Comparative accuracy of cross-sectional echocardiography and cineventriculography for left ventricular evaluation after myocardial infarction

223 patients with a previous myocardial infarction (MI) 29-68 years old, have been studied in a double-blind manner both by 2D-Echocardiography and cineventriculography. 5 cross-sectional views and 2 angiographic projections have been employed in order to assess the presence of aneurysm and the motion of the left ventricle. The left ventricle has been divided into 5 anatomic regions: interventricular septum, anterolateral, posterolateral, apical and inferior walls. By cineangiography an aneurysm was diagnosed in 89 patients (one pseudoaneurysm); by 2D-Echo in 83 patients an aneurysm was diagnosed, whereas in the 6 remaining patients the Echocardiogram was nondiagnostic (specificity 100%, sensitivity 93%). Concerning regional motion characteristics, 997 (89%) of 1115 regions were visualized and 905 (91%) correctly identified according to the angiographic findings. Of 92 discrepancies (9%): 64 were attributed to 2D-Echo (69%) and 28 (31%) were attributed to cineangiography; most of the discrepancies attributed to echo resulted from minor grades of asynergy which caused unresolved disagreements between the Echo and angiography findings. It is concluded that Cross-sectional echocardiography is a valuable tool for the diagnosis of aneurysm of the left ventricle (specificity 100% and sensitivity 93%) and for the study of wall motion characteristics. In cases with generalized abnormality of left ventricle motion, resulting in a picture of congestive cardiomyopathy, 2D-Echo can be a substitute for cineangiography. In all other instances both techniques can provide more complete information on ventricular wall abnormalities.     

A comparison of the families of mothers with borderline and nonborderline personality disorders

The correlation between echocardiographically and angiographically calculated ejection fraction and systolic excursion of the mitral annulus was studied in 81 patients. Knowing that the mitral annulus changes its size, shape, and position during the cardiac cycle, the authors measured systolic excursion of the annulus by 2D echocardiography. Displacement of the mitral annulus was measured from four different points (medial, lateral, anterior, posterior) by apical four-chamber and apical two-chamber approaches. Patients with and without regional wall motion abnormalities were included. Left ventricular volumes and ejection fraction (EF) were calculated in the standard manner introduced by Teichholz et al and also with biplane left ventriculography. As a result, EF calculated by cineangiography, was moderately correlated with the Teichholz method (r = 0.66) while it was highly correlated with measurements of mitral annular motion (MAM) (r = 0.87). The correlation can be expressed by the regression equation, EF (angiography) = 5.7 MAM (in mm) -6.5. They conclude that measurements of annular motion is an easy and reliable index of left ventricular function as an alternative to traditional methods.     

Correspondence of left ventricular ejection fraction determinations from two-dimensional echocardiography, radionuclide angiography and contrast cineangiography

OBJECTIVES: This study assessed the agreement of left ventricular ejection fraction determinations from two-dimensional echocardiography, radionuclide angiography and contrast cineangiography. BACKGROUND: Previously published reports suggest that two-dimensional echocardiography, radionuclide angiography and contrast cineangiography are equally acceptable methods of assessing left ventricular ejection fraction on the basis of high coefficients of correlation. However, correlation of methods does not necessarily imply agreement. METHODS: In a prospective analysis, 25 consecutive subjects all had two-dimensional echocardiography and radionuclide angiography performed within 10 days of each other in the cardiology department of metropolitan community hospital. A retrospective computer search (Medline) revealed seven studies, using the coefficient of correlation (r), comparing two-dimensional echocardiographic left ventricular ejection fraction (n = 268) with radionuclide angiographic (n = 174) or contrast cineangiographic (n = 119) left ventricular ejection fractions. RESULTS: The eight individual studies (n = 293) comparing two-dimensional echocardiography with either radionuclide angiography or contrast cineangiography exhibited coefficients of correlation ranging from 0.78 to 0.93. Agreement analysis using the method of Bland and Altman was performed by averaging the results obtained from the two techniques and determining how disparate any single ejection fraction was (with 95% confidence limits) from the mean value. Agreement ranged from 23% to 42% around the mean ejection fraction. The average lack of agreement between the two methods for all studies involved was 17%, with an average r value of 0.86. CONCLUSIONS: Left ventricular ejection fraction determinations by means of two-dimensional echocardiography, radionuclide angiography and contrast cineangiography exhibit high correlation and only moderate agreement. High correlation does not always imply high agreement. These results suggest that, when validated by agreement analysis, multiple studies may not be necessary in appropriate clinical situations, potentially reducing costs.     

