Search

Purpose As growing numbers of long-term cancer survivors faced with the cardiac side effects by anthracycline treatment, it is necessary to explore the optimal monitoring method for the early detection of cardiac toxicity. Methods We conducted a retrospective analysis of 82 consecutive patients with diffuse large B-cell lymphoma treated with chemotherapy. Echocardiographic Doppler imaging-derived Tei index and mitral annular peak systolic velocity (Sm) measured by tissue Doppler imaging TDI, serum high-sensitivity cardiac troponin T (hs-cTnT) levels, and left ventricular ejection fraction (LVEF) by multigated radionuclide angiography (MUGA) were obtained before, after 2–4, and after 6–8 chemotherapy cycles. Cardiotoxicity was defined as a relative reduction of LVEF ≥10% from the baseline or LVEF

Summary Purpose Estimation of left ventricular ejection fraction (LVEF) with 99MTc-HSA equilibrium radionuclide angiography (RA) is frequently used for assessing cardiac function. The purpose of this study was to investigate the interstudy repeatability of left (LV) and right (RV) ventricular volume and ejection fraction estimations, using a cadmium-zinc-telluride (CZT) SPECT camera. Materials and methods Forty-six patients were scanned twice, interrupted by repositioning. Each acquisition was analysed twice by two experienced technologists. Interstudy and interobserver variations were calculated as the coefficient of variation (CV) and the 95% confidence interval (CI) for limits of agreement (LOA) between each sequence of analyses for each of the two acquisitions. Results The Interstudy variations and 95% CI for LVEF, LV end systolic (LVESV) and end diastolic (LVEDV) volumes were 4·6% (−5·4 to 6·4), 9·3% (−6·90 to 5·20) and 7·0% (−13·9 to 11·1), respectively. For the right ventricle, the corresponding values were 11·9% (−9·40 to 10·8), 9·8% (−14·9 to 10·8) and 8·1% (−20·7 to 16·3). Discussion The CZT detector camera has excellent reproducibility with regard to interstudy variation when assessing LV volumes and EF. Interstudy variation is considerably higher for RV volumes and EF, indicating a lack of consistency in tracing the boarders of the right ventricle.

Background: The objective of this meta-analysis was to evaluate the efficacy of the metabolic agent trimetazidine (TMZ) as monotherapy in the treatment of stable angina pectoris, from echocardiography and radionuclide angiography data. Hypothesis: Treatment with TMZ proved to be as effective as other first-line antianginal agents for coronary patients, and it provided additional efficacy in combination with hemodynamic agents. Methods: A search of the literature published between 1965 and 2008 was performed on the MEDLINE and EMBASE databases. Only randomized, controlled trials were included in this meta-analysis. Patients had to be treated for at least 2 weeks with data on the following 4 parameters at baseline and at the end of the treatment period: left ventricular ejection fraction (LVEF), LV end-diastolic volume (LVEDV), LV end-systolic volume (LVESV), and wall motion score index (WMSI). The quality of the trials was assessed by the Jadad score. Results: Eleven clinical studies meeting our criteria were analyzed. Results showed that TMZ significantly improved LVEF, with a mean increase of 6.88% (95% confidence interval [CI]: 5.50–8.25), and significantly reduced LVESV by 11.58 mL (95% CI: 5.79–17.37) and WMSI by 0.23 (95% CI: 0.07–0.38). Changes in LVEDV were variable. In both the long term and the short term, TMZ can improve LV function. The efficacy was unchanged in patients with diabetes mellitus. Conclusions: This meta-analysis confirmed the efficacy of TMZ monotherapy in improving LV function compared with placebo. © 2011 Wiley Periodicals, Inc. The authors have no funding, financial relationships, or conflicts of interest to disclose.

Aim: Measurement of left ventricular ejection fraction (LVEF) using real time 3D echocardiography (3DE) has been performed in subjects with preserved or modestly reduced systolic function. Our aim was to evaluate this technique in the subset of patients with severe systolic dysfunction. Methods and results: Consecutive patients with LVEF less than 0.35 at two-dimensional echocardiography were included. LVEF obtained by 3DE was compared to the value measured by radionuclide angiography (RNA). Real time full-volume 3DE was performed, with offline semiautomated measurement of LVEF using dedicated software (Cardioview RT, Tomtec) by a single observer blinded to the results of RNA. A total of 50 patients were evaluated, of whom 38 (76%, 27 males, age 69 ± 13 years) had a 3DE of sufficient quality for analysis. LVEF for this group was 0.21 ± 0.07 using 3DE and 0.27 ± 0.08 using RNA. The agreement between the two techniques was rather poor (r = 0.49; P < 0.001; 95% limits of agreements of −0.20 to 0.09). Truncation of the apex was observed in 6 of 38 (16%) patients. Conclusion: In patients with severe systolic dysfunction, 3DE shows poor agreement for measurement of LVEF as compared to RNA. There may be underestimation of up to 20% in absolute terms by 3DE. Accordingly, the two methods are not interchangeable for the follow-up of LV function. A limitation of 3DE may, at least in part, be related to the incomplete incorporation of the apical region into the pyramidal image sector in patients with dilated hearts. (Echocardiography 2010;27:58-63)

Arrhythmogenic right ventricular dysplasia causes ventricular arrhythmias and sometimes heart failure. The condition is easily overlooked, but once suspected, it may be diagnosed non-invasively. This is illustrated by the case reported. The clinical features of this syndrome are discussed, with special emphasis on the non-invasive findings.

Mean transit time (MTT) through a given vascular space is closely related to the effective blood volume in this compartment. Central vascular blood volume in liver cirrhosis is believed to be reduced, but more precise data on the location of the underfilled vascular area are lacking. 99mTechnetium first-pass angiography was performed in 15 cirrhotic patients and in 10 age-matched normals. The method of segmental analysis of MTT was validated by performing an analog study in a plastic tubing/chamber system. The mean tracer sojourn in the central circulation was described in cirrhotic patients (10.25 +/- 2.17 s vs 12.92 +/- 2.88 s; p less than 0.05); however, this finding was not observed beyond cardiopulmonary circulation (MTT between right and left heart chambers). Segmental comparative analysis between cirrhotics and normals revealed significant MTT differences in two vascular subcompartments, i.e. right chamber-pulmonary artery, and within the lung vascular bed. Analysis of time activity lung curves in patients with cirrhosis disclosed a shorter time to peak and more rapid washout of the tracer from this area, without any change in curve symmetry as compared to normals. Ascites had no apparent impact on MTT rate, and cirrhotics with most advanced disease (grade C Child-Pugh) had longer MTT through the cardiopulmonary circulation as compared to combined groups A & B (7.32 +/- 0.13 s vs 6.03 +/- 1.23 s; p less than 0.05). Our data provide further evidence for contraction of the cardiopulmonary vascular space in liver cirrhosis.

