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Left atrial volume and exercise capacity are strong predictors of cardiovascular risk. Decreased exercise capacity is expected when LAV is increased due to its association with abnormal left ventricular filling pressure. However, LAV enlargement is expected in chronic mitral regurgitation as well.To examine the link between LAV and exercise capacity in chronic MR and to determine whether larger LAV has indeed better exercise capacity in patients with chronic severe degenerative MR and good LV systolic function.The study included asymptomatic patients with severe chronic degenerative MR and normal LV systolic function that underwent stress echocardiography. LAV was measured at rest using the biplane Simpson's method and indexed to body surface area. The cutoff of good exercise capacity was determined at 7 METS.The patient group comprised 52 consecutive patients (age 60 +/- 14 years, 36 males). Two subgroups (19 vs. 33 patients), age- and gender-matched, were formed according to LAVi cutoff of 42 ml/m2. Those with higher LAVi had lower exercise capacity (P = 0.004) albeit similar MR grade, baseline blood pressure, LV function and size. Receiver-operator curve analysis revealed indexed LAV value ofor = 42 as 51% sensitive and 88% specific for predicting exercise capacity7 METS (AUC = 0.7, P = 0.03). In multivariate analysis, age, gender and LAVi were identified as independent predictors of exercise capacity.In asymptomatic patients with severe chronic degenerative MR and normal LV systolic function, mild enlargement of the left atrium (or = 42 ml/m2) is associated with good exercise capacity.

The atrial arrhythmia profile during inferior wall acute myocardial infarction (AMI) has not been systematically examined with respect to right ventricular (RV) involvement. To this end, 62 consecutive patients with first inferior wall AMI and no other conditions known to increase susceptibility for rhythm disturbances were studied by 24-hour Holter monitoring during the first and tenth day of infarction. Based on radionuclear ventriculography performed on day 2 of infarction, patients were allocated to two groups: group A--36 patients (58%) with right ventricular ejection fraction (RVEF) less than 40% (mean +/- SD, 31 +/- 6%) and group B--26 patients (42%) with normal (greater than 40%) RVEF (mean +/- SD, 47 +/- 5%). There were no significant differences between the two groups with respect to age, sex, or left ventricular (LV) function. In the group as a whole, ectopic activity in the different categories of atrial arrhythmias was significantly higher during the first day than on the tenth day of infarction. Comparing the two groups, 33 patients (92%) in group A had a mean hourly frequency of one or more atrial premature contractions (APCs) during the first day of infarction compared with 18 patients (69%) in group B (p less than 0.001). Atrial and supraventricular tachycardia were recorded more frequently in group A patients (16 of 36 [44%] versus 8 of 26 [31%]) as well as atrial fibrillation (AF) (7 of 36 [19%] versus 1 of 26 [4%]). Quantitative analysis showed a similar trend for a higher rate of ectopic events in group A patients. Ectopic activity was neither influenced by LVEF nor by age or sex.(ABSTRACT TRUNCATED AT 250 WORDS)

Right-sided chest leads (V3-V4R) were recorded in the early stages of first inferior wall acute myocardial infarction (AMI) in 100 consecutive patients. Nine patients (9%) presenting with S-T segment depression (greater than 1 mm) in these leads were subsequently studied by echocardiography and radionuclear angiography. In this group, there were 5 patients with intact right ventricular (RV) function and 4 other patients with clinical findings compatible with RV infarction. We suggest that one should not rule out RV involvement when S-T segment depression rather than elevation is seen in the right precordial leads in the presence of inferior wall AMI. An individual assessment for RV infarction is recommended when this pattern is apparent on the ECG.

Hemolysis is one of the potentially serious complications of prosthetic heart valves. It is usually associated with either structural deterioration or paravalvular leak. Mild, compensated hemolysis associated with mechanical heart valves is not uncommon even in the current era. Severe hemolysis is rare, however, and usually reflects paravalvular leak. The use of transesophageal echocardiography-guided operative techniques may help prevent or minimize early postoperative paravalvular leakage. There is a gamut of available therapeutic approaches-medical, transcatheter, and surgical-to this complication and therapy should be tailored to the individual patient. Novel pharmacological agents include erythropoietin and pentoxifylline. Several reports described the feasibility of transcatheter closure of paravalvular leak with coils or devices, but their effect on hemolysis is unpredictable. Surgery remains the treatment of choice in severe cases.

Background: Atherosclerosis is a complex histopathologic process that is analogous to chronic inflammatory conditions. Several factors have been shown to correlate with the extent of atherosclerosis. Whereas hypertension, obesity, hyperlipidemia, diabetes, smoking, and family history are all well documented, recent literature points to additional associated factors. Thus, antibodies to oxidized low-density lipoprotein (oxLDL), cytomegalovirus (CMV), Chlamydia pneumonia, Helicobacter pylori, as well as homocysteine and C-reactive protein (CRP) levels have all been implicated as independent markers of accelerated atherosclerosis. Hypothesis: In the current study we attempted to formulate a system by which to predict the extent of coronary atherosclerosis as assessed by angiographic vessel occlusion. Methods: The 81 patients were categorized as having single-, double-, triple-, or no vessel involvement. The clinical data concerning the “classic” risk factors were obtained from clinical records, and sera were drawn from the patients for determination of the various parameters that are thought to be associated with atherosclerosis. Results: Using four artificial neural networks, we have found the most effective parameters predictive of coronary vessel involvement were (in decreasing order of importance) antibodies to oxLDL, to cardiolipin, to CMV, to Chlamydia pneumonia, and to β2-glycoprotein I (β2GPI). Although important in the prediction of vessel occlusion, hyperlipidemia, hypertension, CRP levels, and diabetes were less accurate. Conclusion: The results of the current study, if reproduced in a larger population, may establish an integrated system based on the creation of artificial neural networks by which to predict the extent of atherosclerosis in a given subject fairly and noninvasively.

Fifteen patients aged 10 to 18 years with syncope of unknown origin, and 10 healthy control children aged 11 to 18 years, were evaluated by head-up tilt to 60 degrees for 60 minutes. Six patients (43%) reproduced symptoms of syncope during the examination. Four had a typical vasovagal reaction; two had marked hyperventilation. None of the children in the control group had syncope. The head-up tilt test offers a simple, noninvasive, high-yielding diagnostic tool for evaluation of syncope in children.

