. Microscopy in six patients showed focal fibrous thickening at the site of the rupture but no calcification. One patient developed severe mitral regurgitation due to chordal rupture with an Inoue balloon. The two remaining patients had an echo score of ten and valve calcification on X-ray. Microscopy revealed severe homogeneous chronic rheumatic mitral disease. In one of these two patients, leaflet rupture was related to an 'oversized balloon' (2 x 19 mm + 15 mm). Statistical analysis showed only echo score differences between the two groups (6.9 +/- 1.4 in group I vs 8.2 +/- 1.6 in group II, P < 0.02).(ABSTRACT TRUNCATED AT 250 WORDS)

Of 280 patients treated by balloon mitral commissurotomy (BMC) between 1987 and 1991, 28 (10%) were ≥70 years old. Two patients with associated significant aortic stenosis were excluded from the study. Older patients more often were in New York Heart Association class III or IV (84 vs 67%; p 25% and postmitral valve area >1.5 cm2 was obtained in 16 of the 22 older patients (72%) with the completed procedure (compared with 81% of younger ones; p = 0.1). At 6 months, 20 of the 21 surviving patients (95%) who had not crossed over to surgery had an improvement of ≥1 functional class, and 13% remained improved after a mean follow-up of 28 ± 17 months. Long-term survival of older patients was compared with that of our first 96 younger ones dilated before 1990. The total survival rate at 3 years was 70% in older patients and 92% in younger ones (p < 0.001). Thus, BMC can be an effective therapy for parents aged ≥70 years, but has an increased risk of morbidity and mortality compared with in younger ones. However, the hemodynamic success rate in patients aged ≥70 years with the completed procedure, and the long-term cardiac survival in those with a good initial result are similar to those in younger ones. Therefore, BMC can be performed in older patients with an acceptable risk compared with that of medical treatment or surgery.

Late results after successful percutaneous mitral commissurotomy were assessed by prospective clinical and echocardiographic follow-up. Fiftyseven patients were followed for a mean of 19 ± 6 months (range 9 to 33) after the procedure. Mitral valve area (measured by Doppler half-time method) increased from 1.0 ± 0.2 to 2.2 ± 0.5 cm2 immediately after commissurotomy, and then decreased to 1.9 ± 0.5 cm2 at follow-up (p 50% reduction of initial gain) was seen in 12 of 57 patients (21%). Atrial shunting, detected by transthoracic color Doppler in 61% of patients immediately after the procedure (color flow jet through atrial septum), persisted in 30% at follow-up. Restenosis by univariate analysis correlated with age, smaller valve area after the procedure, and higher echocardiographic score. Multivariate analysis identified leaflet mobility and calcifications as the components of a score that was predictive for restenosis. Magnitude of shunt (pulmonary-to-systemic flow ratio >1.5), use of a Bifoil balloon (2 balloons on 1 shaft), and smaller valve area after the procedure were predictors by multivariate analysis of the persistence of atrial shunting. Clinical improvement persisted at long-term follow-up (mean New York Heart Association class 1.6 ± 0.6 vs 2.6 ± 0.6 before commissurotomy). Improvement of ≥1 functional class was seen in 75% of patients (80% of those without and 58% of those with restenosis); patients with a shunt did not differ from the entire group. Thus, percutaneous mitral commissurotomy provides excellent late (9 to 33 months) clinical results. Echocardiographic restenosis was identified in 20% of patients, and was related to age, valve morphology and a suboptimal result. Atrial shunting (small and clinically well-tolerated) was absent after long-term follow-up in 50% of patients; its persistence was related to the magnitude of the shunt, the size of the deflated balloon, and a suboptimal result.

