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To determine the usefulness of dobutamine stress echocardiography for detecting restenosis after percutaneous transluminal coronary angioplasty, the results of coronary arteriography and dobutamine stress echocardiography were compared in 103 patients 6 months after percutaneous transluminal coronary angiography. The dobutamine stress echocardiograms were obtained on the same day as the coronary arteriograms, which were analyzed by both quantitative and visual estimates of luminal narrowing, The angiographic restenosis rate was 44% by quantitative and 31% by visual estimates of stenosis. Dobutamine stress echocardiography was abnormal in 38% of previously dilated regions with restenosis and normal in 79% of previously dilated regions without restenosis by quantitative coronary angiography. Dobutamine stress echocardiography was concordant in 69% of 16 patients with multivessel disease compared with 40% of 41 patients with 1-vessel disease (p

PURPOSE- To determine the effectiveness of the preoperative evaluation and overall diagnostic efficacy of subxiphoid pericardial biopsy with fluid drainge in patients with new, large pericardial effusions. DESIGN: A prospective interventional case series of consecutive patients admitted with new, large pericardial effusions. PATIENTS AND METHODS: Fifty-seven of 75 consecutive patients admitted to a university tertiary-care center and a university-affiliated Veterans Administration Medical Center with New, large pericardial effusions were studied over a 20-month period. Each patient was assessed by a comprehensive preoperative evaluation followed by subxiphoid pericardiotomy. The patients' tissue and fluid samples were studied pathologically and cultured for aerobic and anaerobic bacteria, fungi, myobateria, mycoplasmas, and viruses. RESULTS: A diagnosis was made in 53 (93%) patients. The principle diagnoses consisted of malignancy in 13 (23%) patients; viral infection in 8 (14%) patient; radiation-induced inflammation in 8 (14%) patients; collagen-vascular disease in 7 (12%) patients, and uremia in 7 (12%) patients. No diagnosis was made in four (7%) patients. A variety of unexpected organism were cultured from either pericardial fluid or tissue: cytomegalovirus (three), Mycoplasma pneumoniae (two), herpes simplex virus (one), Mycobacterium avium-intracellulare (one), and Mycobacterium, chelonei (one). The pericardial fluid yielded a diagnosis in 15 (26%) patients, 11 of whom had malignant effusions. The examination of pericardial tissue was useful in the diagnosis of 13 (23%) patients, 8 of whom had an infectious agent cultured. Of the 57 patients undergoing surgery, the combined diagnostic yield from both fluid and tissue was 19 patients (33%). CONCLUSIONS. A systematic preoperative evaluation m conjunction with fluid and tissue analysis following subxiphoid pericardiotomy yields a diagnosis in the majority of patients with large pericardial effussions. This approach may also result in the culturing of 'unusual' infectious organisms from peneardial tusue and fluid.

To determine the clinical features, course and outcome of patients with cardiac tamponade, 57 consecutive patients with new, large pericardial effusions were prospectively studied. Twenty-five patients (44%) developed cardiac tamponade with venous hypertension and a pulsus paradoxus >10 mm Hg. Electrocardiography, radiographic studies and echocardiography did not differentiate patients with and without tamponade. All 57 patients underwent thorough diagnostic evaluation followed by subxiphoid pericardial biopsy and drainage. A diagnosis was obtained in 53 patients (93%). Collagen vascular disease was significantly more frequent in the 25 patients with than in the 32 without cardiac tamponade (24 vs 3%; p

To determine the safety, diagnostic value, and clinical outcome of patients with malignancy undergoing subxiphoid pericardiotomy for large pericardial effusions, we prospectively studied 25 consecutive patients with malignancy and new, large pericardial effusions diagnosed by echocardiography. Twenty-two of the 25 operations were done under local anesthesia, and no patient died at surgery. Pericardial fluid cytology revealed malignant cells in 11 patients (44 percent), while tumor was seen in only five (45 percent) of these 11 patients on pathologic examination. The remaining 14 patients showed no evidence of pericardial invasion with tumor. Evidence of intrathoracic disease by CT or MRI scanning, tamponade, a sanguineous pericardial fluid character, and an elevated serum and pericardial fluid lactate dehydrogenase level all were suggestive of malignant invasion of the pericardium. All 25 patients were followed at least 12 months postoperatively. Effusions recurred in three patients (12 percent), and one patient required reoperation. Overall mortality was 72 percent with a 91 percent (10 of 11) mortality for those with malignant effusions and a 57 percent (8 of 14) mortality for those with nonmalignant effusions. Diagnostically, subxiphoid pericardiotomy has little advantage over examination of pericardial fluid alone in this group of patients. Therapeutically, however, it is a low morbidity procedure which is safe and effective in treating patients with malignancy and large pericardial effusions., Malignancy has become one of the leading causes of pericardial effusions in the United States.[1] However, many of the effusions found in patients with malignancy are not a result of [...]