Myocardial injury, developed after a period of ischemia/reperfusion (I/R) results in the destruction of functional heart tissue, this being replaced by scar tissue. Intracellular signaling pathways mediating cardiomyocyte death are partially understood and involve the activation of Ras. p38-MAPK, JNK and Mst-1 are downstream effectors of Ras protein. We hypothesized that S-farnesylthiosalicylic acid (FTS), a synthetic small molecule that detaches Ras from the inner cell membrane, consequently inhibiting Ras activity, reduces I/R myocardial injury in vitro and in vivo. Wistar rat hearts were isolated, mounted on the Langendorff apparatus and subjected to ischemia (30 min, 37 degrees C) and reperfusion. During the reperfusion period, the hearts were perfused with FTS (1 microM) solution or control buffer. Left anterior descending (LAD) ligation and subsequent reperfusion was performed in two groups of Wistar rats. Rats received 5mg/kg FTS or PBS according to two protocols: (A) FTS or PBS were administered daily 7 days prior, immediately before and 14 days (every other day) after LAD occlusion or (B) every other day for 14 days post-I/R. Hearts from FTS-treated rats (Langendorff) and FTS-treated rats (protocol A) showed a significant improvement in myocardial performance and smaller scar tissue compared with the PBS group. Infarct size in the FTS-treated group was 12.7+/-2% vs. 23.7+/-4% in the PBS-treated (in vitro) group and 17.3+/-2.5% vs. 36+/-7% compared with control I/R rats (in vivo) p

The study aim was to assess the clinical utility and added value of exercise stress echocardiography (ESE) over exercise testing alone in asymptomatic patients with severe aortic stenosis (AS).The results of treadmill ESE in 101 consecutive patients (59 males, 42 females; mean age 69 +/- 10 years; range: 35-85 years) with asymptomatic severe AS (aortic valve area (AVA)1 cm2 and/or mean transvalvular pressure gradientor =50 mmHg) and normal left ventricular function, were analyzed. The test was considered abnormal if stopped prematurely because of limiting symptoms, a fall or small rise in systolic blood pressure, or complex ventricular arrhythmia.The mean resting AVA was 0.74 +/- 0.13 cm2, and peak and mean transvalvular gradients were 91 +/- 19 and 57 +/- 13 mmHg, respectively. In total, 69 patients (68%) developed an abnormal response, including symptoms (n = 48) and abnormal blood pressure response (n = 44). There were no cases of syncope or other major complications. Exercise transaortic pressure gradients could not be used to discriminate patients with otherwise normal and abnormal ESE or cardiac events. An abnormal contractile response was observed in 12 patients, in seven of whom it was the only ESE abnormal parameter. A total of 96 patients (95%) was followed up for a mean of 35 +/- 14 months. Aortic valve replacement-free survival was significantly lower in patients with an abnormal ESE result compared to those with a normal result.ESE has a limited added value to exercise testing alone in asymptomatic patients with severe AS. In a small percentage of these cases an abnormal contractile response, despite otherwise normal exercise parameters, constitutes a new finding that deserves further investigation.

Tricuspid regurgitation (TR) in patients with mitral valve (MV) disease is associated with poor outcome and predicts poor survival, heart failure, and reduced functional capacity. It is common if left untreated after MV replacement mainly in rheumatic patients, but it is also common in patients with ischemic mitral regurgitation. It is less common, however, in those with degenerative mitral regurgitation. It might appear many years after surgery and might not resolve after correcting the MV lesion. Late TR might be caused by prosthetic valve dysfunction, left heart disease, right ventricular (RV) dysfunction and dilation, persistent pulmonary hypertension, chronic atrial fibrillation, or by organic (mainly rheumatic) tricuspid valve disease. Most commonly, late TR is functional and isolated, secondary to tricuspid annular dilation. Outcome of isolated tricuspid valve surgery is poor, because RV dysfunction has already occurred at that point in many patients. MV surgery or balloon valvotomy should be performed before RV dysfunction, severe TR, or advanced heart failure has occurred. Tricuspid annuloplasty with a ring should be performed at the initial MV surgery, and the tricuspid annulus diameter (or=3.5 cm) is the best criterion for performing the annuloplasty. In this article we will review the current data available for understanding the prognostic implications, mechanism, and management of TR in patients with MV disease.

The shortage of available donor hearts limits the number of cardiac transplantations worldwide and in Israel as well. This organ shortage results in 15%-20% annual mortality of heart transplant candidates. For the sub-group of hospitalized decompensated heart failure patients depending on continuous inotropic support (Status I), the annual mortality is over 50%. Suboptimal utilization of donor hearts has been one of the reasons for the organ shortage. In 2004, only 42% of the potential donor hearts in Israel were eventually transplanted. The objective of this report is to define guidelines regarding the suitability of potential cardiac donors allowing more liberal criteria for accepting borderline donor hearts. Implementing the new guidelines will permit the utilization of organs that otherwise would have been discarded.

Perivalvular leak (PVL) may have significant hemodynamic and/or hematological consequences, and re-do surgery is associated with considerable mortality and morbidity. Herein are reviewed the short-term results of percutaneous closure of PVLs using the Amplatzer occluder.Eleven patients (five males, six females; mean age 59.7 +/- 7.3 years; range: 46-67 years) were referred for percutaneous closure of PVL using the Amplatzer occluder. Patients presented with congestive heart failure (n = 2), hemolysis (n = 1), or both (n = 8). The average number of previous heart operations was 2.4 +/- 1.3 per patient; seven patients had undergone two or more operations. The procedure was performed under general anesthesia, with fluoroscopic and transesophageal echocardiographic guidance. Antegrade and retrograde approaches were used for the mitral and aortic leaks, respectively.The PVLs were in the mitral position (n = 8), aortic position (n = 1), or both (n = 2). Device deployment was achieved in 11 (91.7%) of 12 attempted valves (10 patients, 90.9%). Failure to cross the leak with the wire occurred in one patient, and interruption of mitral leaflet movement occurred in two patients. Leakage was decreased in six patients (60%), but residual leak was observed at 10 of the 11 sites. Hemolysis was reduced in four patients, increased in four, and remained unchanged in two. An improved NYHA functional class of one grade was noted in five patients. One patient required a second operative session to seal a residual leak.Percutaneous closure of PVL using the Amplatzer occluder is feasible, but technically demanding. Although symptoms were improved, there was an inconsistent effect on hemolysis. At present, the Amplatzer occluder should be reserved for poor surgical candidates.

[corrected] The use of intraoperative transesophageal echocardiogram in patients with infective endocarditis is usually reserved for cases of inadequate preoperative testing or suspected extension to perivalvular tissue.To explore the impact of routine intraoperative TEE in patients with infective endocarditis.The impact of intraoperative TEE on the operative plan, anatomic-physiologic results, and hemodynamic assessment or de-airing was analyzed in 59 patients (38 males, 21 females, mean age 57.7 +/- 16.8 years, range 20-82) operated for active infective endocarditis over 56 months.Immediate pre-pump echocardiography was available in 52 operations (86.7%), and changed the operative plan in 6 of them (11.5%). Immediate post-pump study was available in 59 patients (98.3%) and accounted for second pump-run in 6 (10.2%): perivalvular leak (3 cases), and immobilized leaflet, significant mitral regurgitation following vegetectomy, and failing right ventricle requiring addition of vein graft (1 case each). Prolonged de-airing was necessary in 6 patients (10.2%). In 5 patients (8.5%) the postoperative study aided in the evaluation and treatment of difficult weaning from the cardiopulmonary bypass pump. In 21 patients (35.6%) the application of intraoperative TEE affected at least one of the four pre-specified parameters.Intraoperative TEE has an important role in surgery for infective endocarditis and should be routinely implemented.

Actinomyces endocarditis is very rare. At present the only Actinomyces species identified causing endocarditis are A. israelii, A. bovis, A. viscosus, A. pyogenes, A. meyeri and A. funkei. We here report the first case of endocarditis caused by Actinomyces neuii.

Significant association was found between the presence of mitral annular calcium (MAC) and aortic atheroma detected by transesophageal echocardiography. MAC may be an important marker for aortic atherosclerosis.

