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We report a case of tako-tsubo cardiomyopathy, complicated by left ventricular apical thrombus. [ABSTRACT FROM AUTHOR]

An abstract of the article "Comparison among different intraventricular asynchrony indices to predict revese remodelling after cardiac resynchronization therapy (crt)," by L. Ascione and colleagues is presented.

An abstract of the article "Ultrasonographic assessment of coronary flow reserve to predict significant left anterior descending artery stenosis in patients with inferior acute myocardial infarction" by L. Ascione, S. Rumolo and M. Accadia is presented.

An abstract of the article "Impact of acute hyperhomocysteinemia on coronary flow reserve in healthy adults" by L. Ascione and colleagues is presented.

Introduction: We evaluated whether the dobutamine stress-echo test can select responders to cardiac resynchronization therapy (CRT). Up to 50% of patients do not respond to CRT. Lack of response may be due to a significant amount of scar or fibrotic tissue at myocardial level., Methods and Results: We studied 42 CRT patients. After clinical and echocardiographic evaluation, all patients underwent a dobutamine stress-echo test to assess contractile reserve. Cut-off for the test was an increase of 25% of the left ventricular ejection fraction. Patients were implanted with a CRT-defibrillator and followed up at 6 months. Cut-off for CRT response was a reduction of 15% of left ventricular end-systolic volume. Twenty-five patients responded to CRT; all of them showed presence of contractile reserve. The test showed a sensitivity of 100% and a specificity of 88%., Conclusion: Contractile reserve was a strong predictive factor of response to CRT in the studied population.

Background: The aim of this study was to evaluate whether in patients with ischemic heart failure (HF) with mechanical dyssynchrony the echocardiographic assessment of the extent of scarred ventricular tissue by end-diastolic wall thickness (EDWT) could predict reverse remodeling (RR) after cardiac resynchronization therapy (CRT). Recent studies using cardiac magnetic resonance imaging have shown that the burden of myocardial scar is an important factor influencing response to CRT, despite documented mechanical dyssynchrony. EDWT assessed by two-dimensional (2D) resting echocardiography is a simple and reliable marker to identify scar tissue in patients with ischemic left ventricular dysfunction., Methods: Seventy-four patients with ischemic HF were evaluated 1 week before and 6 months after CRT. Inclusion criteria were New York Heart Association class III or IV, ejection fraction < 35%, QRS duration > 120 ms, and mechanical intraventricular dyssynchrony >/= 65 ms. The left ventricle was divided into 16 segments; left ventricular (LV) segments with EDWT < 6 mm were considered scarred. Percentage global scar area (GSA) was calculated by dividing the number of scarred LV segments by 16., Results: RR, defined as a reduction of LV end-systolic volume >/= 15%, was found in 38 patients (51.4%) with ischemic HF. A significant inverse linear relationship was found between GSA and RR (r = -0.57; P = .0001). Mean percentage GSA was significantly higher in nonresponders (31.6 +/- 18% vs 6.4 +/- 11%; P < .001). GSA

Background: Cardiac mechanical efficiency requires that opposing left ventricular regions are coupled both in shortening and lengthening during the same phase of cardiac cycle. Aim of this study was to evaluate whether global measures of mechanical dyssynchrony are able to predict reverse remodeling of the left ventricle in patients receiving cardiac resynchronization therapy (CRT)., Methods: Sixty-two patients underwent a clinical examination, including New York Heart Association class evaluation and 6-minute walking distance and both echocardiographic study before and 6 months after CRT. Intraventricular dyssynchrony was evaluated by two-dimensional strain echocardiography, measuring the amount of uncoordinated contraction and relaxation between septum and free wall for both longitudinal and radial function and was presented as the longitudinal global dyssynchrony index (LGDI) and the radial global dyssynchrony index (RGDI). Reverse remodeling was defined by a left ventricular end systolic volume reduction >or= 15%., Results: After CRT 39 patients showed reverse remodeling. In this group, RGDI (0.74 +/- 0.26 vs 0.32 +/- 0.30; P = 0.0001) and LGDI (0.52 +/- 0.28 vs 0.30 +/- 0.24; P = 0.002) were significantly higher than in nonresponders. A receiver-operating characteristic curve analysis showed that RGDI >0.47 and LGDI >0.34 had a sensitivity and a specificity to predict reverse remodeling of 87% and 74%, 82%, and 74%, respectively. Stepwise forward multiple logistic regression analysis showed that RGDI (O.R.:13.4; 95%C.I.:4.2-120.5; P < 0.0001) was an independent determinant of a positive response to CRT., Conclusion: A radial global dyssynchrony index predicts left ventricular reverse remodeling after CRT.