Anthracycline-related cardiotoxicity has a substantial negative impact on long-term survivors of childhood cancer. The detection of cardiotoxicity is currently based on echocardiography or radionuclide angiography. However, as they depict only the final outcome of myocardial injury in terms of reduced heart contractility, heart specific biomarkers of myocardial destruction or dysfunction could be advantageous by allowing for an earlier detection of cardiotoxicity. In the present study, the usefulness of cardiac troponins and natriuretic peptides, the most commonly used biomarkers of myocardial destruction and ventricular dysfunction respectively, to detect and to predict the development of anthracycline cardiotoxicity has been reviewed.

Background: Although it is well known that left ventricular (LV) function improves after treatment with beta-blockers in heart failure, little attention has been paid to the effects on LV long axis (LAX) function. Aims: To evaluate LV LAX function after treatment with metoprolol, and to assess whether LV LAX contractile reserve could predict future long-term improvement. Methods: Twenty-four heart failure patients were randomised to metoprolol or placebo for 6 months, followed by 6 months of open treatment with metoprolol. Rest and dobutamine stress echocardiography (DSE) was performed before and after each treatment period. Results: After treatment with metoprolol, LV LAX function improved significantly, systolic velocity from 29±8 to 32±15 mm/s, p

Although tissue Doppler (TD) imaging of the left ventricle is now commonly used in clinical settings, TD imaging of the right ventricle (RV) is not routinely practiced. Yet, there are significant data on clinical uses of RV TD imaging, including established normal values using both color and spectral TD. In acute left ventricular (LV) inferior wall myocardial infarction, depressed RV TD velocities have been shown to correlate with the presence of RV impairment, and with patient outcome. In patients with LV heart failure, TD imaging has been correlated to RV ejection fraction by radionuclide angiography, and is an independent predictor of outcome. In patients with congenital heart disease, RV TD has been especially valuable for assessing RV function, and has been correlated to invasive hemodynamic indices, and RV ejection fraction by magnetic resonance imaging. The RV performance (Tei) index has been calculated and validated using TD-derived, rather than conventional pulsed Doppler time intervals. RV TD indices have been shown to be useful in the detection of subclinical and clinical disease in morbid obesity, chronic pulmonary, and systemic disease. TD-derived RV strain imaging can detect segmental myocardial dysfunction, overcoming limitations to conventional TD imaging resulting from tethering. For both TD velocity and strain imaging, however, appreciation of the limitations of these techniques is necessary for their appropriate use. Given its rapid acquisition times, reproducibility, and ease of addition to standard transthoracic echocardiographic protocols, RV TD and strain imaging are important additional modalities in the comprehensive echo-Doppler assessment of RV function.

Giant cell arteritis occurs mainly in the cranial arteries, especially in the temporal area, and rarely in the coronary arteries. Here, we present a case of coronary artery giant cell arteritis in a 51-year-old woman who complained of atypical chest pain. Radionuclide angiography showed dilated left ventricle with global hypokinesia. Despite medical treatment, she suffered progressive heart failure and finally was given a heart transplant. The pathologic examination revealed myocardial infarction due to coronary giant cell arteritis. Unusual giant cell arteritis should be considered in the differential diagnoses of myocardial infarction.

Summary Objective Increased risk of cardiovascular disease has been reported in patients with primary hyperparathyroidism (PHPT). The aim of this study was to evaluate novel plasma risk markers of cardiovascular disease in patients with PHPT. Design PHPT patients were evaluated with a control group. Patients who underwent parathyroidectomy were re-evaluated after 7 and 18 months. Patients Forty-five PHPT patients and 40 matched controls participated. Seventeen patients underwent parathyroidectomy. Measurements Plasma N-terminal pro-B-type natriuretic peptide (NT-proBNP), high-sensitivity C-reactive protein (CRP), interleukin-6 (IL-6) and tumour necrosis factor alpha (TNF-α), lipids and blood pressure were measured. In 27 patients a bicycle exercise test and radionuclide angiography were performed, and repeated in those who underwent parathyroidectomy. Results Plasma NT-proBNP, CRP and TNF-α, but not IL-6, were higher in patients with PHPT than in controls (P

In patients with heart failure and wide QRS complex, cardiac resynchronization therapy (CRT) is associated with improvement of symptoms and cardiac function. This study examined the effects of a 3-month period of CRT on left ventricular (LV) and right ventricular (RV) ejection fraction (EF) and on LV volumes, both at rest and during exercise. A CRT system was implanted in 15 patients with severe heart failure and wide QRS. Before implant and 3 months later, all patients underwent assessment of cardiac performance with equilibrium Tc 9 9 radionuclide angiography with imaging in the best septal left anterior oblique view. Exercise was performed on a bicycle ergometer. At 3 months, a significant improvement in New York Heart Association functional class was observed, and radionuclide angiography showed a significant decrease in LV volumes and a significant increase in LVEF at rest, as well as a significant increase in LVEF during exercise. The remodeling processes associated with CRT did not appear to include RV function, since RVEF did not improve, and changes in RVEF did not correlate with changes in LVEF, neither at rest nor during exercise.

Beta-blocker use improves left ventricular ejection fraction (LVEF) in patients with heart failure. A similar effect of b blockers on right ventricular function has been proposed, although the effect of bisoprolol, a highly selective b-1 blocker, on right ventricular function has not been assessed. This study investigated the short-term effect of bisoprolol on right ventricular function in chronic heart failure patients. A cohort of 30 heart failure patients who were not taking b blockers at baseline was studied prospectively. Right ventricular ejection fraction (RVEF) and LVEF were measured at both baseline and 4 months by radionuclide angiography. Bisoprolol was up-titrated during four monthly visits by a preestablished protocol to a target dose of 10 mg/d. The dose of vasodilators was not changed. Quality of life and brain natriuretic peptide level were assessed. Mean age was 62.7+/-14.3 years. Baseline RVEF was 30.7%+/-6.3% and baseline LVEF was 21.7%+/-9.4%. Mean bisoprolol dose reached was 5.3+/-3.9 mg daily. At 4 months, RVEF significantly increased by 7.1% (95% confidence interval, 3.9-10.2; p=0.0001) and LVEF also increased significantly by 7.9% (95% confidence interval, 4.0%-11.9%; p=0.0003). Quality-of-life score improved from 42.8 to 30.8 (p=0.047). No correlation was found between brain natriuretic peptide levels and RVEF. Bisoprolol treatment for 4 months resulted in a significant improvement of RVEF, which paralleled the improvement of LVEF.