Background After heart valve replacement, patients are at risk of complications that are linked to irregular oral anticoagulation therapy. Depending on the type and position of the valve, the complication rate is 3% to 6% per patient-year. This study presents clinical results of a device enabling early detection of prosthetic dysfunction by frequency measurements. Methods Between November 2003 and March 2006, ThromboCheck devices were handed out to 483 patients after mechanical heart valve replacement from six heart centers. In each case, the devices were calibrated for individual patients early postoperatively. Taking control measurements, the device calculated deviations from calibrated frequency and amplitude ranges using a fast Fourier transform and sent a warning message to the display if any relevant changes occurred. This message was taken as cause to determine morphologic correlations of the disturbance using imaging techniques, for example, echocardiography or fluoroscopy (observation period, 550.7 patient-years; median application period, 15.1 months). Results Twenty-five true positive, 1 false positive, and no false negative measurements occurred. Eleven patients (44%) received thrombolytic therapy with streptokinase or recombinant tissue-type plasminogen activator, resulting in normalization of the digital frequency analysis. In 4 patients (16%), international normalized ratio levels were adjusted under temporary heparinization therapy. Normalization of the valve sounds were achieved within 3 to 7 days. Seven patients (28%) required reoperation despite lysis therapy. Sensitivity was 100% during the observation period; specificity was 99.8%. Conclusions Digital frequency analysis represents a reasonable addition to the monitoring of patients after artificial heart valve replacement to detect prosthesis-related complications early on.

We have previously found that uridine 5′-triphosphate (UTP) significantly reduced cardiomyocyte death induced by hypoxia via activating P2Y2 receptors. To explore the effect of UTP following myocardial infarction (MI) in vivo we studied four groups: sham with or without LAD ligation, injected with UTP (0.44 µg/kg i.v.) 30 min before MI, and UTP injection (4.4 µg/kg i.v.) 24 h prior to MI. Left ventricular end diastolic area (LVEDA), end systolic area (LVESA) fractional shortening (FS), and changes in posterior wall (PW) thickness were performed by echocardiography before and 24 h after MI. In addition, we measured different biochemical markers of damage and infarct size using Evans blue and TTC staining. The increase in LVEDA and LVESA of the treated animals was significantly smaller when compared to the MI rats (p < 0.01). Concomitantly, FS was higher in groups pretreated with UTP 30 min or 24 h (56 ± 14.3 and 36.7 ± 8.2%, p < 0.01, respectively). Ratio of infarct size to area at risk was smaller in the UTP pretreated hearts than MI rats (22.9 ± 6.6, 23.1 ± 9.1%, versus 45.4 ± 7.6%, respectively, p < 0.001). Troponin T and ATP measurements, demonstrated reduced myocardial damage. Using Rhod-2-AM loaded cardiomyocytes, we found that UTP reduced mitochondrial calcium levels following hypoxia. In conclusion, early or late UTP preconditioning is effective, demonstrating reduced infarct size and superior myocardial function. The resulting cardioprotection following UTP treatment post ischemia demonstrates a reduction in mitochondrial calcium overload, which can explain the beneficial effect of UTP.

ObjectiveSeveral studies have recently reported an association between aortic valve calcification and atherosclerosis of the cardiovascular system, suggesting that aortic valve calcification might represent an atherosclerosis-like process. Hence the aim of the present study was to determine whether there is a similar association between aortic stenosis and aortic atheromas.MethodsWe evaluated the records and echocardiographic videotapes of 91 consecutive patients with severe aortic stenosis who underwent intraoperative transesophageal echocardiography before aortic valve replacement to measure the presence and characteristics of aortic atheromas. There were 50 men (55%) and 41 women (45%). The mean age was 71.9 ± 9.4 years (range, 34–91 years). These patients were compared with 91 sex-and age-matched patients without aortic stenosis who underwent transesophageal echocardiography for various indications. Aortic atheroma was defined as localized intimal thickening of 3 mm or larger. A lesion was considered complex if there was a plaque extending 5 mm or more into the aortic lumen; if the lesion was protruding, mobile, or ulcerated; or both.ResultsThe aortic stenosis group had significantly higher rates of aortic atheromas (85% vs 37%, P < .001) and complex atheromas (47% vs 9%, P < .001) compared with the control group. In the vast majority of patients in the aortic stenosis group, the aortic atheromas were localized in the aortic arch (60 [66%] patients, with 50% being complex aortic atheromas) and in the descending aorta (70 [77%] patients, with 45.7% being complex aortic atheromas); in only 4 (4.4%) patients, the aortic atheromas were localized in the ascending aorta (50% complex aortic atheromas).ConclusionsThere is a strong association between the presence of severe aortic stenosis and the presence and severity of aortic atheromas, suggesting that aortic stenosis might be a manifestation of the atherosclerotic process. These findings imply that (1) aggressive atherosclerotic risk-factor modification for patients with aortic stenosis might be advisable and (2) consideration of evaluation of the aorta by means of transesophageal echocardiography before aortic valve replacement in selected patients might be helpful.

Aortic root dilation has been previously reported to be associated with aortic stenosis (AS), but data to support this statement are scarce. The dimensions of the aortic root were measured at 4 levels (annulus, sinuses, sinotubular junction, and ascending aorta) in 88 patients (mean age 71.2+/-9.7 years; 56% men) with severe AS who underwent intraoperative transesophageal echocardiography immediately before aortic valve replacement. These patients were compared with 76 gender- and age-matched patients without AS who underwent transesophageal echocardiography for various indications. The etiology of aortic valve stenosis was degenerative in 62 (70.5%), bicuspid aortic valve (BAV) in 15 (17.0%), and rheumatic in 11 (12.5%). The ascending aorta was significantly wider in AS with various etiologies (BAV, rheumatic, degenerative) than in the controls (39+/-6.9, 35.0+/-4.2, 33.1+/-4.1, and 31.3+/-3.7 mm, respectively; p0.001). The dimensions of the sinuses and sinotubular junction were significantly less in those with AS of degenerative etiology than in the controls (29.5+/-4.0 vs 32.5+/-4.3 mm and 23.6+/-3.0 vs 26.8+/-3.0 mm, respectively, p0.001). The prevalence of a dilated aorta (37 mm) was 3.9%, 13.1%, 36.4%, and 60% in the control group and AS patients with degenerative, rheumatic, and BAV etiology, respectively (p0.0001). In conclusion, patients with severe AS due to BAV had significant dilation of the aortic root. Patients with degenerative and rheumatic etiology had less remarkable dilation compared with control group, and most values were within the normal range.