Two dimensional echocardiographic analysis of wall motion abnormalities during handgrip exercise in patients with coronary artery disease

Studies were made of the feasibility and value of two dimensional echocardiography in detecting left ventricular asynergy during handgrip exercise in 45 patients with suspected coronary artery disease. Resting echocardiography revealed normal wall motion in 32 patients, and in 17 of these handgrip exercise induced abnormal wall motion. All 17 patients had significant stenoses in the coronary arteries. However, only 65 percent of patients with coronary artery disease whose resting two dimensional echocardiogram revealed normal wall motion showed abnormal wall motion during handgrip exercise. The left ventricular wall visualized in the short axis plane was divided into 5 segments, and a total of 225 segments were analyzed. Of 49 segments with exercise-induced asynergy, 46 (94 percent) reflected significant stenosis in the perfusing coronary artery. In particular, 16 (89 percent) of 18 segments with exercise-induced akinesia reflected stenosis of greater than 90 percent. Resting or exercise two dimensional echocardiography (or both) was able to diagnose multivessel disease with a predictability of 92 percent. It is concluded that two dimensional echocardiography combined with handgrip exercise has high specificity in detecting coronary artery disease and would be useful for predicting severely stenotic or multivessel coronary arterial lesions.     

Prevalence of myocardial ischemia as depicted by regional wall motion abnormality in blacks

Coronary artery disease with subsequent myocardial ischemia is a common cause of morbidity and mortality in the United States, and data are scarce on the prevalence of the disease in blacks. Regional wall motion abnormality correlates either directly or indirectly with myocardial ischemia. This study examines the two-dimensional (2-D) echocardiography of patients > or = 45 years for men and > or = 55 years at Metropolitan Nashville General Hospital, Nashville, Tennessee. A total of 601 2-D echocardiographic studies were performed on patients who presented with symptoms and signs of cardiovascular disease. Of these, 377 (62.7%) met the age criteria and formed the study group; 92 were excluded for various reasons, leaving 285 (75%) in the analysis group. A total of 80 (28.1%) patients had regional wall motion abnormality while 205 (71.9%) did not. On analysis of the 80 patients with regional wall motion abnormality, the segment of the heart commonly affected was the septal area, although more than one segment of the myocardium was affected in all of the patients. A total of 36 (45%) patients had normal left ventricular size. In relation to race, blacks had a higher prevalence of regional wall motion abnormality compared with whites (29.2% versus 26.2%, respectively), but the difference was not statistically significant. These prevalence rates indicate the importance of looking for this abnormality during echocardiographic evaluation of a patient. The presence of regional wall motion abnormality on 2-D echocardiography in the presence of other cardiovascular risk factors necessitates further investigation and management to minimize later complications of coronary artery disease.     

Automatic backscatter analysis of regional left ventricular systolic function using color kinesis

Assessment of regional wall motion by 2-dimensional echocardiography can be performed by either semiquantitative wall motion scoring or by quantitative analysis. The former is subjective and requires expertise. Quantitative methods are too time-consuming for routine use in a busy clinical laboratory. Color kinesis is a new algorithm utilizing acoustic backscatter analysis. It provides a color encoded map of endocardial motion in real time. In each frame a new color layer is added; the thickness of the color beam represents endocardial motion during that frame. The end-systolic image has multiple color layers, representing regional and temporal heterogeneity of segmental motion. The purpose of this study was to validate the use of color kinesis for semiquantitative analysis of regional left ventricular systolic function and quantitatively in measurement of endocardial excursion. Semiquantitative wall motion scoring was performed in 18 patients using both 2-dimensional echo and color kinesis. Scoring was identical in 74% of segments; there was 84% agreement in definition of normal vs. abnormal. There was less interobserver variability in wall motion scoring using color kinesis. Endocardial excursion was quantified in 21 patients. 70% of the imaged segments were suitable for analysis. Correlation between 2-dimensional echocardiographic measurements and color kinesis was excellent, r = 0.87. The mean difference in excursion as measured by the 2 methods was -0.05 +/- 2.0 mm. In conclusion, color kinesis is a useful method for assessing regional contraction by displaying a color map of systolic endocardial excursion. This algorithm may improve the confidence and accuracy of assessment of segmental ventricular function by echocardiographic methods.     