Objective: To evaluate the impact of multiple cardiovascular risk factors on coronary flow reserve (CFR) in a large patient population with acute chest pain referred for coronary angiography., Methods: Three hundred and ninety-four consecutive patients (mean age 59 +/- 10 years) were enrolled in the study. Blood flow velocity was measured, using transthoracic echocardiography, in the middle-distal tract of the left anterior descending coronary artery (LAD) at rest and during infusion of high-dose dipyridamole in 6 min. CFR was calculated as the ratio of hyperaemic to basal peak diastolic flow velocity. All patients underwent coronary angiography within 48-72 h of CFR evaluation and a LAD stenosis was considered significant for lumen diameter narrowing > or =70%., Results: Out of 394 patients, 11 patients (3%) were excluded because of inadequate quality of the spectral Doppler envelope. In the group of 269 patients with LAD stenosis <70%, CFR was significantly reduced in 64 patients with >2 risk factors compared to 205 patients with < or =2 risk factors (2.24 +/- 0.48 vs. 2.52 +/- 0.53, P < 0.005). On multiple logistic regression analysis, age, hypertension and diabetes mellitus were related to reduced CFR. In 114 patients with significant LAD disease, CFR was not reduced in patients with multiple cardiovascular risk factors. On multiple logistic regression analysis, the percentages of stenosis and diabetes mellitus were independent determinants of CFR., Conclusions: In patients with acute chest pain, the occurrence of multiple cardiovascular risk factors adversely affected CFR in an additive manner, in absence of significant angiographic stenosis. Diabetes mellitus was a powerful coronary risk factor decreasing CFR both in patients with or without significant LAD disease.

A 60-year-old woman with severe chest pain and ECG diagnostic for acute transmural ischemia was transferred to cath lab for primary PTCA. After procedure, transesophageal echocardiography (TEE) views revealed an intramural haematoma extending from the ostium of the RCA throughout the sino-tubular junction. These findings and the stable clinical conditions of patient guided us to a conservative therapeutic approach. A TEE study, performed 5 days after admission, showed a complete resolution of intramural haematoma. A waiting strategy can be a valid therapeutic option in selected patients with iatrogenic haematoma and TEE is a useful diagnostic tool for clinical decision making.

Objective: Coronary blood flow exhibits a biphasic pattern at rest with a higher diastolic and a smaller systolic component. In the present investigation, we evaluated whether a decreased diastolic to systolic velocity ratio of basal coronary flow may be useful in the identification of subjects with significant left anterior descending coronary artery (LAD) stenosis., Methods: One hundred and twenty-nine consecutive patients (62 with unstable angina, 25 with acute myocardial infarction and 42 with chronic coronary artery disease) were included in the study. Blood flow velocities were recorded in the mid-distal portion of the LAD using an ATL 5000 CV HDI ultrasound system. All patients underwent coronary angiography and were divided into two groups according to the absence (group 1) or the presence (group 2) of significant LAD stenosis (lumen narrowing > or = 70%). In 60 of the 129 patients, coronary flow reserve was evaluated non-invasively., Results: Adequate Doppler recordings in the LAD were obtained by transthoracic echocardiography in 113 patients. There were no differences between groups with regard to sex, cardiovascular risk factors, left ventricular mass and volumes, ejection fraction, whereas the diastolic to systolic velocity ratio of basal coronary flow was significantly lower in group 2 patients (1.41 +/- 4.7 vs. 2.08 +/- 0.64, P < 0.00001). The receiver operating characteristic curve showed that a diastolic to systolic velocity ratio < 1.6 had a sensitivity of 77%, a specificity of 91%, a positive predictive value of 77%, a negative predictive value of 97%, and a diagnostic accuracy of 84% for the presence of significant LAD stenosis. In 55/60 patients, results of basal coronary flow and coronary flow reserve were concordant. On multivariate logistic regression analysis, the diastolic to systolic velocity ratio was a strong independent predictor of LAD stenosis > or = 70% (odds ratio 4.90, 95% confidence interval 1.65-7.30)., Conclusions: The present findings suggest that assessment of basal coronary flow in the LAD may be useful to rule out the presence of significant stenosis.