The objective of the study was to evaluate the association between heart valve calcification and atherosclerosis and outcome in systemic lupus erythematosus (SLE). One-hundred and seven patients with SLE (mean age 45.9 +/- 14.7 years) were studied by 2D transthoracic echocardiography. Mitral annulus calcification (MAC) was detected in 24 patients (22.6%) and aortic valve calcification (AVC) in 22 (20.1%). Both MAC and AVC were associated with older age (r = 0.2, p = 0.02; r = 0.40, p

Tissue Doppler imaging (TDI) provides rapid assessment of systolic and diastolic myocardial function. However, the added value of TDI to standard Doppler echocardiographic measurements in predicting symptoms and outcome of advanced heart failure remains unknown.The study cohort comprised 45 patients with congestive heart failure, defined as New York Heart Association functional class III and IV, who were referred to our department for evaluation for heart transplantation. Twenty healthy subjects were the controls. Conventional echo Doppler was used to assess left ventricular (LV) ejection fraction, peak velocities of transmitral early and late diastolic LV filling, the ratio of transmitral early to late LV filling velocity, and E-deceleration time. TDI measurements recorded at the mitral annulus included systolic velocity, early and late diastolic velocities, and the ratio of early to late diastolic velocity. The ratio of transmitral early LV filling velocity to early diastolic TDI velocity of the mitral annulus (E/E') was calculated. All patients were followed for cardiac-related death and hospitalization for heart failure.Patients with functional class IV had a significantly higher E/E' ratio than did patients with functional class III (12.9 +/- 2.8 vs 8.3 +/- 1.7, p0.001) and the controls (5.4 +/- 1.3, p0.001). Except for transmitral late filling velocity, all conventional echo Doppler parameters and TDI variables significantly correlated with functional class. On multivariate stepwise analysis, however, the E/E' ratio was the only independent predictor of functional class (p = 0.003). E/E' also correlated with cardiac mortality and hospitalization.Conventional Doppler indices and TDI parameters correlated with functional class in patients with advanced heart failure. The E/E' ratio, which probably reflects high LV end-diastolic pressure, was the best measure for differentiating patients with functional class III and IV, and it also correlated with cardiac mortality and hospitalization for worsening heart failure, thereby providing additional value to standard echocardiographic measures.

Background: To investigate possible association between infection with CagA + strains of Helicobacter pylori and aortic atheroma diagnosed by transesophageal echocardiography. Methods and results: One hundred and eighty-eight consecutive subjects prospectively examined for presence of aortic atheroma (localized intimal thickening of ≥3mm) by transesophageal echocardiography were tested for serum IgG antibodies against H. pylori (enzyme-linked immunosorbent assay) and CagA protein (Western blot assay). The association between infection with H. pylori , CagA status of the infecting H. pylori strains, and aortic atherosclerosis was evaluated after adjusting for coronary artery disease risk factors. There was a linear trend for presence of atheroma in subjects with CagA-positive H. pylori infection (51/81, 63%) compared to subjects with CagA-negative H. pylori infection (21/45, 46.7%) and uninfected subjects (18/62, 29%) ( p =0.003). H. pylori seropositivity was not associated with aortic atheroma (OR 2.9; 95% CI, 0.8–10.3; p =0.11) when CagA status is not taken into account. On multivariate analysis, parameters associated with risk of aortic atheroma were CagA-positive H. pylori seropositivity (OR 4.4; 95% CI, 1.4–14.7; p =0.01), older age (OR 1.2; 95% CI, 0.9–14.7; p =0.01), having ever smoked cigarettes (OR 3.6; 95% CI, 1.3–10.0; p p =0.02). Conclusions: After controlling for H. pylori infection and coronary artery disease risk factors, infection with a CagA-positive strain of H. pylori was independently associated with aortic atherosclerosis. This study suggests a gradient of atherosclerosis between uninfected individuals and patients with CagA-positive H. pylori infection and should prompt research into the role of CagA-positive H. pylori infection in the inflammatory atherosclerotic process.

Background The role of intraoperative transesophageal echocardiography (IOTEE) in valve replacement surgery is not well established. The aim of this study was to explore the impact of immediate postpump IOTEE in valve replacement surgery at a single tertiary medical center. Methods The departmental database was screened for valve replacement operations (mechanical or bioprosthetic valves) performed during a 55-month period that were succeeded by immediate postpump IOTEE. Data was gathered regarding the impact of IOTEE on the immediate postoperative course. Results The study group included 417 patients (44.8% male, 55.2% female, age 65.2 ± 13.9 years). Prepump IOTEE was performed in 352 patients (84.4%). A single valve was replaced in 336 patients (80.6%) and two or more valves were replaced in 81 patients (19.4%). Overall 501 valves were inserted: mitral, 237 (131 mechanical, 106 biological); aortic, 221 (89 mechanical, 132 biological); tricuspid, 43 (2 mechanical, 41 biological). Unexpected pathologic echocardiographic findings on postpump IOTEE necessitated immediate surgical correction in 15 patients (3.6%): perivalvular leak in 8 patients (4 mitral, 4 aortic), immobilized leaflet in 4 patients (3 mitral, 1 tricuspid), coronary obstruction by an aortic bioprosthesis in 2 patients, and incompetent xenograft in 1 patient. Prolonged removal of air was necessary in 45 patients (10.8%). In 47 patients (11.3%) the postpump IOTEE contributed to the evaluation of difficult weaning from the bypass pump and to its appropriate therapeutic management (volume expansion, inotropic agents, vasodilators, or mechanical assistance). Conclusions Immediate postpump IOTEE is an important diagnostic and therapeutic role in valve replacement surgery and should be widely implemented.

Decreased elasticity of the aorta is associated with aging and several risk factors of atherosclerosis. The data regarding this phenomenon in patients with familial hypercholesterolemia are rather sparse.To evaluate non-invasively the elasticity of the proximal ascending aorta of 51 heterozygous FH patients compared to 42 normal age and gender-matched controls.Aortic elasticity was estimated by transthoracic echocardiography using the "pressure-strain" elastic modulus and aortic strain formulas.The elastic modulus score was higher in the FH group than in the controls (1.12 +/- 0.91 10(6) dynes/cm2 vs. 0.65 +/- 0.46 10(6) dynes/cm2 respectively, P = 0.01). This was consistent in both the pediatric (0.5 +/- 0.2 10(6) dynes/cm2 vs. 0.4 +/- 0.1 10(6) dynes/cm2 respectively, P = 0.009) and adult subgroups (1.3 +/- 1.0 10(6) dynes/cm2 vs. 0.8 +/- 0.5 10(6) dynes/cm2 respectively, P = 0.0004). Aortic strain was significantly lower in patients with FH than in controls (6 +/- 4% vs. 9 +/- 5% respectively, P = 0.0002). These findings reflected decreased elasticity of the proximal ascending aorta in the FH patients. In multivariate analysis, age, serum cholesterol level and serum triglycerides level were the independent predictors of the elastic modulus score, whereas age was the predictor of aortic strain.The elasticity of the proximal ascending aorta is decreased in heterozygous FH patients.