Apical muscular ventricular septal defects between the left ventricle and the right ventricular infundibulum. Diagnostic and interventional considerations

BACKGROUND: Effective transcatheter or surgical closure of apical muscular ventricular septal defects (VSDs) requires accurate delineation of variable and often complex anatomy. These defects have generally been considered as communications between the apexes of both left and right ventricles. METHODS AND RESULTS: Among 50 consecutive patients with multiple muscular VSDs referred for transcatheter device closure between October 1987 and April 1993, a subset of 10 patients (aged 7 days to 28 years) with apical muscular VSDs shared a unique set of anatomic characteristics: (1) large and often single opening in the left ventricle; (2) multiple right ventricular openings in the anterior aspect of the apical septum; and (3) separation of the right ventricular apical region into which the VSDs open from the rest of the right ventricular inflow and outflow by prominent muscle bundles. Additional analysis of the anatomy by use of echocardiography and cineangiography showed that these muscular defects were between the left ventricular apex and right ventricular infundibular apex. In 6 patients, the transcatheter devices used to create a septum in these hearts were placed in the right ventricle, straddling muscle bundles that separated the apical VSD from the rest of the right ventricular inflow and outflow, resulting in incorporation of a portion of the right ventricular infundibular apex into the physiological left ventricle. Three patients had devices placed between the apexes of the left ventricle and the infundibulum. The defect closed spontaneously within the right ventricle in 1 patient. One patient died after surgery for tetralogy of Fallot in situs inversus. The remaining 9 patients were all clinically well at the time of their most recent follow-up visit (follow-up duration, 32 +/- 11 months). This distinct type of apical VSD was identified by echocardiography in 20 of 274 patients who were followed up clinically for muscular VSDs. CONCLUSIONS: Left ventricular-infundibular apical VSDs constitute a distinct morphological type of muscular VSD that can be distinguished by echocardiography and cineangiography. In selected cases, the infundibular apex can be separated from the rest of the right ventricular inflow and outflow to eliminate flow across these defects.     

Detection of left ventricular aneurysms by cross-sectional echocardiography

Real-time cross-sectional echocardiographic studies of the left ventricle were performed in 31 consecutive patients with angiographically proven left ventricular aneurysms (group I). In each of these patients the presence and location of the aneurysm was visualized by the cross-sectional echocardiography. In four patients discrepancy in the extent of the aneurysm was noted due either to failure of the cross-sectional technique to visualize the entire anterior wall of the ventricle (3) or failure of the single plane angiogram to adequately define the lateral extent of the aneurysm (1). Ventricular shape and contraction sequence in patients with aneurysms were compared with similar patterns in 20 patients with normal left ventricles (group II), and 20 patients with ischemic heart disease and localized ventricular dysfunction without aneurysm formation (group III). Other noninvasive methods for detecting aneurysms (including physical examination, chest roentgenography, electrocardiography, and M-mode echocardiography) were also evaluated in the aneurysm group. This report suggests that cross-sectional echocardiography is a useful method for detecting ventricular aneurysms noninvasively.     