Summary Background:Mental stress testing is considered a reliable method for diagnosing patients with coronary heart disease (CHD) who may be at risk for future events. It has been shown recently that myocardial ischemia induced during mental stress tests is specifically associated with peripheral arterial vasoconstriction. Hypothesis:The study was undertaken to test the diagnostic capability of peripheral arterial tonometry (PAT) to detect peripheral arterial vasomotor changes. Methods: We monitored pulsatile finger blood volume changes using a specially designed finger plethysmograph, PAT that can detect peripheral arterial vasomotor changes. Equilibrium radionuclide angiography (ERNA) was simultaneously performed in 18 male patients at rest and during a mental arithmetic stress test with harassment. All patients had previously diagnosed coronary disease and positive exercise tests. Myocardial ischemia was diagnosed by ERNA when global ejection fraction fell ≥ 8% during mental stress or new (or worsened) focal wall motion abnormalities occurred. Peripheral arterial tonometry tracings were considered abnormal when the pulse wave amplitude decreased by ≥ 20% from baseline. Results: In 18 patients there were 16 usable studies. In eight patients, both ERNA and PAT were abnormal, and in six patients the tests were negative by both methods. In two cases, the results were discordant. Therefore, when considering an abnormal PAT tracing as indicative of mental stress-driven myocardial ischemia, concordance of the two methods was 88%. Conclusion: The use of PAT may facilitate both clinical testing and research during mental stress.

Beta-adrenergic receptor blockade is an established treatment of chronic heart failure (HF). Previous studies have suggested a potential pharmacogenetic interaction between beta-blocker therapy and the angiotensin-converting enzyme (ACE) I/D polymorphism in patients with HF.We designed this study to analyze changes in myocardial function of HF patients in response to beta-blocker therapy as a function of the ACE I/D polymorphism.We studied 199 consecutive patients with chronic HF not treated with beta-blockers. Before initiation of beta-blockers and 3 months after the maximal tolerated dose was reached, patients underwent echocardiography, radionuclide angiography, and a cardiopulmonary exercise test. We extracted genomic DNA from white blood cells and determined the ACE I/D polymorphism. Thirty-five (18%) patients had the II genotype, 86 (43%) the ID genotype and 78 (39%) the DD genotype. A significant and similar improvement in left ventricular ejection fraction (LVEF) was observed in II (from 0.30+/-0.10 to 0.41+/-0.13; P0.0001), ID (from 0.29+/-0.11 to 0.39+/-0.13; P0.0001) and DD patients (from 0.31+/-0.11 to 0.40+/-0.13; P0.0001). Peak Vo(2) before and after beta-blockade was similar among the three groups. The proportion of responders to beta-blockers (patients without cardiac events during titration who had an increase in LVEF5% after beta-blockers) was similar among the three groups (II: 65.9%%, ID: 60.6%%, DD: 65.9%; P=NS). During a median follow-up of 933 days, there was no evidence for any effect of ACE I/D polymorphism on cardiac survival.We observed no evidence of pharmacogenetic interaction between the ACE I/D polymorphism and the effects of beta-blockade on LVEF and other prognostic parameters in patients with chronic HF. Our results support the initiation of beta-blockers in HF patients with the II or the ID genotype as well as in those with the DD genotype.

Background: the effects of long-term administration of β-blockers on left ventricular (LV) function during exercise in patients with ischemic heart disease (IHD) and idiopathic dilated cardiomyopathy (DCM) are controversial. Patients and methods: patients with stable congestive heart failure (CHF) (New York heart association [NYHA] class II and III) and ejection fraction (EF) ≤0.40 were randomized to metoprolol, 50 mg t.i.d. or placebo for 6 months. Patients were divided into two groups: ischemic heart disease (IHD) and idiopathic dilated cardiomyopathy (DCM). The mean EF was 0.29 in both groups and 92% were taking angiotensin-converting enzyme (ACE) inhibitors. In the IHD group, 84% had suffered a myocardial infarction (MI) and 64% had undergone revascularization at least 6 months before the study. LV volumes were measured by equilibrium radionuclide angiography. Mitral regurgitation was assessed by Doppler echocardiography. All values are changes for metoprolol subtracted by changes for placebo. Results: metoprolol improved LV function markedly both at rest and during sub-maximal exercise in both groups. The mean increase in EF was 0.069 at rest (P

Objectives: The aim of this study was to validate the correlation of left ventricular ejection fraction (LVEF) between two-dimensional (2D) echocardiography with harmonic imaging modality and radionuclide angiography (RNA) in a large number of patients. Background: Subjective visual estimation of LVEF is the most prevalent method in evaluating left ventricular systolic function. Previous published reports demonstrated that visual estimation from 2D was superior to other mathematical calculations, however the studies contained less than 50 patients. Methods: Retrospective review of 377 consecutive medical records containing LVEF from both 2D echocardiography and RNA obtained from the same patient within 15 days from January 1998 to September 1999. Results: Correlation coefficient value (r) between 2D echocardiography subjective visual estimation and RNA was 0.84. The r value was further increased to 0.87 when heart transplant recipients excluded. The agreement of LVEF between 2D echocardiography and RNA are higher in normal or severely depressed LV. Conclusion: Excellent correlation of LVEF exists between 2D echocardiography subjective visual estimation and RNA, especially in normal or severely depressed LV. (ECHOCARDIOGRAPHY, Volume 20, April 2003)

We sought to determine the characteristics of brain perfusion in patients with corticobasal degeneration (CBD) using single photon emission computed tomography (SPECT) and statistical parametric mapping (SPM). Thirteen patients with CBD and 10 age-matched healthy volunteers were examined using brain perfusion SPECT and (99m)Tc-ethyl cysteinate dimer (ECD). Regional cerebral blood flow (rCBF) measurements were performed noninvasively using a graphic analysis method. Both the absolute rCBF data (raw data) and the adjusted rCBF data (global CBF normalized to 50 ml/100 g/min) were used in the SPM analysis. A significant decrease in the absolute rCBF was observed in extended areas of the brain in CBD patients compared to the control group. These areas included the frontal, parietal, and temporal cortices; basal ganglia; thalamus; and pontocerebellar regions. Our results suggest that the extent of the reduced rCBF region in CBD patients is more widespread than previously reported.