Among 126 consecutive patients undergoing percutaneous mitral valvuloplasty, 34 were judged to be at high risk for surgery on the basis of age >70 years (n = 13), New York Heart Association functional class IV (n = 11), ejection fraction ≤35% (n = 3), severe pulmonary hypertension (n = 7), need for associated coronary bypass (n = 4) or additional valve surgery (n = 20) or severe pulmonary disease (n = 3). Baseline features of the high risk group were substantially worse than those of the other patients: age (65 ± 11 versus 49 ± 12 years; p = 0.0001) and echocardiographic score (9.4 ± 1.8 versus 8.2 ± 1.5; p = 0.005) were higher, whereas cardiac output (2.9 ± 0.9 versus 4.1 ± 1.2 liters/min; p = 0.0001) and mitral valve area (0.9 ± 0.4 versus 1.1 ± 0.3 mm2; p = 0.002) were lower.Three high risk patients experienced technical failures and three others had major complications. Among the remaining 28 patients, 18 (65%) had a complete hemodynamic success, 4 (14%) an incomplete success and 6 (21%) hemodynamic failure. Stepwise logistic regression analysis retained echocardiographic score as the only factor independently predictive of success. The percent increase in mitral valve area also correlated with echocardiographic score (r = 0.51, p < 0.01). Mitral regurgitation did not change after the procedure in 15 (56%) of 27 patients and increased by one grade in the remaining 12. Atrial shunting was detected by venovenous dye-dilution curves in 71% of the patients, but only 4 (14%) had a pulmonary to systemic flow ratio >1.5. Three patients (9%) died within 48 h of the procedure and by 6 months, three additional patients had died. Twenty (80%) of survivors had improvement by at least one functional class.Thus, in patients at high surgical risk, the risk of percutaneous mitral valvuloplasty is also increased, but is acceptable compared with that of surgery. Although high risk patients have more severe mitral stenosis and less hemodynamic improvement, their clinical status 6 months after valvuloplasty usually is greatly improved.

Retrograde cardioplegia is relatively safe, with a rate of coronary sinus rupture of 0.6%. With the advent of perioperative transesophageal echocardiography, it is now possible to detect and evaluate the extent of damage consequent to the use of retrograde cardioplegia and better formulate an intraoperative course of action. The evolution of these lesions can also be monitored by transesophageal echocardiography during the postoperative period.

Acute anterior wall myocardial infarction is a rare but often catastrophic presentation of ascending aortic dissection. We report the case of a patient who was successfully treated by direct stenting of the left main coronary artery, allowing for definitive surgical correction.

Mechanical prostheses induce artifacts that decrease the accuracy of conventional transthoracic echocardiographic imaging for the detection and quantitation of periprosthetic mitral regurgitation. In 15 patients undergoing transthoracic echocardiography, injection of sonicated albumin significantly enhanced the assessment of periprosthetic mitral regurgitation with an accuracy similar to that of transesophageal echocardiography.

Balloon mitral commissurotomy (BMC) was performed in 113 patients. Of these patients, 27 (24%) (25 women and 2 men, aged 49 ± 13 years) had recurrent mitral stenosis 13 ± 6 years (range 5 to 29) after surgical Commissurotomy. Eleven patients (41%) were considered at high risk for surgery. BMC resulted in an increase in mitral valve area from 1.1 ± 0.3 to 1.9 ± 0.7 cm2 (p < 0.0001), and a decrease in mean mitral gradient from 16 ± 7 to 6 ± 3 mm Hg (p < 0.0001). An optimal result of BMC (increase in valve area ≥25% with a post-BMC valve area ≥1.5 cm2) was obtained in 18 patients (67%). The results did not differ from those observed in the 86 patients of our entire series without prior surgical Commissurotomy. Patients with an optimal result of BMC had a more recent surgical Commissurotomy and lesser morphologic alterations of the mitral valve than did those with a nonoptimal result. Patients with echocardiographic scores

We report 3 patients having a grade II milking effect of the proximal left anterior descending artery (LAD) and suffering from angina. Preoperative myocardial ischemia was demonstrated by stress ECG in all 3 and by pacing and lactates studies in 2. Surgical decompression of the systolically constricted artery has resulted in disappearance of angina, milking, and ischemia. Severe milking of the LAD is a rare entity, probably congenital in origin, capable of producing myocardial ischemia and possibly causing sudden death. More studies regarding its etiology and pathophysiology are necessary. Biopsy of the myocardium surrounding the artery could be useful.

We have studied the natural history of left ventricular aneurysms (LVA) in 40 patients not treated surgically who were followed for a mean period of 5 years, 8 months. These patients have been divided into two groups according to the presence (Group B) or absence (Group A) of significant symptomatology. The causes of death are dominated by arrhythmias and congestive heart failure (CHF). The survival rate at 10 years is 66.7% for the entire group. In asymptomatic patients the 10 year survival rate is 90%, but it is only 46.3% in those who were symptomatic at the time of the initial diagnosis. In general, the clinical course of survivors is stable in Group A but has deteriorated steadily in Group B. Nonfatal complications include arrhythmias (observed in 34% of all patients), thromboembolic phenomena (29%), CHF (29%), and recurrent myocardial infarction (22.5%). Factors influencing prognosis are the extent of the aneurysm, the association of asynergic segments, the ejection fraction of the residual ventricle, the left ventricular end-diastolic pressure (LVEDP), and the presence of ventricular extrasystoles at the time of diagnosis. The mere presence of aneurysm is not, in itself, an indication for operation. Incapacitating angina and refractory CHF are the most valuable indications for surgical resection. The question is raised as to the value of operation in patients with little or no symptoms, in those with isolated life-threatening arrhythmias, and in those in whom a mural thrombus is the only distressing feature.