Severe tricuspid regurgitation (TR), diagnosed with echocardiography, is not necessarily symptomatic. The study aim was to identify echocardiographic markers associated with right-sided congestive heart failure (RCHF) in patients with severe TR.Ninety-six patients (30 males, 66 females; mean age 67 +/- 11 years) with echocardiographic findings of severe TR were followed clinically and with transthoracic echocardiography (TTE). Clinical data were collected on heavy diuretic consumption and signs of volume overload (neck vein congestion, lower-limb edema, ascites). TTE included evaluation of the right heart chamber dimensions, systolic function, pulmonary pressure and change in inferior vena cava (IVC) diameter during respiration. Patients were subdivided according to the presence (group A, n = 52) or absence (group B, n = 44) of signs of RCHF that included volume overload and heavy diuretic consumption (i.e.or = 80 mg furosemide/day or combined furosemide/spironolactone at any dosage).Among the patients, 52 (54.2%) had RCHF and 44 (45.8%) did not. Atrial fibrillation was present in 88% of group A and 76% of group B (p = NS). Group A patients had a significantly larger right ventricular area, right atrial area and IVC diameter than group B patients, but a significantly smaller variation in IVC diameter during respiration (11.2 +/- 8.5% versus 24.3 +/- 14.1%, p = 0.001). Right ventricular systolic function and systolic pulmonary pressure were similar in the two groups. On multivariate analysis, respiratory-related variation in IVC diameter (p0.001) and systolic pulmonary artery pressure (p = 0.04) were the only independent echocardiographic markers of RCHE CONCLUSION: Diminished respiratory variation in IVC diameter and systolic pulmonary artery pressure are independent markers of volume overload in patients with severe TR. These findings may reflect exhaustion of IVC capacitance due to markedly increased right heart filling pressures, though intrinsic changes in IVC tonus may also be involved.

ObjectivesThe goal of this study was to evaluate whether quantitation of thrombus burden with transesophageal echocardiography (TEE) can help risk-stratify patients undergoing thrombolysis of prosthetic valve thrombosis (PVT).BackgroundThrombolytic therapy of PVT has an unpredictable risk of embolization and complications.MethodsAn international registry of patients with suspected PVT undergoing two-dimensional/Doppler and TEE before thrombolysis was established. All TEE studies were reviewed and quantitated by a single observer blinded to all data.ResultsFrom 1985 to 2001, 107 patients (71 females; age 24 to 86 years) from 14 centers (6 in the U.S.) were identified. The majority of cases involved the mitral valve (79 mitral, 13 aortic, and 15 tricuspid). Hemodynamic success rate was achieved in 85% and was similar across valves. Overall complications were observed in 17.8%, and death in 5.6%. Predictors of complications were: New York Heart Association (NYHA) functional class, presence of shock, sinus tachycardia, hypotension, previous history of stroke, thrombus extension beyond the valve ring, and thrombus area. Multivariate analysis demonstrated that two variables were independent predictors of complications: thrombus area by TEE (odds ratio [OR] 2.41 per 1 cm2increment, 95% confidence interval [CI] 1.12 to 5.19) and prior history of stroke (OR 4.55, 95% CI 1.35 to 15.38). A thrombus area

The study aim was to explore the feasibility of demonstrating prosthetic bileaflet valve leaflet motion by two-dimensional (2D) transthoracic echocardiography (TTE).A total of 103 consecutive patients (55 females, 48 males; mean age 60.0+/-13.7 years), with a total of 119 normally functioning left-sided bileaflet valves (61 mitral, 58 aortic), was studied prospectively by TTE in six views each. A distinct, symmetric movement of both leaflets in opposite directions was considered a positive finding.Bileaflet motion imaging was feasible for all mitral prostheses. The mean number of positive views per valve was 3.6+/-0.9, and this was unaffected by valve model. The number of positive views was less for small (25 mm) valves than larger valves (2.7+/-1.1 versus 3.7+/-0.9; p = 0.007). The best views were four- and three-chamber (82% and 75.4% positive, respectively). Bileaflet imaging was feasible in 77.6% of patients with aortic prostheses (50% in two or more views). The mean number of positive views was 1.6+/-1.2, and this was unaffected by valve model and size. The parasternal short- axis and subcostal views provided the majority of positive imaging (84.4%).2D imaging on TTE can reliably demonstrate normal mitral bileaflet motion. However, this procedure is less accurate for aortic valves, and other diagnostic modalities (transesophageal echocardiography or fluoroscopy) should be implemented when malfunction is suspected.

Background: The interruption of oral anticoagulant (OAC) administration is sometimes indicated in patients with mechanical heart valves, mainly before noncardiac surgery, non-surgical interventions, and pregnancy. Unfractionated heparin (UH) is currently the substitute for selected patients. Low-molecular-weight heparin (LMWH) offers theoretical advantages over UH, but is not currently considered in clinical guidelines as an alternative to UH in patients with prosthetic valves. Hypothesis: The aim of the present study was to review the data accumulated so far on the use of LMWH in this patient population and to discuss its applicability in common practice. Methods: For this paper, the current medical literature on LMWH in patients with mechanical heart valves was extensively reviewed. Results: There were eight series and six case reports. None of the studies was randomized, and only one was prospective. Data to establish the thromboembolic risk were incomplete. After excluding case reports, the following groups were constructed: (a) short-term administration, after valve insertion (n = 212);(b) short-term, perioperative (noncardiac)/periprocedural (n = 114);(c) long-term, due to intolerance to OAC (n = 16);(d) long-term, in pregnancy (n = 10). The incidence rate of thromboembolism was 0.9% for all the studies and 0.5, 0, 20, and 0% in groups a, b, c, and d, respectively; for hemorrhage, the overall rate was 3.4% (3.8, 2.6, 10, and 0% for the respective groups). Conclusions: In patients with mechanical heart valves, short-term LMWH therapy compares favorably with UH. Data on mid- and long-term LMWH administration in these patients are sparse. Further randomized studies are needed to confirm the safety and precise indications for the use of LMWH in patients with mechanical heart valves.

Background : Aortic valve calcification without obstruction (AVC) is common in the elderly and is associated with increased cardiovascular mortality and morbidity. We hypothesized that AVC detected by transthoracic echocardiography (TTE) is a marker for significant coronary artery disease in patients undergoing coronary angiography. Methods: The study group included 388 patients with AVC (259 males, 129 females; mean age 72.2±9 years) who underwent coronary angiography for various indications. Data were compared with 320, age- and sex-matched patients without AVC who underwent coronary angiography for the same indications. AVC was detected in TTE as focal areas of increased echogenecity and thickening of the aortic-valve leaflets without restriction in motion. Significant obstructive coronary artery disease was defined as either a ≥70% reduction of the internal diameter of the left anterior descending, right coronary, or left circumflex artery distribution or a ≥50% reduction of the internal diameter of the left main coronary artery. Risk factors for atherosclerosis including hypertension, smoking, hypercholesterolemia and diabetes were also investigated. Results: Compared with control group, the AVC group had a higher prevalence of significant coronary artery disease (90 vs. 85%, P =0.019), and a trend for lower frequency of coronary arteries without obstruction (6 vs. 9%, P =0.l1); a trend was also noted for 3-vessel disease (38 vs. 33%, P =0.14). Multivariate analysis identified age ( P =0.000l), sex ( P =0.000l), hypercholesterolemia ( P =0.005) and AVC ( P =0.02) as independent predictors for significant coronary artery disease. Conclusions: There is a significant association between AVC and significant coronary artery disease in patients undergoing coronary angiography. Thus AVC can serve as a window to atherosclerosis of the coronary arteries. These results reinforce a previous observation regarding association between AVC and increased risk of cardiovascular morbidity.