It has been reported that cerebral blood flow is decreased in chronic alcoholics without neurological diseases. We performed SPECT by the resting and vascular reserve (RVR) method in 11 chronic alcoholics (mean age 59.1 +/- 10.4, all males) and 11 age-matched healthy controls (mean age 58.8 +/- 10.1, all males). The resting and vascular reserve (RVR) method is a consecutive (99m)Tc-ECD SPECT study before and after acetazolamide administration with adjunctive radionuclide angiography, which is easy to perform for a routine clinical study and quite useful for evaluating regional cerebral blood flow and the cerebrovascular response to acetazolamide. Regional cerebral blood flows in almost all regions in the alcoholic group were lower than those in the control group. However, there were no significant differences in increased rates of blood flow in response to acetazolamide in almost all regions between the chronic alcoholic group and the control group. In both groups, the increased rates of blood flow in response to acetazolamide in the supratentorial region, cerebellum, and brain stem were 30-40%, 20-25%, and 42-48%, respectively. The cerebrovascular response to acetazolamide in chronic alcoholics was not impaired, therefore the reduction of brain metabolism may be one of the important factors causing the decreased cerebral blood flow in chronic alcoholics.

Jensen-Urstad M, Samad BA, Jensen-Urstad K, Hulting J, Ruiz H, Bouvier F, Hojer J (Karolinska Hospital, Karolinska Institute, Stockholm; Soder Hospital, Karolinska Institute, Stockholm; Karolinska Hospital, Karolinska Institute, Stockholm; and Soder Hospital, Karolinska Institute, Stockholm, Sweden). Risk assessment in patients with acute myocardial infarction treated with thrombolytic therapy. J Intern Med 2001; 249: 527–537. Objective. Several noninvasive methods have prognostic information regarding mortality and new coronary events after an acute myocardial infarction (AMI). The practical for clinical decision-making in the immediate postmyocardial infarction (MI) period is, however, less evident. We investigated consecutive patients with AMI treated with thrombolysis to further clarify this issue. Design. A total of 100 patients (27% women) aged 64 ± 9 years (mean ± SD) were studied. Risk assessment based on a clinical score system, myocardial perfusion scintigraphy single photon emission computed tomography (SPECT) at rest and during adenosine stress, echocardiography, radionuclide angiography, symptom-limited exercise stress test, and 24-h Holter ECG recording with ST-analysis and analysis of heart rate variability (HRV) were performed 5–8 days after hospital admission. Mortality, nonfatal reinfarction, and the need for revascularization were followed during 12 months. Setting. A university hospital. Results. A total of 6 patients died, seven had a nonfatal reinfarction, and 23 were revascularized. Inability to perform an exercise test (P=0.004) and an ejection fraction (EF)

Right ventricular infarction (RVI) as assessed by various diagnostic methods accompanies inferior-posterior wall myocardial infarction (MI) in 30 to 50% of patients. Recognition of the syndrome of RVI is important as it defines a significant clinical entity, which is associated with considerable immediate morbidity and mortality and has a well-delineated set of priorities for its management. Patients may clinically present with hypotension, elevated jugular venous pulse (JVP), and occasionally shock, all in the presence of clear lung fields. The ST-segment elevation of > or = 0.1 mV in the right precordial leads V4R is a readily available electrocardiographic sign used for diagnosis of RVI. Other diagnostic approaches for assessing RVI include echocardiography, radionuclide ventriculography, technetium pyrophosphate scanning, and hemodynamic measurements. The proper management of RVI includes volume loading to maintain adequate right ventricular preload, ionotropic support, and maintenance of atrioventricular synchrony. Reperfusion therapy should be initiated at the earliest signs of right ventricular dysfunction. Finally, complete recovery over a period of weeks to months is a rule in a majority of patients, suggesting right ventricular "stunning" rather than irreversible necrosis has occurred.

OBJECTIVE Previous studies have suggested that hypothyroidism affects both systolic and diastolic cardiac function. We have applied equilibrium radionuclide angiography to the study of heart function at rest in hypothyroidism. DESIGN A prospective study, evaluating cardiac function at rest in primary hypothyroidism. METHODS Cardiac function was studied by means of equilibrium radionuclide angiography. Screening echo-Doppler examinations were performed on each patient. PATIENTS Twenty-six consecutive untreated hypothyroid patients without clinical or echocardiographic cardiac disease and 20 healthy matched controls. RESULTS Between patients and controls, the time to peak emptying rate (161 ± 6 msec vs. 144 ± 6 msec, P

The objective of the study was evaluation of the pulmonary venous blood flow (PVF) pattern and the influence of ventricular function and atrioventricular valve regurgitation on this flow in patients with univentricular hearts post total cavo-pulmonary connection (TCPC). Transthoracic or transoesophageal echocardiographic studies were performed in 24 children with normal hearts (group A) and in 24 patients with univentricular hearts (group B). Ventricular function and atrioventricular valve regurgitation was semiquantitatively assessed. Systolic/diastolic maximal velocities and velocity time integrals (VTI) were measured from PVF tracings. Ejection fraction was measured by radionuclide angiography in 11 patients. Twelve patients underwent heart catheterization and angiography. In group B the PVF showed a biphasic flow velocity curve. The systolic integrals were smaller and the diastolic integrals were larger than in group A (6·4 vs. 13·0 cm, P = 0·0001, and 13·9 vs. 10·0 cm, P = 0·005). The pulmonary venous systolic flow fraction in 13 patients with an open fenestration and/or atrioventricular valve regurgitation grade 2–3 was significantly lower than in those 11 patients without fenestration and none/small regurgitation (0·19 vs. 0·40, P = 0·05). In conclusion, the PVF pattern in children with univentricular hearts palliated with TCPC is similar to the PVF pattern found in individuals with biventricular hearts showing a biphasic flow velocity curve despite the absence of pulsative pulmonary artery flow. The PVF in patients with TCPC-palliated univentricular hearts is influenced by atrioventricular valve regurgitation and fenestration flow.

Calculation of global cardiac function parameters has been validated using fast, segmented k-space, breath-hold, gradient-echo, magnetic resonance images. Images of phantoms, experimental animals, normal volunteers, and patients were acquired with a 1.5 T clinical scanner. Humans were imaged using two phased-array surface coils in multicoil mode. Myo-cardial contours were extracted using a new interactive, semi-automated method based on the active contour model method. Images were acquired in the short-axis orientation, and, using a new imaging and analysis strategy, in rotating plane long-axis orientations, to provide better definition of the valve planes and the apex, and also to reduce the number of slices (compared with the short-axis method) required to sample the whole heart. Validation was accomplished through calculation of the volumes of phantoms and left and right ventricular masses of animal hearts. Functional parameters from MRI were compared with those from echocardiograms and radionuclide angiograms in normal volunteers and patients, respectively.