It has been a standard practice during selective coronary angiography to obtain multiple angulated views of the coronary vessels in a single transverse plane.These views usually provide an excellent definition of the longitudinally oriented right coronary artery and middle and distal segments of the left coronary artery. However, the proximal branches of the left coronary artery are more transversely oriented and can be parallel to the axis of the x-ray beam in this plane of rotation. This results not infrequently in superimpositions and incomplete tangential views of these segments. Therefore, stenoses in these areas can be overlooked or underestimated.We have found that these difficulties can be overcome, in most instances, by the systematic use of additional views in a sagittal plane, angulated approximately 25° either in a cranial or caudal direction or both.

Of 5,250 patients undergoing coronary arteriography over a 5 year period, 27 (0.51 percent) had an intramyocardial segment of the left anterior descending coronary artery producing a milking effect or constriction of the artery during systole. Of these, 11 patients with otherwise normal coronary arteries were studied. Hemodynamic data, coronary sinus blood flow and myocardial lactate extraction were measured during atrial pacing at rates of 120 and 150 beats/min and during a 60 watt supine ergocycle exercise test. The degree of narrowing of the left anterior descending coronary artery during systole was graded 3 (greater than 75 percent), 5 patients; 2 (50 to 75 percent), 4 patients; and 1 (less than 50 percent), 2 patients. Four patients with a grade 3 milking effect had S-T depression in the electrocardiogram indicating anterior wall ischemia and lactate production during pacing at 149 ± 2 (mean ± standard error of the mean) beats/min. Three patients had severe angina during pacing. Two patients with a grade 2 milking effect had angina-like chest pain and electrocardiographic changes during pacing at 150 beats/min. However, lactate extraction was unchanged during pacing. Two patients with a grade 1 milking effect had no angina and no electrocardiographic or metabolic abnormalities. Coronary sinus blood flow increased significantly with pacing and ergocycle exercise in all patients (rest 118 ± 8 ml/min; pacing at 150 beats/min 219 ± 27 ml/min; ergocycle exercise 251 ± 17 ml/min) (P < 0.001). We conclude that a grade 3 milking effect observed at coronary arteriography can result in significant obstruction of the left anterior descending coronary artery with typical angina and anterior wall ischemia during tachycardia. Surgical periarterial muscle resection or bypass of the left anterior descending coronary artery might be considered in symptomatic patients with this rare anomaly.

The increased exercise capacity after physical training in patients with coronary artery disease has been attributed to improved oxygen supply to the myocardium by way of increased collateral circulation or reduction of myocardial oxygen consumption by extracardiac factors, or both. Fourteen patients aged 43 to 61 years (mean 51 years) with 50 percent or greater obstruction in one, two or three vessels (three, six and five patients, respectively) underwent 13 months of physical training. Clinical status was either stable or improved with training. Treadmill exercise capacity, as measured by oxygen consumption, increased 25 percent from 21.9 ± 4.8 (standard deviation) to 27.4 ± 4.1 ml/kg-min at heart rates of 154 ± 17 and 156 ± 12 beats/min, respectively. After training, new collateral vessels, apparently secondary to progression of the disease, were observed in 2 of 21 arteries significantly but not completely obstructed before training. These data are in contrast to those reported for trained dogs with incomplete obstruction. Coronary arterial lesions progressed in only 4 of 14 patients. Coronary arteriographic data from this laboratory do not support the hypothesis that the increased exercise capacity after training in patients with coronary disease can be attributed to the development of collateral circulation. It is possible that physical training may retard the progression of coronary artery disease.