Mechanism of impaired left ventricular wall motion in the diabetic heart without coronary artery disease

OBJECTIVE: To elucidate whether impairment of the myocardial free fatty acid (FFA) metabolism and small vessel abnormalities in the myocardium are etiologic or contributory factors of myocardial dysfunction in patients with NIDDM without any significant coronary artery disease. RESEARCH DESIGN AND METHODS: We performed myocardial imaging with 123I-labeled beta-methyl-p-iodophenyl pentadecanoic acid (BMIPP), a branched analog of FFA, and dipyridamole-infusion 201thallium scintigraphy (Dip) in nine patients who demonstrated left ventricular wall motion abnormalities without any significant coronary artery disease and in fifteen control cases. As an index of myocardial FFA metabolism, the heart-to-mediastinum count ratio (H/M) of BMIPP was calculated from the mean count in the regions of interest at the heart and the upper mediastinum. RESULTS: Nine patients with reduced wall motion documented by left ventriculography (LVG), (hypokinetic group) demonstrated significantly lower BMIPP uptake (2.1 +/- 0.2, mean +/- SD) than fifteen patients with normal wall motion (normokinetic group) (2.3 +/- 0.2, P < 0.05). Regional ventricular wall motion observed by LVG, regional BMIPP uptake, and regional redistribution phenomenon (RD) were evaluated for five regions of the left ventricle: anterior, septal, apical, lateral, and inferoposterior regions. Wall motion was abnormal in 24 out of 120 regions. Regional BMIPP uptake was reduced in 47 regions. RD in Dip was observed in 23 regions. In regional analysis, the existence of defect in the BMIPP image showed significant correlation with wall motion abnormality (P < 0.01), but there was no significant relationship between the RD in Dip and regional wall motion abnormality (P = 0.16). Myocardial biopsy specimens obtained from the right ventricle of 20 patients showed no pathologic changes, with the exception of two patients. CONCLUSIONS: Our findings suggest that impairment of myocardial FFA metabolism rather than small vessel abnormalities in the myocardium is responsible for modest left ventricular dysfunction in patients with diabetes.     

Randomized trial of a home-based family intervention for children who have deliberately poisoned themselves

OBJECTIVE: Intraoperative myocardial contrast echocardiography was used to determine whether the identification of regional myocardial flow patterns during revascularization could predict myocardial contractile function immediately after separation from cardiopulmonary bypass (CPB) and at 1 month after coronary artery bypass grafting (CABG) surgery. DESIGN: A prospective, open-labeled, longitudinal analysis. SETTING: Two independent university hospitals. PARTICIPANTS: Twenty patients, during and up to 1 month after CABG. INTERVENTIONS: The contrast agent Albunex (Mallenckrodt Medical, Inc, St Louis, MO) was injected into the aortic root during CPB. MEASUREMENTS AND MAIN RESULTS: Myocardial contrast echocardiography opacification of flow was graded from intraoperative transesophageal echocardiographic images of the left ventricle in the short-axis, midpapillary view. The same myocardial images were also evaluated for regional wall motion abnormalities at 15, 30, and 60 minutes, 24 hours, 5 to 8 days, and 1 month after CPB. Logistic regression analysis was used to analyze the flow scores and regional function data from identical segments. Regional flow represented by contrast enhancement was assessed in 70% of the myocardial regions (55 of 80 possible segments; 95% confidence interval [CI], 61 to 76). Flow was more easily evaluated in the posterior region (95%) than in the anterior (70%) or septal regions (60%), and least likely evaluated in the lateral regions (50%). Regional wall motion was scored in 84% of the myocardial regions (469 of 560 possible regions). Function (segmental wall motion) was assessed in all regions with equal success. Segmental function and flow scores were matched to the same regions 66% of the time (53 of 80 possible series; 95% CI, 55 to 76). Regional myocardial contrast flow patterns did not predict myocardial function at 15, 30, or 60 minutes after separation from CPB. However, contrast opacification of flow did predict regional myocardial function at 1 week (p < or = 0.05) and at 1 month (p < or = 0.01) after CABG surgery. The probability that myocardial function would be normal at 1 month was 0.62 when intraoperative flow opacification was abnormal and 0.98 when flow opacification was normal. For patients with normal flow, the estimated odds of having normal myocardial function were 3.33 times those of patients with abnormal flow at 1 week (odds ratio, 3.33; 95% CI, 1.09 to 10.19) and 18.5 times those of patients with abnormal flow at 1 month (95% CI, 2.44 to 140.48). CONCLUSION: Intraoperative application of myocardial contrast echocardiography to determine regional flow patterns after revascularization may help differentiate conditions of left ventricular systolic dysfunction immediately after separation from CPB for CABG surgery and appear to predict myocardial function at 1 month.     