Cardiac function was assessed in longterm survivors of malignant bone tumors who were treated according to Rosen's T-5 or T-10 protocol, both including doxorubicin. Thirty-one patients, ages 10-45 years (median age 17.8 years) were evaluated 2.3-14.1 years (median 8.9 years) following completion of treatment. Cumulative doses of doxorubicin were 225-550 mg/m(2) (median dose 360). The evaluation consisted of a history, physical examination, electrocardiogram (EGG), signal averaged EGG, 24-hour ambulatory ECC, echocardiography and radionuclide angiography. Eighteen of 31 (58%) patients showed cardiac toxicity, defined as having one or more of the following abnormalities: late potentials, complex ventricular arrhythmias, left ventricular dilatation, decreased shortening fraction, or decreased ejection fraction. The incidence of cardiac abnormalities increased with length of follow-up (P less than or equal to .05). No correlation could be demonstrated between cumulative dose of doxorubicin and cardiac status, except for heart rate variability. When adjusted to body surface area, the left ventricular posterior wall thickness (LVPW index) was decreased in all patients. The incidence of doxorubicin-induced cardiotoxicity is high and increases with follow-up, irrespective of cumulative dose. Life-long cardiac follow-up in these patients is warranted. The results of our study suggest that heart rate variability and LVPW index could be sensitive indicators for cardiotoxicity. (C) 1996 Wiley-Liss, Inc.

To determine whether asymmetrical septal hypertrophy (ASH) in patients with essential hypertension (HT) is a type of hypertensive left ventricular (LV) hypertrophy or hypertrophic cardiomyopathy (HCM) combined with HT, we investigated a group of 7 hypertensive patients with ASH compared with 12 HCM patients and 10 healthy controls using radionuclide angiography and right ventricular endomyocardial biopsy. The LV time-volume curve and its first and second derivative curves were constructed from cardiac output and time-activity curves constructed by combined forward and reverse-gating from the R wave. The LV wall thickness and ejection fraction were significantly greater in both the HT and HCM groups than in the control group, whereas there were no differences in these indices between the HT and HCM groups. Rapid filling volume index and rapid filling fraction showed significantly lower values in the HCM group than in the control group (p < 0.005). In contrast to the HCM group, these indices in the HT group did not differ from those in the control group. The time to peak filling rate was prolonged in the control, hypertension, and HCM groups in increasing order. Histopathological study revealed a higher incidence of myocardial cell disarray in the HCM than in the HT group. The above results suggest that ASH in hypertensive patients is a type of hypertensive LV hypertrophy.

There is scant information regarding the effect of exercise training begun soon after hospital discharge for myocardial infarction (MI) with respect to subsequent improvement in exercise tolerance, enhancement of regional myocardial perfusion, or left ventricular function. Accordingly, 19 post-MI patients (mean age 53 ± 7 years) underwent treadmill exercise quantitative thallium-201 (Tl-201) scintigraphy and rest radionuclide angiography (RNA) prior to and after 12 weeks of thrice-weekly exercise training which was targeted to 70–85% of maximum exercise heart rate achieved. Training was begun at 25 ± 3 days after hospital discharge. Eight Tl-201 scan segments were each scored from 1–6 points based upon uptake and washout criteria with 6 being the most severe defect (>50% reduction in Tl-201 events with no delayed redistribution). When matched to the pretraining peak workload on exercise testing, 12 weeks of training significantly lessened heart rate (120±4 to 97±4, p

Displacement of the atrioventricular (AV) plane toward the cardiac apex in systole was studied quantitatively by echocardiography in 37 patients with first-time acute myocardial infarction (MI) in order to evaluate left ventricular systolic function. The amplitude of AV plane displacement was recorded from the apex at four different sites corresponding to the septal, lateral, anterior, and posterior walls of the left ventricle from apical 4- and 2-chamber views. The patients had a decreased displacement of the AV plane compared with controls which was more pronounced at the sites of infarction. The mean value of the AV plane displacement (AV mean) correlated linearly with the left ventricular (LV) ejection fraction calculated by radionuclide angiography (r = 0.87, p less than 0.001, SEE = 6.2). An AV mean of 10 mm or more had a high sensitivity (95%) and specificity (82%) in defining a normal ejection fraction (greater than or equal to 50%). A high correlation coefficient was found between LV wall motion index and the AV plane displacement. Thus, in acute MI the LV function can be assessed noninvasively using AV plane displacement.

The rare presentation of a follicular thyroid carcinoma mimicking the clinical and radionuclide features of subacute thyroiditis is described. Granulomatous thyroiditis was initially suspected on the clinical basis of acute onset of a hard, tender right lobe thyroid enlargement with associated systemic symptoms, modest elevation of thyroid hormone levels and suppressed thyroid RAIU. Fine needle aspiration cytology specimens were unsatisfactory for characterization. Three weeks later the thyroid RAIU was normal. The thyroid enlargement persisted, now being clearly visualized as a hypofunctional nodule on scintiscan. Repeat fine needle aspiration cytology was suggestive of acinar proliferation with hyperfunction. Ultrasonography revealed a solid nodule with a peripheral sonolucent halo. Radionuclide angiography showed intense arterial flow of Tc-99m pertechnetate through the right lobe thyroid enlargement suggestive of malignant thyroid pathology. Surgical excision and histopathological examination revealed a follicular carcinoma involving the right lobe. The possibility of carcinomatous involvement should be considered in those patients where initially tender thyroid nodularity persists longer than expected for a benign inflammatory disease, careful follow-up and relevant investigations being necessary to confirm the diagnosis.

Radionuclide angiography was used to document occlusion of the distal aorta by thromboemboli in two dogs. Findings were confirmed by necropsy. The location of the thrombus corresponded with the scintigraphic lesion. Information obtained by the radionuclide angiogram was instrumental in patient management. We suggest the use of radionuclide angiography as a quick, non-invasive alternative to contrast angiography in animals suspected of having aortic thromboembolism.