Objective To evaluate the role of transesophageal echocardiography (TEE) in detecting cardiac and thoracic aortic sources of retinal emboli. Design Retrospective observational case series. Participants The study population consisted of 18 patients who were initially seen with retinal artery occlusion (7 central, 11 branch) and underwent TEE as part of the systemic evaluation. Intervention All patients underwent TEE, consisting of complete two-dimensional and Doppler color flow examinations. TEE was done immediately after transthoracic echo (TTE) examination. The medical records were reviewed. Main outcome measure Detection of a possible cardiac or thoracic aortic source of retinal embolus. Results Cardiac or thoracic aortic pathologic conditions, which were a possible source of the retinal emboli, were detected by TEE in 13 of the 18 patients (72%). They included aortic arch atheroma (n = 7), mitral annulus calcification (n = 4), left atrial appendage thrombus (n = 2), valvular abnormalities (n = 5), left atrial smoke (n = 3), and patent foramen ovale (n = 3). In 11 patients (61%), at least one cardiac or aortic source of emboli detected by TEE was missed by TTE. Significant carotid artery disease (≥40% stenosis) was present in 3 of 16 patients (17%). Conclusions TEE is a potentially useful modality for detecting possible sources of retinal artery emboli and may be considered as an adjunct to the routine evaluation of affected patients.

Mitral annulus calcification has been associated with embolic events, but the precise pathophysiology has not been elucidated. The authors describe four patients who experienced embolic events whose transesophageal echocardiograms showed a mitral annulus calcification, with a mobile component that exhibited the same echogenicity as the calcification. Three patients had no other conditions known to be associated with embolism. On follow-up transesophageal echocardiography, the mobile component of the mitral annulus calcification had disappeared in three patients. These findings support the hypothesis that mitral annulus calcification not only is associated with but also is possibly a direct cause of embolic events in some patients.

Mitral annulus calcification (MAC) is a chronic, non-inflammatory, degenerative process of the fibrous support structure of the mitral valve. It occurs more often in women and the elderly. MAC is associated with known atherosclerotic risk factors such as diabetes mellitus, hypertension and hypercholesterolemia. It is also known that patient with MAC have higher prevalence of left atrial and left ventricular enlargement, hypertrophic cardiomyopathy, atrial fibrillation, aortic valve calcification and stenosis, various cardiac conduction defects, bacterial endocarditis, cardiovascular events and stroke, though the etiological basis is unknown. Pathological studies from the 80s present a theory that MAC is a form of atherosclerosis. In order to test this theory we conducted during the last years a few clinical studies to examine the association of MAC and known atherosclerotic phenomena. We found higher prevalence of aortic atheroma in patients with MAC and atheroma thickness. We also found in MAC patients higher prevalence of carotid artery stenosis, coronary artery stenosis, peripheral artery stenosis and higher levels of beta2-Glycoprotein I antibodies in patients with MAC thickness equal or greater than 5 mm. These studies support the theory that MAC is a form of atherosclerosis and define a group of patients with higher prevalence of atherosclerotic disease in multiple blood vessels. The purpose of this review is to summarize the data concerning MAC and atherosclerotic processes, emphasizing that MAC in itself may be an atherosclerotic process.

Recently it was shown that subjects with aortic valve calcium (AVC) are at increased risk for future cardiovascular disease including stroke. We hypothesized that the increased risk of stroke may be due to an association with carotid artery atherosclerotic disease. Between 1995 and 1999 our laboratory made a diagnosis of AVC without significant stenosis in 3,949 patients. Of those, 279 patients without other cardiac structural exclusion criteria (148 men and 131 women; mean age 73 +/- 9 years, range 45 to 90) underwent carotid artery duplex ultrasound for various indications, and formed the study group. Age- and sex-matched patients without AVC (n = 277), who underwent carotid artery duplex ultrasound during the same period and for the same indications, served as the control group. Compared with the control group, the AVC group had a significantly higher prevalence of carotid stenosis (40% to 60%, 89% vs 78% [p0.001];60% to 80%, 43% vs 23% [p0.001];and80% to 100%, 32%vs 14% [p0.001]). The AVC group had a similar, significantly higher prevalence ofor = 2-vessel disease and bilateral carotid stenosis (stenosis levels of20% to 40%,40% to 60%,60% to 80%, and80% to 100%). In multivariate analysis, AVC, but not traditional risk factors, was the only independent predictor of severe carotid atherosclerotic disease (stenosis80% to 100%; p = 0.0001). Thus, there is a significant association between the presence of AVC and carotid atherosclerotic disease.

Background and purpose: Although mitral annulus calcification (MAC) has been reported to be a significant independent predictor of stroke, no causative relationship was proven. It is also known that aortic atheroma (AA), especially those ] 5m m thick and:or protruding and:or mobile are associated with stroke. This study was designed to determine whether an association exists between MAC and AA. Methods: We prospectively evaluated the records of 279 consecutive patients who underwent transesophageal echocardiography (TEE) for various indications to measure the presence and characteristics of AA. The 105 patients in whom a diagnosis of MAC was made on transthoracic echocardiography (TTE) immediately preceding the TEE, were compared with 174 age-matched patients without MAC. MAC was defined as a dense, localized, highly reflective area at the base of the posterior mitral leaflet. We measured MAC thickness with two-dimensional-TTE in four-chamber view and AA thickness, protrusion and mobility with TEE. AA was defined as localized intimal thickening of ] 3 mm. A lesion was considered complex if there was plaque extending ]5 mm into the aortic lumen and:or if it was protruding, mobile or ulcerated. Results: No differences were found between the groups in risk factors for atherosclerosis or in indications for referral for TEE. Significantly higher rates were found in the MAC group for prevalence of AA (91 vs. 44%, PB 0.001), atheromas ] 5 mm thick (68 vs. 19%, PB0.001), protruding atheromas (44 vs. 15%, PB0.001), ulcerated atheromas (10 vs. 1%, PB 0.001) and complex atheroma (74 vs. 22%, PB0.001). Sixty patients had MAC thickness ] 6 mm and 45B 6 mm. AA thickness was significantly greater in the patients with a MAC thickness of ]6 mm (6.192.8 vs. 5.09 2.6 mm, P 0.03). On multivariate analysis MAC, hypertension and age were the only independent predictors of AA (P 0.0001, 0.005 and 0.007, respectively). Conclusions: There is a significant association between the presence and severity of MAC and AA. MAC may be an important marker for atherosclerosis of the aorta. This association may explain in part the high prevalence of systemic emboli and stroke in patients with MAC. © 2000 Elsevier Science Ireland Ltd. All rights reserved.

Aortic valve calcium without stenosis and mitral annulus calcium (MAC) are known to correlate with atherosclerotic risk factors. Recently, it has been reported that MAC is associated with atherosclerosis of the cardiovascular system, suggesting MAC as an atherosclerotic process by itself. Hence, the aim of the present study was to determine whether a similar association between aortic valve calcium and aortic atheroma exists. Ninety-six patients (54 men and 42 women, mean age 72 +/- 12 years) with aortic valve calcium who underwent transesophageal echocardiography (TEE) formed the study group. They were compared with 92 sex- and age-matched patients without aortic valve calcium who underwent TEE for the same indications during the same period. The presence and echocardiographic features of aortic atheromas were evaluated by TEE. No differences were found between the groups in risk factors for atherosclerosis or in indications for referral for TEE. Significantly higher rates were found in the aortic valve calcium group for prevalence of aortic atheroma (86% vs 30%, p = 0.001). This significant trend was also consistent with the dimension and complexity of the atheromas. On multivariate analysis aortic valve calcium, and MAC were the only independent predictors of aortic atheroma (p = 0.0001, 0.006 respectively). We conclude that there is a significant association between the presence of aortic valve calcium and the presence and severity of aortic atheroma. Thus, aortic valve calcium may serve as a window to atherosclerosis of the aorta.