Resection of the metatarsal head for diabetic foot ulcers

Dobutamine-induced hypotension has been disregarded as a marker of more severe functional abnormalities in patients with suspected coronary artery disease. However, its functional significance in patients with myocardial infarction has not been studied. The aim of this study was to define the predictors of systolic blood pressure (SBP) response to dobutamine in patients with previous myocardial infarction. Dobutamine stress (up to 40 microg/kg per minute) echocardiography was performed in 326 patients with prior myocardial infarction referred for evaluation of myocardial ischemia. A 16-segment, four-grade score model was used to assess left ventricular function. Wall motion score index was derived by summation of wall motion score divided by 16. SBP and heart rate increased from rest to peak dobutamine stress (127 +/- 22 vs 134 +/- 27 mm Hg and 72 +/- 14 vs 122 +/- 24 bpm, p < 0.00001 in both). An increase of SBP > or = 30 mm Hg occurred in 50 patients (15%). By multivariate analysis, independent predictors of failure of SBP increase were higher peak wall motion score index (p < 0.001), higher resting SBP (p < 0.01), and medication with calcium channel blockers (p < 0.05). SBP drop > or = 20 mm Hg occurred in 54 patients (17%). Independent predictors of SBP drop were higher resting wall motion score index (p < 0.001), higher resting SBP (p < 0.0001), and older age (p < 0.05). In patients with myocardial infarction, left ventricular function and baseline systolic blood pressure are powerful predictors of SBP response to dobutamine stress testing.     

Hypercholesterolemia enhances oxidant production in mesenteric venules exposed to Ischemia/Reperfusion

BACKGROUND: Three-dimensional echocardiography allows calculation of left ventricular ejection fraction without geometric assumption on the ventricular shape. Our aim was to validate this technique in a paediatric population with distorted ventricles. METHODS: Twenty-one patients aged 6 months to 17 years underwent equilibrium radionuclide angiography and three-dimensional echocardiography. Fourteen patients had dilated cardiomyopathy and seven had univentricular hearts. A new, easy to handle, transthoracic rotational probe was used and motion artefacts were limited during the rotation (3 degrees intervals with ECG and respiratory gating). Left ventricular volumes and ejection fraction were calculated using the Simpson's rule with 12 slices. RESULTS: Three-dimensional echocardiography correlated well with equilibrium radionuclide angiography for ejection fraction measurement (r = 0.90; the mean difference between the two methods being 3.8 +/- 6%). Intra-observer and inter-observer variabilities for 3D echocardiography were 2.4% and 4.5%. CONCLUSIONS: Three-dimensional echocardiography is an accurate, non-invasive, and reproducible methods to measure left ventricular ejection fraction in children.     

Prospective, randomized trial comparing blood and oxygenated crystalloid cardioplegia in reoperative coronary artery bypass grafting

OBJECTIVES: Reoperative coronary artery bypass grafting presents unique challenges for myocardial preservation. The purpose of this study was to compare oxygenated blood cardioplegia with oxygenated crystalloid cardioplegia during reoperative coronary artery bypass grafting using transesophageal echocardiography to assess regional wall motion of the left ventricle before and after cardiopulmonary bypass. METHODS: Sixty-one patients undergoing reoperative coronary artery bypass grafting were prospectively randomized to receive oxygenated blood cardioplegia or oxygenated crystalloid cardioplegia delivered with a combined antegrade-retrograde technique. Transgastric short axis views of the left ventricle were made with transesophageal echocardiography during the operation before cardiopulmonary bypass and immediately after cardiopulmonary bypass. Regional wall motion was graded by a blinded observer, and before cardiopulmonary bypass scores were compared with after cardiopulmonary bypass scores. RESULTS: No significant differences were found in the change in regional wall motion score from before cardiopulmonary bypass to after cardiopulmonary bypass between the blood and crystalloid cardioplegia groups. CONCLUSIONS: This study found blood and crystalloid cardioplegia to be equally efficacious for myocardial preservation during reoperative coronary artery bypass grafting.     