In order to evaluate the possible cardiosparing effect of a prolonged infusion of doxorubicin as compared with the standard mode of administration 62 consecutive patients with metastatic carcinoma of the breast or carcinoma of the ovary Stage III or IV were prospectively randomized to receive doxorubicin either as a rapid infusion over 15 to 20 minutes at 8 AM or as a continuous infusion over 6 hours, 8 AM to 2 PM. The remaining protocol was identical for the two groups. The cardiotoxic effect of doxorubicin was evaluated by history and physical examination and by the decline in resting ventricular ejection fraction (LVEF) as determined by gated pool radionuclide angiography with technetium 99m (99mTc) and by the decline in the height of the QRS complexes in the standard leads of the echocardiogram (ECG). Initially there were 31 patients in each group. The cumulative dose of doxorubicin, was 410 mg/m2 +/- 42 SD in the standard infusion group and 428 mg/m2 +/- 48 SD in the 6-hour infusion group. The mean decline in LVEF after a cumulative doxorubicin dose of 300 mg/m2 was 17% in the first group and only 4.1% in the second. After 400 mg/m2 the mean fall in LVEF was 21% in the first group and 6% in the second. The mean decline in QRS voltage after 300 mg/m2 was 29% and 1.5%, respectively. Four patients, all in the standard infusion group, developed congestive heart failure. These data suggest that slow infusion of doxorubicin is associated with reduced cardiotoxicity.

Introduction: The purpose of this study was to determine the impact of the left ventricular (LV) segmental wall motion abnormalities detected by equilibrium radionuclide angiography (ERNA) on the improvement in LV and right ventricular (RV) function during biventricular (BIV) stimulation. Results: We studied 28 patients in NYHA functional classes III or IV and QRS duration >150 ms on resting electrocardiogram. ERNA was performed before and during BIV stimulation at a 6-month follow-up. A significant shortening of QRS duration was observed during BIV stimulation (165 ± 5 ms before vs 133 ± 6 ms during, P < 0.01). Wall motion abnormalities (WMA) were observed in 16 patients (10 with nonischemic cardiomyopathies). In this group, LV and RV ejection fractions (EF) did not increase during BIV stimulation (LVEF = 22 ± 2% vs 20 ± 1.6%, ns; RVEF = 34 ± 3% vs 37 ± 3.8%, ns). Significant increases in RVEF (23 ± 3.2% →38 ± 2.9%, P = 0.001) and LVEF (20 ± 2.5% → 30 ± 3%, P = 0.01) were observed in the group of patients without segmental WMA and with global hypokinesia (GH). In this group, a significant decrease in the dispersion in the phase of RV contraction was observed (SD = 39 ± 5 vs 26 ± 2 ms; P < 0.01). WMA predicted an increase in LVEF, in contrast to a baseline 6-minute-walk test, maximal oxygen consumption and LVEF, or amount of QRS shortening. Conclusions: BIV stimulation increased in LV and RV EF in patients with ventricular dyssynchrony in absence of segmental WMA. ERNA was reliable in the selection of candidates for CRT.

Testicular circulatory isolation (TCI) holds promise as a method to avoid drug-induced infertility in male patients about to receive cancer chemotherapy. Complete exclusion of blood flow to the testicle is essential to the success of this technique. We have compared the hand-held Doppler probe and radionuclide angiography (technetium-99m pertechnetate) as monitors of testicular blood flow in 10 patients subjected to unilateral TCI. When Doppler evaluation indicated that testicular circulation had been interrupted, the radionuclide angiogram uniformly confirmed and quantified this conclusion. These results validate the hand-held Doppler as an appropriate tool for assessing testicular blood flow in patients undergoing TCI. © 1993 Wiley-Liss, Inc.

Purpose: Phase analysis of single photon emission computed tomography (SPECT) radionuclide angiography (RNA) has been investigated for its potential to predict the outcome of cardiac resynchronization therapy (CRT). However, phase analysis may be limited in its potential at predicting CRT outcome as valuable information may be lost by assuming that time-activity curves (TAC) follow a simple sinusoidal shape. A new method, cluster analysis, is proposed which directly evaluates the TACs and may lead to a better understanding of dyssynchrony patterns and CRT outcome. Cluster analysis algorithms were developed and optimized to maximize their ability to predict CRT response. Methods: About 49 patients (N = 27 ischemic etiology) received a SPECT RNA scan as well as positron emission tomography (PET) perfusion and viability scans prior to undergoing CRT. A semiautomated algorithm sampled the left ventricle wall to produce 568 TACs from SPECT RNA data. The TACs were then subjected to two different cluster analysis techniques, K-means, and normal average, where several input metrics were also varied to determine the optimal settings for the prediction of CRT outcome. Each TAC was assigned to a cluster group based on the comparison criteria and global and segmental cluster size and scores were used as measures of dyssynchrony and used to predict response to CRT. A repeated random twofold cross-validation technique was used to train and validate the cluster algorithm. Receiver operating characteristic (ROC) analysis was used to calculate the area under the curve (AUC) and compare results to those obtained for SPECT RNA phase analysis and PET scar size analysis methods. Results: Using the normal average cluster analysis approach, the septal wall produced statistically significant results for predicting CRT results in the ischemic population (ROC AUC = 0.73;p < 0.05 vs. equal chance ROC AUC = 0.50) with an optimal operating point of 71% sensitivity and 60% specificity. Cluster analysis results were similar to SPECT RNA phase analysis (ROC AUC = 0.78, p = 0.73 vs cluster AUC; sensitivity/specificity = 59%/89%) and PET scar size analysis (ROC AUC = 0.73, p = 1.0 vs cluster AUC; sensitivity/specificity = 76%/67%). Conclusions: A SPECT RNA cluster analysis algorithm was developed for the prediction of CRT outcome. Cluster analysis results produced results equivalent to those obtained from Fourier and scar analysis.

Diving-induced acute alterations in cardiovascular function such as arterial endothelial dysfunction, increased pulmonary artery pressure (PAP) and reduced heart function have been recently reported. We tested the effects of acute antioxidants on arterial endothelial function, PAP and heart function before and after a field dive. Vitamins C (2 g) and E (400 IU) were given to subjects 2 h before a second dive (protocol 1) and in a placebo-controlled crossover study design (protocol 2). Seven experienced divers performed open sea dives to 30 msw with standard decompression in a non-randomized protocol, and six of them participated in a randomized trial. Before and after the dives ventricular volumes and function and pulmonary and brachial artery function were assessed by ultrasound. The control dive resulted in a significant reduction in flow-mediated dilatation (FMD) and heart function with increased mean PAP. Twenty-four hours after the control dive FMD was still reduced 37% below baseline (8.1 versus 5.1%, P = 0.005), while right ventricle ejection fraction (RV-EF), left ventricle EF and endocardial fractional shortening were reduced much less (∼2–3%). At the same time RV end-systolic volume was increased by 9% and mean PAP by 5%. Acute antioxidants significantly attenuated only the reduction in FMD post-dive (P < 0.001), while changes in pulmonary artery and heart function were unaffected by antioxidant ingestion. These findings were confirmed by repeating the experiments in a randomized study design. FMD returned to baseline values 72 h after the dive with pre-dive placebo, whereas for most cardiovascular parameters this occurred earlier (24–48 h). Right ventricular dysfunction and increased PAP lasted longer. Acute antioxidants attenuated arterial endothelial dysfunction after diving, while reduction in heart and pulmonary artery function were unchanged. Cardiovascular changes after diving are not fully reversed up to 3 days after a dive, suggesting longer lasting negative effects.