OBJECTIVES We sought to evaluate the effectiveness and safety of thrombolytic therapy in stuck mitral bileaflet heart valves in the absence of high-risk thrombi. BACKGROUND Current recommendations for the thrombolytic treatment of stuck prosthetic mitral valves are partially based on older valve models and inclusion of patients in whom high-risk thrombi were either ignored or not sought for. The feasibility and safety of thrombolysis in bileaflet models may be affected by the predilection of thrombi to catch the leaflet hinge. METHODS We studied 12 consecutive patients (men/women = 5/7, age 58.8 ± 14.9 years) who experienced one or more episodes of stuck bileaflet mitral valve over a 33-month period and received thrombolytic therapy with streptokinase, urokinase or tissue-type plasminogen activator. Transesophageal echocardiography was performed in all patients. Patients with mobile or large (>5 mm) thrombi were excluded. Functional class at initial episode was I–II in 4 patients (33.3%) and III–IV in 8 patients (66.6%). RESULTS Patients receiving thrombolytic therapy achieved an overall 83.3% freedom from a repeat operation or major complications (95% confidence interval 51.6–97.9%). Minor bleeding occurred in three patients (25%) and allergic reaction in one (8.3%). Transient vague neurologic complaints, without subjective findings, occurred in four patients (33.3%). Three patients had one or more relapses within 5.2 ± 3.1 months from the previous episode, and readministration of thrombolytics was successful. CONCLUSIONS In clinically stable patients with stuck bileaflet mitral valves and no high-risk thrombi, thrombolysis is highly successful and safe, both in the primary episode and in recurrence. The best thrombolytic regimen is yet to be established.

OBJECTIVESTo examine the relationship between the persistence of ST segment depression in leads V5–V6 after Q-wave anterior wall myocardial infarction (MI) and the filling pattern of the left ventricle (LV).BACKGROUNDPrecordial ST segment depression predominantly in leads V5–V6 is associated with increased in-hospital morbidity and mortality after acute myocardial ischemia, perhaps due to reduced diastolic distensibility of the LV.METHODSWe prospectively studied 19 patients after Q-wave anterior wall MI (>6 months). All patients underwent 12-lead ECG recording, symptom-limited treadmill exercise testing with single photon emission computed tomography thallium-201 imaging, transthoracic Doppler echocardiography, cardiac catheterization and measurement of circulating atrial natriuretic peptide (ANP) and brain natriuretic peptide (BNP) levels. Patients were classified based on the presence of ST segment depression in leads V5–V6: Group I = ST segment depression

Ten patients, who were admitted to the Intensive Coronary Care Unit during a one year period with symptomatic bradycardia while on combination therapy with oral diltiazem and beta-blocker agents, are described. The important features of this adverse reaction to drug combination were that it appeared mainly in a relatively elderly age group and with presenting symptoms of lethargy, dizziness, syncope, chest pain, and (in one patient with poor left ventricular function) pulmonary edema. It was not dose dependent and occurred even in very low doses of each drug. Electrophysiologic abnormalities were localized to the sinus node in all 10 patients and the primary rhythm disorders were junctional escape rhythm, sinus bradycardia, and sinus pause. These rhythm abnormalities resolved within 24 h following withdrawal of the offending drugs. Temporary pacemaker insertion was necessary in four patients. The duration of drug combination used before the acute episode range from within hours to up to 2 years. In conclusion, although combination diltiazem/beta blocker therapy is very effective in ischemic syndrome, caution is advised when this combination is used especially in the elderly or in patients with left ventricular dysfunction or antecedent sinoatrial or atrioventricular conduction abnormality.

Background and Purpose —It has been established that mitral annulus calcification (MAC) is an independent predictor of stroke, though a causative relationship was not proved, and that carotid artery atherosclerotic disease is also associated with stroke. The aim of this study was to determine whether there is an association between the presence of MAC and carotid artery atherosclerotic disease. Methods —Of the 805 patients in whom the diagnosis of MAC was made by transthoracic echocardiography between 1995 and 1997, 133 patients (60 men and 73 women; mean age, 74.3±8 years; range, 47 to 89 years) underwent carotid artery duplex ultrasound for various indications; the study group comprised these patients. They were compared with 129 age- and sex-matched patients without MAC (57 men and 72 women; mean age, 73.6±7 years; range, 61 to 96 years) who underwent carotid artery duplex ultrasound during the same period for the same indications. MAC was defined as a dense, localized, highly reflective area at the base of the posterior mitral leaflet. MAC was considered severe when the thickness of the localized, highly reflective area was ≥5 mm on 2-dimensional echocardiography in the 4-chamber view. Carotid artery stenosis was graded as follows: 0%, 20%, 40%, 60%, 80%, and 100%. Results —Compared with the control group, the MAC group showed a significantly higher prevalence of carotid stenosis of ≥40% (45% versus 29%, P =0.006), which was associated with ≥2-vessel disease (23% versus 10%, P =0.006) and bilateral carotid artery atherosclerotic disease (21% versus 10%, P =0.011). Severe MAC was found in 48 patients. More significant differences were found for the severe MAC subgroup (for carotid stenosis of ≥40%) in rates of carotid artery atherosclerotic disease (58% versus 29%, P =0.001), and ≥2-vessel disease (31% versus 10%, P =0.001), in addition to bilateral carotid artery stenosis (27% versus 10%, P =0.004) and even bilateral proximal internal carotid artery stenosis (21% versus 8%, P =0.015). Furthermore, significant carotid artery atherosclerotic disease (stenosis of ≥60%) was significantly more common in the severe MAC subgroup than in the controls (42% versus 26%, P P =0.02) and bilateral carotid artery stenosis (17% versus 7%, P =0.05). On multivariate analysis, MAC and age but not traditional risk factors were the only independent predictors of carotid atherosclerotic disease ( P =0.007 and P =0.04, respectively). Conclusions —There is a significant association between the presence of MAC and carotid artery atherosclerotic disease. MAC may be an important marker for atherosclerotic disease of the carotid arteries. This association may explain the high prevalence of stroke in patients with MAC.