G1 accumulation caused by iron deprivation with deferoxamine does not accompany change of pRB status in ML-1 cells

In hypertension, several factors disturb coronary circulation and the metabolic reserve of the heart. This study was undertaken to test whether in hypertensive patients global and regional left ventricular (LV) function is related during exercise to the presence of significant coronary stenosis and whether lowering of coronary perfusion pressure through rapid normalization of the diastolic pressure may modify the dynamics of the left ventricle. Thirty-five patients with mild to moderate hypertension undergoing coronary angiography for the evaluation of chest pain were included in the study; upright bicycle exercise echocardiography tests were performed without therapy and 1 day later 1 h after sublingual administration of nifedipine. LV ejection fraction and regional wall motion scores were evaluated and compared at baseline, peak exercise, immediate postexercise, and recovery phases in each test through digital on-line storing of echocardiographic images. Twenty-one patients had normal coronary arteries (group 1) and 14 significant coronary stenoses (group 2); age, gender, heart rate, blood pressure, left ventricular diameter and mass index, and ejection fraction were similar in the two groups. At peak exercise LV ejection fraction slightly increased in group 1, whereas it slightly decreased in group 2 (both during the test without therapy and after nifedipine administration). All patients in group 1 had normal left ventricular wall motion during exercise; 13 of 14 patients in group 2 had LV wall motion abnormalities at peak exercise. Nifedipine did not produce any effect on LV regional wall motion in group 1, but it induced significant changes in LV regional wall motion in seven patients in group 2. Changes in LV wall motion between the two test groups were related to the number of the stenotic coronary vessels: the normal exercise test before and after therapy and the two normalized tests after nifedipine administration were in fact observed in patients with one-vessel disease, whereas worsening or changes in the site of ischemia were observed only in patients with multivessel disease. Regional and global left ventricular dynamics during exercise is mainly dependent on the existence of significant coronary artery disease. Rapid decrease of blood pressure does not alter the regional dynamics of the left ventricle during exercise in patients without coronary artery disease, but it may induce normalization, worsening, or changes in the site of wall motion abnormalities in hypertensives with significant coronary stenoses.     

Functional myocardial perfusion abnormality induced by left ventricular asynchronous contraction: experimental study using myocardial contrast echocardiography

OBJECTIVES: The aim of this study was to clarify how myocardial perfusion is impaired by asynchronous contraction. BACKGROUND: False septal hypoperfusion is noted in some patients with left bundle branch block. METHODS: Eight dogs were examined with epicardial pacing at the left ventricular posterior wall, the right ventricular anterior wall and, as a control, the right atrial appendage. The pacing rate was 80, 110 and 150 beats/min (bpm). Myocardial perfusion was assessed by contrast echocardiography. RESULTS: Left ventricular pacing at 80 and 110 bpm did not change systolic wall thickening or contrast intensity at the pacing site, although an early excitation notch was noted at the pacing site. However, at 150 bpm, systolic thickening was impaired (23.3 +/- 4.2% vs. 37.0 +/- 2.6% during atrial pacing, p < 0.05), and the peak intensity ratio of the pacing site to the ventricular septum was significantly decreased (24.1 +/- 5.7% vs. 37.0 +/- 2.8% at a pacing rate of 80 bpm, p < 0.01). The peak intensity ratio correlated with systolic wall thickening at the pacing site (y = 0.413 x -0.028, r = 0.81, p < 0.0001). However, right ventricular pacing did not change either systolic thickening or the peak intensity ratio at any pacing rate, although an early excitation notch was noted on the ventricular septum. CONCLUSIONS: Wall motion abnormalities after early excitation vary depending on the pacing mode. When tachycardia induces regional wall motion abnormalities, the ventricular wall of the pacing site is functionally hypoperfused.     