A clinical syndrome of severe cardiomyopathy often accompanies administration of high doses of anthracycline agents. We studied 36 patients serially with radionuclide angiography. At three weeks following drug administration, 8 of 36 patients showed depression of ejection fraction (EF). All had received at least 280 mg/m2 of the drug and 7 had received more than 380 mg/M2. Definite clinical syndromes of congestive cardiomyopathy developed only in patients showing EF depression and in some patients, EF depression developed without signs of congestive heart failure. Ejection fraction studies at 5 minutes, 1 hour, 4 hours, 24 hours, 72 hours, and one week following drug administration showed no changes when compared to immediate preg-drug EF. Seven patients who died during the study underwent histologic examination. Only the single patient with a depressed EF showed histologic evidence of athracycline cardiotoxicity, although all but 1 of these patients had received at least 400 mg/M2. We conclude that serial radionuclide EF just prior to anthracycline administration is a potentially useful predictor of cardiac toxicity, and that EF depression and/or preservation of a normal EF should be weighed in the decision for administering a drug of this type at high dosage levels.

One hundred and one soft tissue sarcoma patients from an adjuvant chemotherapy study of the Surgery Branch, National Cancer Institute who had received greater than or equal to 430 mg/m2 (range, 430-600 mg/m2) of doxorubicin were followed for evidence of cardiomyopathy. Fourteen patients developed clinical congestive heart failure attributable to doxorubicin. Nine of these fourteen were evaluated by radionuclide angiography (RNA), and all were abnormal with mean ejection fraction both at rest and exercise less than 30%. Sixty-one asymptomatic patients were studied at least once with RNA. In this asymptomatic group, 13 of 61 patients (21%) had abnormal resting left ventricular function. Exercise studies identified an additional 19 abnormal individuals (31%). Overall incidence of cardiomyopathy, as evidenced by RNA, in the asymptomatic group was 52%. By including the fourteen symptomatic patients, the incidence of cardiomyopathy detected either clinically or by RNA in the 75 evaluated patients was 46%. Comparison of patients by age (less than 40 versus greater than 40) revealed a highly significant difference in the incidence of cardiomyopathy (P less than .001). Fourteen of 36 patients (38%) less than or equal to 40 had either clinical or RNA evidence of cardiotoxicity while 32 of 39 (82%) individuals greater than 40 demonstrated cardiomyopathy. No significant difference was seen in those asymptomatic patients in whom RNA was performed less than or equal to 12 months as compared with greater than 12 months after the end of doxorubicin treatment. In the entire group there was no apparent improvement in cardiomyopathy with time, but results suggest that left ventricular function in the group older than 40 years does deteriorate. The cardiac function of patients younger than age 40 appeared to remain stable or possibly improve with time after the completion of treatment. Sex, tumor location, and radiation treatment were not associated with an increased risk of cardiomyopathy. These results emphasize the dangers of full-dose doxorubicin therapy. This high incidence of cardiomyopathy became apparent because of our ability to prospectively evaluate a large group of patients with prolonged life expectancy that received adjuvant doxorubicin chemotherapy after surgery.

To test the value of combining treadmill exercise with radionuclide angiography for detecting exercise-induced left ventricular dysfunction, ejection fractions were calculated at rest, peak supine bicycle exercise, and during three supine post-treadmill recovery periods (2-4 min, recovery 1;4-6 min, recovery 2;8-10 min, recovery 3) in ten coronary artery disease patients and eight normal subjects. Both the normal subjects and coronary artery disease patients had normal resting ejection fractions (greater than 0.50). In the normal subjects the mean ejection fraction increased significantly (p less than 0.005) from rest (0.61 +/- 0.03) to peak supine bicycle exercise (0.71 +/- 0.04), and the mean ejection fraction also remained significantly higher (p less than 0.005) at rest than during 10 min post-treadmill exercise. However, the coronary artery disease patients did not significantly change the mean ejection fractions from rest (0.59 +/- 0.06) to peak supine bicycle exercise (0.55 +/- 0.08), and the average ejection fraction during each one of the post-treadmill recovery periods was not significantly different from rest. At the third recovery period all the normals but no coronary artery disease patients had higher ejection fraction than the resting ejection fraction. We thus conclude that the magnitude of change in ejection fraction from rest to 8-10 min post-treadmill exercise in patients with normal resting ejection fraction may be helpful in identifying those with coronary disease.

The changes in ventricular function after reperfusion by coronary thrombolysis are important when deciding about further definitive treatment necessary to ensure long-term vessel patency. The purpose of this study was to evaluate the early changes in left ventricular function after reperfusion. Left ventricular function was serially evaluated for 10 days in a group of 18 patients receiving intracoronary thrombolytic therapy for an acute myocardial infarction. Comparison of the global ventricular function in the successfully and unsuccessfully reperfused groups of patients showed significantly better function in the successful group than the unsuccessful group after the first day, which was maintained for the entire study period. Global and regional ventricular function in the successfully reperfused patients showed significant early improvement during the initial 72 h with maintenance of this improvement for the study period of 10 days. In the patients in whom reperfusion was unsuccessful, regional ventricular function showed no change, while the global function declined from day 5 to day 8 of the study period. This study then confirms the significant improvement in ventricular function after successful reperfusion. The time course pattern of the change in ventricular function indicates that the most significant improvement occurs within the first 72 h after reperfusion. These changes are similar to those previously reported in experimental animals.