A report is presented from the Council on Scientific Affairs of the American Medical Association concerning the diagnostic use of ultrasonography in cardiology. The kinds of ultrasound applied to cardiology include M-mode echocardiography (which studies moving structures), Doppler methods (to evaluate blood flow in the heart's chambers and the large vessels attached to the heart), and Doppler methods combined with two-dimensional anatomic imaging. Evaluations are presented of cardiac ultrasound to evaluate coronary artery disease (disease of the arteries that supply blood to the heart); disease of the heart valves (which separate the chambers from each other, and the great vessels from the chambers); congenital heart disease; disease of the pericardium (the sac that surrounds the heart) and myocardium (the heart muscle); masses, such as those associated with infections or malignancy, around and in the heart; and abnormalities of the aorta and aortic arch (blood flows through the aorta as it is pumped from the heart). Specialized uses of cardiac ultrasonography are also discussed: some of these are echocardiography during surgery; imaging of the coronary arteries; and fetal echocardiography. This noninvasive approach can dramatically reduce the number of patients with congenital defects or valve disorders who must undergo cardiac catheterization (insertion of a thin tube into the heart, through which dye is injected to visualize structures). More invasive techniques are often used, however, in cases where coronary artery disease is suspected. (Consumer Summary produced by Reliance Medical Information, Inc.)

Validation of catheter-based intravascular ultrasound imaging has been based on comparisons with histology and digital angiography, each of which may have limitations in the assessment of arterial size and morphology. External, high-frequency ultrasound can accurately determine vessel dimensions and morphology and because, like intravascular ultrasound, it also provides crosssectional arterial ultrasound images, it may be a more appropriate technique for the in vivo comparison of arterial dimensions and morphology determined by intravascular ultrasound. Thus, intravascular ultrasound, external 2dimensional ultrasound, Doppler color-flow imaging and digital angiography were compared for assessment of arterial dimensions and war morphology at 29 femeral artery sites in 15 patients. Intravascular ultrasound and the other 3 imaging modalities correlated well in determination of lumen diameter (2-Dimensional, r = 0.98, standard error of the estimate [SEE] = 0.14; Doppler color flow, r = 0.91, SEE = 1.11; angiography, r = 0.95, SEE = 0.91) and cross-sectional area (2-dimensional, r = 0.97, SEE = 0.04; Doppler color flow, r = 0.92, SEE = 0.14; angiography, r = 0.96, SEE = 0.08). However, lumen size measured by Doppler color flow was consistently smaller than that measured by the other 3 imaging modalities. Intravascular ultrasound detected arterial plaque at 15 sites, 5 of which were hypoechoic (soft) and 10 hyperechoic with distal shadowing (hard). Plaque was identified at 12 of 15 sites by 2-dimensional imaging (p = 0.30 vs intravascular ultrasound), but at only 6 of 15 sites by angiography (p = 0.003 vs intravascular ultrasound), only 1 of which was thought to be calcified plaque. These data indicate that arterial dimensions determined by intravascular ultrasound correlate well with both external ultrasound and angiography in normal and minimally diseased peripheral arteries. Doppler color flow underestimates true lumen size. Angiography is often discordant with both intravascular and external ultrasound in determining the presence and composition of arterial plaque. (Am J Cardiol 1991,-67:817-M), Vascular imaging techniques are important for examining blood vessels for decreased size, vessel wall damage, accumulation of fatty plaque (hardened material stuck to wall of blood vessel) and other signs of disease. Currently used imaging techniques include external ultrasound, which uses high-frequency sound waves to image vessel dimensions and flow of blood vessels from outside the body, and digital angiography, which uses X-rays of vessels after a contrast material has been injected into them. A newly developed technique for these purposes is intravascular ultrasound. It also uses high-frequency sound waves for imaging purposes, but does so within the vessels by means of a catheter inserted into the vessels. This accuracy of this technique has not been completely validated and its results have conflicted with results from angiography regarding changes inside the vessel. Either intravascular ultrasound is more sensitive than older methods, or else it cannot accurately determine vessel morphology. All four imaging techniques were evaluated for measuring vessel dimensions and morphology to examine the accuracy of this intravascular ultrasound. Fifteen patients with no prior history of peripheral artery disease were examined using two-dimensional and Doppler external ultrasound, intravascular ultrasound, and digital subtraction angiography. Results from all four methods were approximately equivalent in measurements of vessel diameters and cross-sectional areas. Intravascular ultrasound detected 15 plaque sites, with external ultrasound finding 12 of these 15, and angiography imaging only 6 of them. On the other hand, neither angiography nor external ultrasound found plaque sites not found by intravascular ultrasound. Interpretations of angiography and intravascular ultrasound disagreed in 9 out of 10 cases of hard plaques as to whether the lesions were calcified. These results demonstrate intravascular ultrasound can determine vessel dimensions as well as other techniques. It also seems better able to find plaque sites. Further research needs to be done to see if is more accurate than angiography in characterizing these plaque sites. (Consumer Summary produced by Reliance Medical Information, Inc.)