In the field of echography, there is a large interest for the diagnostic potential of textures or speckle patterns encountered in echographic B-scan images. In this work, we present a new approach to this problem. We study the capability and the diagnostic value of a method to extract parameters describing tissue dynamics by tracking myocardial speckle pattern motion during the cardiac cycle. Such speckle motion is shown to be closely related to the myocardial tissue dynamics and therefore should be of diagnostic significance. A model was previously developed to generate typical B-scan images of the myocardium during the cardiac cycle. We appropriately modified the tissue parameters in our model to simulate the deformations happening during cardiac contraction (translation, wall thickening, fiber contraction, rotation etc.). The resulting simulated speckle pattern motion was then studied. An optical flow algorithm developed in our laboratory was successfully used to quantify this motion as a velocity field described by a set of linear equations. The correlation between this velocity field and the myocardial deformation was clearly established from the model for small deformation rates. In practice, the time interval between echographic frames (1/30 second) was expected to be adequate for only small tissue deformations to occur between frames; we could thus expect our method to be successful with real echocardiographic data. Clinical data studied with this procedure have indeed confirmed that velocity field could be obtained from myocardial speckle tracking; this allowed to characterize quantitatively the myocardial dynamics, in particular with respect to local wall thickening and myocardial contraction during the cardiac cycle. Those results indicate a potential for speckle tracking as a diagnostic tool to study myocardial deformation and contractility.

Twenty-one cases of echocardiographically visible mitral annulus calcification have been reviewed. Seventeen of these were also visible on chest radiographs, the remainder were proved by fluoroscopy. Factors which may lead to diagnostic confusion are: (a) failure to identify the posterior mitral leaflet (7/21); (b) diminished anterior leaflet mobility (mean 15 mm); (c) accoustic shadowing of the left ventricular wall (18/21); (d) pseudosystolic anterior motion. Fifteen of the 21 patients had aortic stenosis.

A retrospective study was carried out in 114 unoperated and 197 operated patients having left main coronary artery (LMCA) stenosis greater than or equal to 50%. Including the operative mortality of 9.1%, survival at seven years was significantly greater following pure aortocoronary bypass graft surgery, 77.5% as compared to 48.5% for the unoperated patients (P less than 0.01). The surgical mortality was significantly less during the last five years (1972-1976), 6.2% as compared to 17% during 1969-1971 (P less than 0.025). The three year survival in patients operated since 1972 was 90.2% as compared to 60.4% for unoperated patients. Survival remained significantly higher in the operated patients when studied as subsets on the basis of the severity of the LMCA stenosis (less than 70% as opposed to greater than or equal to 70%), and on the extent of associated obstructive disease of major coronary arteries (0-1 versus 2-3 arteries). It was significantly higher, however, only in operated patients with associated stenosis greater than or equal to 70% of the right coronary artery. Survival was higher following surgery only when the ejection fraction was at least 0.45, or the left ventricular end-diastolic pressure below 20 mm Hg.

Left ventricular size following endurance, sprint, and strength training. Med. Sci. Sports Exercise, Vol. 14, No. 5, pp. 344-347, 1982. Left ventricular dimensions in adolescent boys were determined before and after three types of training regimens: endurance (END), N = 8, means = 16.8 yr; sprint (SPR), N = 8, means = 16.3 yr; strength (STR), N = 12, means = 18.7 yr. With training the END group significantly increased VO2max in 1 X min-1 (3.71 +/- 0.27 to 4.16 +/- 0.57, P less than 0.05) and in ml X min-1 X kg-1 (58.4 +/- 5.6 to 64.2 +/- 5.5, P less than 0.05). The SPR group increased VO2max in 1 X min-1 (3.63 +/- 0.63 to 3.98 +/- 0.78, P less than 0.05) but not in ml X min-1 X kg-1 (59.5 +/- 4.1 to 63.2 +/- 5.4) because body weight increased from 61.2 +/- 10.5 to 63.1 +/- 10.7 kg (P less than 0.05) with no change in percent body fat. The STR training group significantly improved upper body strength. Despite these specific training adaptations no significant modifications were found for interventricular and left ventricular posterior wall thickness or for left ventricular internal diameter in either training group. However, calculated left ventricular mass was slightly but significantly higher by 10% and 4% in the END and STR training groups, respectively. These small increases in calculated left ventricular mass with short-term training are probably caused by small but insignificant increases in left ventricular internal diameter secondary to a training bradycardia (END group: 76 +/- 8 to 64 +/- 1 beats X min-1) and to increased diastolic filling time rather than to true cardiac hypertrophy. Significant increases in aerobic capacity and in strength can occur without modification of left ventricular dimensions.