Twenty-one normal young male subjects underwent resting and exercise (bicycle) radionuclide angiography in the full supine and 70 degrees upright tilt positions in order to examine the effects of position on left ventricular size and performance, hemodynamics, and exercise duration. All subjects also underwent full (90 degrees) upright bicycle ergometry with respiratory gas analysis to establish the level of maximal exercise capacity for each. Body position significantly (p less than 0.05) affected resting and exercise cardiovascular parameters. End-diastolic and endsystolic left ventricular volumes and stroke volume were larger in the supine position, both at rest and during exercise. The cardiac output at rest and during exercise were comparable for the two positions; an increase in resting and exercise heart rate in the 70 degrees tilt position compensated for the reduced stroke volume of this posture. At maximal exercise, the 70 degrees upright position was associated with a greater response in left ventricular ejection fraction, otherwise this parameter was not position related. Exercise capacity, in terms of duration and workload, was significantly higher in the supine (1870 +/- 390 s) and full upright (1830 +/- 250 s) positions than in the 70 degrees tilt position (1730 +/- 260 s). Changes in body position significantly alter parameters of ventricular, cardiovascular, and exercise performance.

Previous studies show no correlation between resting systolic left ventricular performance assessed as the ejection fraction and exercise tolerance. This study examined the relation between left ventricular diastolic performance and exercise tolerance in 63 patients with left ventricular dysfunction (ejection fraction less than 50%) due to known or suspected coronary artery disease. The 51 men and 12 women, aged 54 +/- 8 years (mean +/- standard deviation), underwent symptom-limited upright exercise testing on a bicycle ergometer. The exercise end-points were angina (n:5), dyspnea (n:16), and fatigue (n:42). The patients were divided into three groups: group 1 (n:28) with normal exercise tolerance (9.5 +/- 2.4 minutes), group 2 (n:18) with mild exercise intolerance (5.8 +/- 0.5 minutes), and group 3 (n:17) had severe exercise intolerance (3.7 +/- 0.9 minutes). The three groups did not differ in age, ejection fraction, end-diastolic volume, exercise end-point, exercise heart rate, and left ventricular peak filling rate at rest. The exercise peak filling rate was, however, significantly higher in group 1 (p = 0.03). Stepwise multivariate discriminant analysis of important variables identified the exercise peak filling rate as the only predictor of exercise tolerance (F = 6.0). Thus, variation in exercise peak filling rate may in part explain the variability of exercise tolerance in patients with left ventricular dysfunction; patients with preserved exercise capacity have higher exercise peak filling rate than those with exercise intolerance.

Fifteen patients with hypertrophic (HCM) and 15 with dilative cardiomyopathy (DCM) were examined with radionuclide angiography and M-mode echocardiography to evaluate the combination of two noninvasive methods for measuring left ventricular performance. The patients with HCM had delayed myocardial relaxation and rapid filling time with preserved peak rate of early ventricular filling. DCM patients, on the contrary, had low values of left ventricular systolic performance and low peak filling rate. Myocardial relaxation and rapid filling time, however, were short, indicating compensatory mechanisms in the failing ventricle improving rapid filling.

Summary. A series of studies were performed with a single crystal detector system, nuclear stethoscope (N.S.) (Bios®) used for measuring left ventricular function (ejection fraction [EF]). Counting capacity, validity, reproducibility, effect of repositioning of the instrument and of different operators were investigated. Counting capacity was found to be approximately linear up to a count rate of 40,000 cps. Validity was studied by comparing measurements in the same subject using the N.S. with those obtained by a gamma-camera computer system with software using a background subtraction similar to that in the N.S. The mean difference in EF (0·01) was not significant. Maximum emptying and filling velocity measurements with the two instruments were also compared r= 0·86 and r= 0·89, respectively, and a coefficient of variation of 18·1% and 17·9%. Reproducibility was determined from duplicate determinations under identical conditions. The standard error of a single determination was 5%. Repositioning by the same operator increased the variation to 9·1% without any systematic difference. Comparison between two operators did not increase the coefficient of variation (8·8%). There was a systematic difference between measurements using the two acquisition modes, ventricular function mode and position monitor mode. Beat-to-beat variation of EF values during 12 s in 25 patients with coronary heart disease studied under standardized resting conditions was 11·9%.

Clinical, echocardiographic, and nuclear angiographic findings in a 51-year-old woman who presented with a history of dyspnea are discussed. Initial echocardiography revealed no abnormality. However, a subsequent radionuclide angiogram revealed a filling defect on the right side of the heart. This represented a right atrial myxoma. Radionuclide angiography can provide a useful noninvasive tool in the diagnosis of intracardiac tumors when echocardiography has not been helpful.

Summary: This study was performed to define the signs of cardiac tamponade on radionuclide angiography. The first pass studies were performed on a large field gamma camera, using a bolus of technetium pertechnetate. Three hundred and seventy-two studies were analysed. Cardiac tamponade requiring surgical intervention was present at the time in 28 studies The diagnostic signs of cardiac tamponade on radionuclide angiography were: (1) Right ventricular compression—sensitivity 82%, specificity 97%, predictive value of a positive result 72%, predictive value of a negative result 99%, and (2) Right atrial compression—sensitivity 21%, specificity 99%, predictive value of a positive result 75%, predictive value of a negative result 94%. Cardiac tamponade can be accurately diagnosed on radionuclide angiography and thus indicate those pericardial effusions which require urgent drainage.

Both echocardiography and radionuclide angiography have been proposed as noninvasive modalities for the diagnosis of left ventricular pseudoaneurysm. In the only three cases seen at our institution over the past five years, this diagnosis was missed with radionuclide blood pool imaging, while two-dimensional echocardiography demonstrated the typical features of a pseudoaneurysm. Our patients were asymptomatic and diagnosis was made incidentally 4 to 6 years after myocardial infarction. Although the patients survived an extended period without surgery, the reported incidence of rupture is high, and prophylactic surgical repair probably is indicated. It is likely that the increased use of noninvasive cardiac imaging techniques will lead to the detection of other cases of unsuspected left ventricular pseudoaneurysm. Two-dimensional echocardiography appears superior to planar radionuclide ventriculography in establishing the diagnosis.

The aim of this study was to determine the factors influencing the different response of the ejection fraction (EF) of the left ventricle at exercise observed in patients with and without significant coronary heart disease. We have studied 98 patients referred for coronary angiography (82 men, 16 women), of whom 49 patients had a previous myocardial infarction and 71 patients had significant coronary heart disease. Exercise testing was performed and combined with a cardiac blood pool imaging at equilibrium. The variation of the EF between rest and peak exercise (delta EF) was measured. Twelve clinical, exercise-related, isotopic, and coronary arteriographic variables were examined in a linear univariate and statistical analysis. In the univariate regression, seven variables were significant regressors on the delta EF. In the multivariate regression, only four variables were significant regressors on the delta EF. Three independent predictors were found: the rate-pressure product, the ST depression, and the occurrence of a previous myocardial infarction. These three independent predictors reflect the myocardial functional reserve.