Left ventricular lesions in arrhythmogenic right ventricular dysplasia and 12-lead electrocardiographic findings

Left ventricular lesions in arrhythmogenic right ventricular dysplasia have not been well described, and the relationship between the left ventricular lesions and the 12-lead electrocardiographic findings has not been analyzed. This study examined whether the presence of left ventricular lesions and the extent of right ventricular lesions due to arrhythmogenic right ventricular dysplasia are predictable by 12-lead electrocardiographic findings. The 12-lead electrocardiograms during sinus rhythm and left and right ventriculography were studied in 29 patients (27 males and 2 females, mean age 42.6 +/- 15.5 years) diagnosed by the current criteria for this disease. After evaluation, patients were divided into two groups: those with normal left ventricles (normal group) and those with left ventricular wall motion abnormalities (abnormal group). Seventeen of the 29 patients (59%) were classified into the abnormal group. Left ventricular wall motion abnormalities were located in the posterolateral (4 patients), apical (1), and posterolateral and apical regions (12). QS patterns of abnormal Q waves in lead I, aVL or V5, V6 rS patterns (R/S ratio < 1) in leads I and V6, and/or R or Rs patterns (R/S ratio > 1) in lead V1 were observed in all patients in the abnormal group, but in none in the normal group. There was a positive correlation between the right ventricular end-diastolic volume index and the number of precordial negative T waves (r = 0.746, p < 0.0001), and the time from onset of the QRS to the terminal portion of the epsilon wave in lead V1 (r = 0.627, p < 0.001). The correlation coefficients showed no significant differences between the groups. A left ventricular lesion associated with arrhythmogenic right ventricular dysplasia was not unusual (59%), and our study suggests that the posterolateral and apical regions are the most frequent sites. The presence of these lesions were predictable by the QRS abnormalities. Moreover, regardless of the presence of such a lesion, the extent of the right ventricular lesion is also predictable by the 12-lead electrocardiographic findings.     

Regional myocardial motion and thickening assessed at rest by ECG-gated 99mTc-MIBI emission tomography and by magnetic resonance imaging

We have validated ECG-gated emission tomography using technetium-99m methoxyisobutylisonitrile for the assessment of regional ventricular function by comparing it with cine magnetic resonance imaging (MRI). Gated tomography was performed at rest in 24 patients referred for myocardial perfusion imaging [17 males and seven females with a mean age of 58 years, nine of whom had had a previous myocardial infarction (MI)]. Scores were assigned to each of nine myocardial segments for wall motion and for thickening. Cine MRI was analysed in an identical fashion. Four out of 216 (2%) segments were uninterpretable by gated tomography because of inadequate tracer uptake. In eight patients without coronary artery disease (CAD), wall motion and thickening were normal by both methods. Gated tomography showed abnormal wall motion or thickening in all patients with previous MI and in five of seven patients with CAD but no prior MI. Association between wall motion and thickening was good (rs=0. 86). Overall, there was good agreement between gated tomography and MRI for both wall motion (178/212 segments, kappa=0.66) and wall thickening (184/212 segments, kappa=0.69). In segments with severely reduced perfusion, however, there was poorer agreement (kappa=0.31). Interobserver and intraobserver agreement was high (kappa from 0.61 to 0.78). Thus, in patients investigated for CAD, there is good overall agreement between gated tomography and MRI but the agreement is lower in segments with severe perfusion defects.     