Background: Lead III ST-segment depression during acute anterior wall myocardial infarction (AMI) has been attributed to reciprocal changes. However, the value of the T-wave direction (positive or negative) in predicting the site of obstruction and type of the left anterior descending (LAD) artery is not clear and has not been studied before. Hypothesis: The aim of the study was to assess retrospectively the correlation between two patterns of lead III ST-segment depression, and type of LAD artery and its level of obstruction during first AMI. Methods: The study group consisted of 48 consecutive patients, admitted to the coronary care unit for first AMI, who showed ST-segment elevation in lead aVL and ST-segment depression in lead III on admission 12-lead electrocardiogram. The patients were divided by T-wave direction into Group 1 (n = 31), negative T wave, and Group 2 (n = 17), positive T wave. The coronary angiogram was evaluated for type of LAD (“wrapped”, i.e., surrounding the apex or not), site of obstruction (pre- or postdiagonal branch), and other significant coronary artery obstructions. Results: Mean lead III ST-segment depression was 1.99 ± 1.32 mm in Group 1 and 1.13 ± 0.74 mm in Group 2 (p = 0.004); mean ST-segment elevation in aVL was 1.35 ± 0.84 mm and 1.23 ± 0.5 mm, respectively (p = 0.5). A wrapped LAD was found in 12 patients (38.7%) in Group 1 and in 13 in Group 2 (76.4%) (p = 0.02). The sensitivity of lead III ST-segment depression with positive T wave to predict a wrapped LAD was 52%, and the specificity was 82% with a positive predictive value of 76%. On angiography, 25 patients (80%) in Group 1 and 13 (76%) in Group 2 had prediagonal occlusion of the LAD (p = 0.77 ). No significant difference between groups was found for right and circumflex coronary artery involvement or incidence of multivessel disease. Conclusions: The presence of lead III ST-segment depression with positive T wave associated with ST-segment elevation in aVL in the early course of AMI can serve as an early electrocardiographic marker of prediagonal occlusion of a “wrapped” LAD.

Background: The correlation between ST elevation in lead V1 during anterior wall acute myocardial infaction (AMI) and the culprit lesion site in the left anterior descending (LAD) coronary artery is poor. Hypothesis: The study was undertaken to assess the electrocardiographic (ECG) characteristics and angiographic significance of ST-segment elevation in lead V1 during anterior wall acute myocardial infarction (AMI). Methods: Data from 115 patients with anterior wall AMI, who underwent coronary angiography within 14 days of hospitalization, were studied. The admission 12-lead ECG was examined and the coronary angiogram was evaluated for the nature of the conal branch of the right coronary artery (RCA) and for the culprit lesion site in the left anterior descending (LAD) coronary artery. Results: Mean ST-segment deviation and the frequency of patients with ST-segment elevation > 0.1 mV were significantly lower in lead V i than in lead V2 (0.136 $$ 0.111 mV vs. 0.421 $$ 0.260 mV, and 37 vs. 96%, for leads Vi and Vi, respectively). A small conal branch not reaching the interventricular septum (IVS) was more prevalent among patients with ST-segnicni elevation >0.1 mV in lead Vi (67%), whereas a large conal branch was more prevalent in patients with ST-segment deviation (1 mV in that lead (83%, p

Background —The most troublesome complication of acute pericarditis is recurrent episodes of pericardial inflammation, occurring in 15% to 32% of cases. The cause of the recurrence is usually unknown, although in some cases it may be traced to viral infection or may be a consequence of coronary artery bypass grafting. The optimal method for prevention has not been fully established; accepted modalities include nonsteroidal anti-inflammatory drugs, corticosteroids, immunosuppressive agents, and pericardiectomy. Methods and Results —Based on the proven efficacy of colchicine therapy for familial Mediterranean fever (recurrent polyserositis), several small studies have used colchicine successfully to prevent recurrence of acute pericarditis after failure of conventional treatment. Recently, we reported the results from the largest multicenter international study on 51 patients who were treated with colchicine to prevent further relapses and who were followed up for ≤10 years. Conclusions —In light of new trial data that have accumulated in the past decade, we review the evidence for the efficacy and safety of colchicine for the prevention of recurrent episodes of pericarditis. Clinical and personal experience shows that colchicine may be an extremely promising adjunct to conventional treatment and may ultimately serve as the initial mode of treatment, especially in idiopathic cases.

We report on a follow-up of 210 patients who underwent coronary angiography before age 40. We found that young patients with normal coronary arteries have an excellent prognosis, whereas those with single-vessel disease have an unfavorable outcome resembling that of patients with multivessel disease.

The rate of progression of the degree of chronic aortic regurgitation (AR) is unknown. Furthermore, although left ventricular (LV) dilation has been studied in patients with severe AR, its rate and determining factors, and specifically, its relation to the degree of regurgitation remain to be established and have not previously been studied for mild and moderate AR. The purpose of this study was to explore the progression of chronic AR by 2-dimensional and Doppler echocardiography, and the relation of LV dilation to the fundamental regurgitant lesion and its progression in patients with a full spectrum of initial AR severity. We studied 127 patients with AR by 2-dimensional and Doppler echocardiography (69 men; 59 +/- 21 years; 67 with mild, 45 with moderate, 15 with severe AR). AR increased in 38 patients (30%) (25% of mild, 44% of moderate, and 50% of moderate to severe lesions; p

Precordial ST-segment depression (PSD) in inferior wall acute myocardial infarction (IAMI), especially when maximal in leads V4-V6, has been shown to portend a higher rate of heart failure and mortality. To better understand the pathophysiology behind this phenomenon, we evaluated patients with a first IAMI by echocardiography 48-72 h after the acute event, using segmental scoring (0 = normal to 3 = dyskinesia) of left ventricle wall motion, and a dichotomous assessment of right ventricle involvement. Patients were categorized into 3 groups: I = no PSD (n = 14); II = maximal PSD in leads V1-V3 (n = 28); III = maximal PSD in leads V4-V6 (n = 8). As compared with group I, patients in groups II-III had more severe wall motion abnormalities in inferior segments (1.36 +/- 0.97 vs. 2.19 +/- 1.74, p = 0.04), and a similar trend for posterior and lateral segments (1 +/- 1.75 vs. 2 +/- 2.41, p = 0.11), translating into a worse total left ventricle score (2.36 +/- 2.34 vs. 4.25 +/- 4.05, p0.05). Frequency of right ventricle involvement was similar in patients with and without PSD (6 (43%) vs. 9 (25%), p = 0.37). Segmental scores for groups I, II, and III, respectively, were not different for inferior (1.36 +/- 1, 2.25 +/- 1.82 and 2 +/- 1.51, p = 0.24), posterior and lateral (1 +/- 1.75, 1.96 +/- 2.32 and 2.13 +/- 2.9, p = 0.38), and septal, anteroseptal and anterior segments (0 +/- 0, 0.04 +/- 0.19 and 0.13 +/- 0.35, p = 0.28). Right ventricle abnormalities occurred in 43, 21 and 38% of patients in groups I, II and III, respectively, p = 0.3. Thus, IAMI with PSD is associated with worse left ventricle wall motion. However, since patients with maximal PSD in leads V4-V6 do not have greater wall motion abnormalities or higher rate of right ventricle involvement, their poorer prognosis cannot be explained by worse systolic dysfunction. We propose that maximal PSD in leads V4-V6 reflects transient diffuse ischemia and altered diastolic distensibility due to extensive coronary artery disease, causing increased left ventricle end-diastolic pressure.

Purpose To document a case of Candida tropicalis endophthalmitis as the only manifestation of pacemaker endocarditis. Methods We examined a 75-year-old man with diabetes mellitus who was initially examined for bilateral multifocal endophthalmitis complicating endocarditis 2 years after a permanent pacemaker for sick sinus syndrome was implanted. Results Transesophageal echocardiography showed a large vegetation with a 3-cm diameter attached to the pacing electrode in the right ventricle. Six consecutive blood cultures grew C tropicalis. Conclusions Ocular involvement, including multifocal endophthalmitis, may occur as the only manifestation of C tropicalis endocarditis, complicating an intravenous permanent pacemaker.