Background: B-mode ultrasound studies indicate that hyperhomocysteinemia is associated with preclinical structural and functional arterial abnormalities. This study was designed to evaluate the effect of elevated plasma homocysteine levels on coronary flow reserve (CFR)., Methods: A total of 20 healthy subjects aged 41 +/- 7 years were studied on 2 separate days, a week apart, before and after methionine load (100 mg/kg of body weight) or placebo in a double-blind crossover study. At each visit, homocysteine levels were measured by high performance liquid chromatography and CFR was determined by transthoracic Doppler echocardiography., Results: After methionine load, plasma homocysteine increased from 10.7 +/- 2.8 mumol/L to 30.4 +/- 5.1 mumol/L ( P < .0001) and CFR decreased from 3.0 +/- 0.4 to 2.3 +/- 0.3 ( P < .001). CFR was inversely related to postload homocysteine levels ( r = -0.21, P = .02). After placebo, there was no change in CFR., Conclusion: In asymptomatic adults, acute hyperhomocysteinemia is associated with a significant reduction in CFR.

We report a case of idiopathic hypereosinophilic syndrome in a young man, who showed symptoms and electrocardiographic findings mimicking an acute coronary syndrome. Two-dimensional echocardiography, together with laboratory data, allowed us to make the diagnosis and to start a treatment with imatinib mesylate, a 2-phenylamonopyrimidine-based tyrosine kinase inhibitor, which reversed the cardiac abnormalities.

Background: Regurgitant orifice area (ROA) has been proposed as a marker of severity in patients with mitral regurgitation (MR). However, such fundamental quantitative echocardiographic parameter has failed to achieve widespread use, since it is difficult to measure. In the present study, we evaluated the accuracy and feasibility of a simplified method for quantification of ROA in patients with varying grades of MR., Methods: We studied two groups of individuals with echocardiographically diagnosed MR. Group I included 70 patients retrospectively evaluated, in whom we were able to obtain an adequate flow convergence region by color Doppler and recording of continuous-wave Doppler regurgitant jet. Group II included 32 MR patients prospectively evaluated. The degee of MR was assessed by two quantitative echocardiographic measures: the regurgitant fraction and the ROA, calculated either dividing peak flow rate by the maximal velocity through the orifice or with the simplified formula: r2/2., Results: In group I, the mechanism of MR was organic in 18 patients and ischemic/functional in 52 patients. ROA calculated by the simplified formula correlated well with the conventional one (r = 0.85) and with the regurgitant fraction (r = 0.72). In group II, we could calculate the ROA by the conventional method in 56% of patients, whereas use of the simplified approach allowed ROA evaluation in 78% of patients., Conclusion: Our data suggest that the use of a simplified formula may increase the number of patients having ROA, a fundamental parameter of MR severity, measured in clinical practice.