Use of laser flare-cell photometry to count anterior chamber canine leukocytes and latex beads in vitro

The object of this study was to assess the value of CK in the evaluation of left ventricular wall motion. Fifteen coronary patients aged 56 +/- 12 years were included: 8 patients were examined after acute myocardial infarction and 7 after unstable angina with a history of myocardial information. The left ventricle was divided into 7 segments after a modified Heger model, excluding the basal septal and basal lateral segments not seen on angiography. The left ventricular wall motion was assessed in two-dimensional echocardiography (2DE) and colour kinesis (CK) by two observers and compared with the results of left ventriculography, considered the reference method. Over all the 105 segments studied (7 segments for each of the 15 patients), CK was significantly better than 2DE (80% of segments correctly evaluated by CK vs 68% by 2DE, p < 0.05). Colour kinesis significantly improved the study of all segments except the interventricular septum (67% vs 60%, p = NS). The inter-observer variability in 2DE and CK evaluated over 135 segments (9 per patient) by the kappa was improved by colour kinesis (0.57 in 2DE, 0.7 in CK). The authors conclude that CK enables evaluation of left ventricular wall motion with greater precision and less inter-observer variability.     

Characteristics of medical care related to autopsy authorization in a pediatric hospital

Patients with atypical chest pain frequently lack significant coronary artery disease (CAD) and are, therefore, at low risk for future adverse cardiovascular events. We hypothesized that in this group of patients, stress echocardiography could identify those at risk for cardiac events. We retrospectively reviewed (mean follow-up 23.0 +/- 7.2 months) the prognostic value of stress echocardiography for major (cardiac death, myocardial infarction, congestive heart failure, and unstable angina) and total (major events plus coronary revascularization) cardiac events in 661 patients with atypical chest pain, normal global left ventricular (LV) systolic function, and no history of CAD. A positive stress echocardiogram was defined as the development of new or worsening wall motion abnormalities with exercise stress (80%) or dobutamine (20%). A total of 41 cardiac and 16 major events were noted. The event-free survival for total cardiac events was 97% for a normal stress echocardiogram and 93% for a normal stress electrocardiogram (ECG) at 30 months. A positive stress ECG predicted an event-free rate of 86% compared with 74% for stress-induced wall motion abnormalities and 42% if stress-induced LV dysfunction accompanied the wall motion abnormalities. A strategy recommending invasive studies based on positive stress echocardiogram results increased the per-patient cost, but led to greater savings per cardiac event predicted and provided incremental prognostic value for future cardiac events beyond clinical and stress electrocardiographic data. Thus, stress echocardiography in low-risk patients for CAD appears to be more cost effective than a stress ECG.     

Coronary collateral circulation behaviour and myocardial viability in chronic total occlusion treated with coronary angioplasty

AIMS: We explored the role of microcirculation integrity following the chronic occlusion of an infarct-related artery to assess the behaviour of collateral circulation during and after reperfusion by coronary angioplasty METHODS AND RESULTS: Eighteen patients with a proximally occluded left anterior descending artery and firm evidence of intercoronary collateral circulation were studied with selective coronary angiography and selective intracoronary myocardial contrast echocardiography, before coronary angioplasty, and at 5 and 15 min and 12 h later. Myocardial enhancement during myocardial contrast echocardiography was evaluated with a semiquantitative score (0-3), which was correlated to basal and 6 months' regional left ventricular wall motion results. 16/18 procedures were successfully performed; four patients with an inadequate acoustic window were excluded. Restenosis was evident at the 6 months' follow-up in two patients. Basal myocardial contrast echocardiography indicated that 81/192 segments from the left anterior descending coronary artery and 90/192 from the right coronary artery were perfused; no perfusion was observed in 21 segments either before or after coronary angioplasty. After coronary angioplasty, the angiographic intercoronary collateral circulation immediately disappeared, and myocardial contrast echocardiography revealed that there was a progressive reduction of segments perfused by the right coronary artery and an increase in segments perfused by the left anterior descending coronary artery. Regional left ventricular wall motion analysis demonstrated that there was abnormal motion in 51/192 segments. There was no improvement in segments with score 0 and abnormal motion after 6 months (100% sensitivity), but 16/17 segments with score 3 did show an improvement (98% specificity). The predictive value of intermediate scores (1-2) in detecting long-term improvement, was only 43%. CONCLUSION: These data show that the adaptive mechanism observed in the behaviour of epicardial and microvascular circulation after reperfusion of a chronic occluded infarct-related artery can vary. In addition, this study clearly shows that microvascular integrity detected by myocardial contrast echocardiography can provide myocardial viability.