Cogan's syndrome is a rare disease characterized by the following abnormalities: interstitial keratitis, or inflammation of the cornea, which is the covering on the front portion of the eyeball; tinnitus, a ringing or tinkling sound in the ear; vertigo or dizziness; and often deafness. Eye disease in Cogan's syndrome may also involve inflammation of other portions of the eye, such as the iris or conjunctiva, and can progress to a more severe vision-threatening stage. Cogan's syndrome may also be associated with vasculitis, or inflammation of the blood vessels, which occurs in about 10 percent of patients. Out of 43 patients with Cogan's syndrome examined between 1977 and 1989, four cases are described. These cases include one patient with vision-threatening inflammatory eye disease, two patients with large-vessel vasculitis, and one patient with both disorders. The patients were successfully treated with a combination of immunosuppressive agents, which are drugs that suppress the immune or natural defense system, and corticosteroids. Immunosuppressive therapy included combinations of prednisone and cyclophosphamide or prednisone and cyclosporin A. (Consumer Summary produced by Reliance Medical Information, Inc.)

The presence of left ventricular outflow tract obstruction (LVOTO) of either a resting or dynamic nature may have important therapeutic and prognostic implications in patients with hypertrophic cardiomyopathy (HCM). Doppler [...]

The purpose of this study was twofold: (1) to determine interobserver variability of echocardiographic characteristics of vegetations in patients with infective endocarditis, and (2) to assess the value of these vegetation characteristics in predicting embolic events. Although echocardiography contributes to the diagnosis of patients with infective endocarditis, its prognostic role in predicting embolic events is controversial. The echocardiograms of 41 patients with infective endocarditis were independently reviewed by 4 echocardiographers blinded to the clinical data. If a vegetation was present, the following characteristics were analyzed: involved site, size, mobility, shape, and pedunculated or sessile attachment. Each echocardiographer also made a 'gestalt' estimate of embolic risk based on these vegetation characteristics. Interobserver agreement on vegetation characteristics and their relation to embolic events was then determined using K statistics and logistic regression analysis. Interobserver agreement was 98% with regard to echocardlographic vegetation presence and 97% with regard to the involved site. Of the 30 patients in whom vegetations were observed, complete observer agreement was achieved with regard to size in 22 (73%), mobility in 17 (57%), shape in 11 (37%), and attachment in 12 (40%). Vegetations with a maximal diameter of >10 mm were associated with a 50% incidence of embolic events, compared with a 42% incidence of emboli in patients with vegetations measuring [less than to equal]10 mm. Interobserver variability was great with respect to vegetation shape, mobility, and attachment characteristics. Echocardiographic vegetation characteristics were not helpful in defining the risk of embolic complications in patients with endocarditis. (Am J Cardiol 1994;74:799-801)

Using echocardiography effectively Twenty-five years after echocardiography was introduced in this country, indications for its use continue to multiply. Up-to-date knowledge of its applications is the key to ordering it [...]

Infective endocarditis is the inflammation of the lining membrane of the heart resulting from infection by microorganisms, and may affect the endocardium (the inner lining membrane of the heart). Mural vegetations are abnormal fiber-like growths on the wall of the heart, and commonly result from a lesion in the wall caused by a regurgitant stream, or backflow of blood, into the heart. Vegetations can be detected by two-dimensional echocardiography, a diagnostic technique that uses sound waves to visualize internal structures. The incidence of vegetations in infective endocarditis ranges from 43 to 100 percent, and vegetations may be indicative of embolic complications (disorders associated with the formation of unstable blood clots). Cases are described of six patients with infective endocarditis and mural vegetations, which were detected and characterized by two-dimensional echocardiography. Doppler color flow imaging, a diagnostic technique which permits the analysis of blood flow within the heart, showed that the mural vegetations developed in the left atrium, and most likely resulted from a regurgitant stream. In the transesophageal form of echocardiography, the transducer (device that detects the sound wave signals) is placed in the area of the esophagus. This method was shown to be effective in studying the location and size of the vegetations attached to left atrial wall. Five of the six patients developed blood clots (emboli), suggesting that mural vegetations are associated with a high risk of emboli formation. (Consumer Summary produced by Reliance Medical Information, Inc.)