Objective: We sought to assess the ability of a Doppler index of global myocardial performance (MPI), measured at entry, to predict inhospital cardiac events in a series of patients with first acute myocardial infarction (AMI)., Methods: A complete 2-dimensional and Doppler echocardiographic examination was performed within 24 hours of arrival at the coronary care department in 96 patients (81 men and 15 women; mean age 58 +/- 9 years) with first AMI. Patients were divided a posteriori into 2 groups according to their inhospital course: group 1 comprised 75 patients with an uneventful course and group 2 comprised 21 patients with a complicated inhospital course (death, heart failure, arrhythmias, or post-AMI angina)., Results: There were no significant differences between the 2 groups with regard to history of hypertension, diabetes mellitus, hypercholesterolemia, site and size of infarction, and conventional parameters of diastolic function. However, patients with complications were significantly older (63 +/- 10 vs 55 +/- 8 years, P =.005) and had higher wall-motion score index and left ventricular end-systolic volume compared with patients without events (1.84 +/- 0.27 vs 1.52 +/- 0.30, P =.001; and 66 +/- 29 vs 47 +/- 21 mL, P =.009, respectively), whereas the ejection fraction was reduced (40 +/- 10% vs 52 +/- 10%, P =.0001). The mean value of the MPI was significantly higher in patients with cardiac events than in those without events (0.65 +/- 0.20 vs 0.43 +/- 0.16, P =.0001). A MPI >/= 0.47 showed a sensitivity of 90% and specificity of 68% for identifying patients with events, on the basis of the receiver operator curve. In a multivariable model, the MPI at admission remained independently predictive of inhospital cardiac events (odds ratio 15.6, 95% confidence interval 2.4-99, P =.003)., Conclusion: These data suggest that in the acute phase of AMI, the MPI measured at entry may be useful to predict which patients are at high risk for inhospital cardiac events.

We present an unusual case of painless acute aortic dissection with an atypical echocardiographic presentation that could be confused with an aortic stenosis. Transesophageal echocardiography excluded the presence of aortic stenosis and disclosed a systolic anterior movement of the mitral valve as the cause of left ventricular outflow tract obstruction. It also revealed a type A aortic dissection.

Background: The aim of this study was to evaluate if dipyridamole-atropine stress echocardiography (DASE) performed between the third-fifth day in uncomplicated acute myocardial infarction allows for an effective risk stratification with an early discharge in some cases., Methods: Between February 1997 and September 1998, 190 patients (138 males and 52 females, mean age 59 +/- 10.3 years), with acute myocardial infarction, were enrolled in the study. DASE was performed between the third-fifth day with a dipyridamole infusion of 0.84 mg/kg over 10 min followed by 1 mg of atropine from the twelfth to the fifteenth minute. DASE was considered positive in the presence of a new or worsening dyssynergy. Patients with heart failure, angina, major arrhythmias, and poor acoustic window were excluded. In the follow-up spontaneous events were defined as cardiac death, non-fatal myocardial reinfarction, unstable angina or heart failure (with hospitalization)., Results: DASE was performed in 92 patients (48.4%), all without complications: 29 patients (31.5%) had a negative DASE result, and 63 patients (68.5%) had a positive DASE. The average hospital stay of patients with a negative test was significantly lower in comparison with that of patients with a positive test (7.55 +/- 1.32 vs 9.29 +/- 1.61 days, p < 0.0001). Events occurred in 19 patients (20.6%), 2/29 patients with a negative DASE (6.9%), 17/63 patients with a positive DASE (27%), 6/43 patients with homozonal positivity after atropine or high-dose dipyridamole (14%), 11/20 patients with heterozonal positivity or homozonal positivity after low-dose dipyridamole (55%). On univariate analysis the variables significantly associated with spontaneous events were: age (chi 2 = 6.41, p = 0.019), left ventricular ejection fraction at rest (chi 2 = 8.89, p = 0.004), number of asynergic segments after stress (chi 2 = 6.87, p = 0.010), increase in the number of asynergic segments after stress (chi 2 = 4.01, p = 0.039), wall motion score index after stress (chi 2 = 9.60, p = 0.003), increase in wall motion score index after stress (chi 2 = 3.60, p = 0.049), DASE positivity (chi 2 = 4.89, p = 0.029), homozonal positivity after low-dose dipyridamole (chi 2 = 8.57, p = 0.013), heterozonal positivity (chi 2 = 13.10, p = 0.001). On Cox's multivariate analysis independent predictors of events were: age (relative risk 3.92, p = 0.0146), DASE positivity (relative risk 1.79, p = 0.0054)., Conclusions: DASE between the third-fifth day in uncomplicated acute myocardial infarction is feasible, tolerable, safe, and effective for early risk stratification. A negative DASE detects a "very low-risk" patient group, and allows for an earlier hospital discharge, without an increased risk of events. The heterozonal positivity or the homozonal positivity after low-dose dipyridamole indicates the need for a coronarography, due to the high risk of events at follow-up.

We describe an unusual case of a 51-year-old woman affected with familial non-obstructive cardiomyopathy and syncopal vasospastic angina. The use of hyperventilation stress-echo testing, recommended by the authors because of its simplicity and safety, was decisive in showing the causal role of coronary spasm of the left anterior descending artery. The coronarography had not shown obstructive lesions of the coronary arteries, but during the procedure the patient had refused ergonovine or acetylcholine injections.

Background: Hypertensive patients with left ventricular hypertrophy can be affected with angina pectoris for significant epicardial coronary stenosis or microvascular disease with normal coronarography. Exercise-electrocardiography test is positive in both conditions. The aim of the present study was to assess the accuracy of dipyridamole-echocardiography test and thallium exercise myocardial scintigraphy in the diagnosis of epicardial coronary stenosis or microvascular disease in hypertensive patients with left ventricular hypertrophy and angina pectoris., Methods: Forty-two hypertensive patients (22 males, age 40-76 years, mean 58.6 +/- 10.1), with left ventricular hypertrophy, typical angina pectoris, ischemia that can be induced by exercise-electrocardiography test, without previous myocardial infarction, myocardial revascularization or diabetes mellitus, underwent dipyridamole-echocardiography test, thallium exercise myocardial scintigraphy and coronarography. Dipyridamole-echocardiography test was performed with dipyridamole (0.56 mg/kg over 4 minutes, followed by 0.28 mg/kg from the 8th to the 10th minute) + atropine (1 mg from the 12th to 15th min.) and was positive for a transient dyssynergy of contraction of at least 2 myocardial segments; the left ventricle was divided into 16 segments. SPECT thallium myocardial scintigraphy was performed after bicycle exercise and then three hours later, and it was positive for reversible uptake defects of at least 2 segments with a 22-segment model. Coronarography was performed with Judkin's technique and was positive if at least one large epicardial vessel was narrowed by more than 50%., Results: Coronarography: normal in 25 cases (59.5%, 8 males), pathologic in 17 (40.5%, 14 males): left main coronary artery in 1 (5.9%), three vessels in 5 (29.4%), two vessels in 3 (17.7%), 1 vessel in 8 (47%). Dipyridamole-echocardiography-test: positive in 15 cases (35.7%), negative in 27 (64.3%); sensitivity 88.2%, specificity 100%, diagnostic accuracy 95.2%, positive predictive value 100%, negative predictive value 92.6%. Thallium exercise myocardial scintigraphy: positive in 30 cases (71.4%), negative in 12 (28.6%); sensitivity 100%, specificity 48%, diagnostic accuracy 69%, positive predictive value 56.7%, negative predictive value 100%., Conclusions: Dipyridamole-echocardiography test has higher diagnostic accuracy and when positive, it predicts significant epicardial coronary stenosis. It can be less sensitive in one-vessel patients (2 false negatives were stenosis 75% of left anterior descending and 60% of 1st diagonal). Thallium exercise myocardial scintigraphy is complementary because when negative, it excludes epicardial coronary stenosis and confirms microvascular disease. In hypertensive patients with left ventricular hypertrophy and suspected angina pectoris, the following flow-chart may be proposed: the first test is exercise-electrocardiography test. Only those who are positive at low-to-intermediate workload then undergo dipyridamole-echocardiography test. Those who are positive in this then undergo coronarography, while the negative ones undergo thallium exercise myocardial scintigraphy. Those who are positive at thallium exercise myocardial scintigraphy perform the coronarography, while cases with negative results do not undergo further diagnostic tests since they are affected with microvascular disease.