In vitro expansion of tumour cells derived from blood and tumour tissue is useful to redefine personalized treatment in non-small cell lung cancer patients

The clinical development of locally and advanced non-small cell lung cancer (NSCLC) suffers from a lack of biomarkers as a guide in the selection of optimal prognostic prediction. Circulating Tumour Cells (CTCs) are correlated to prognosis and show efficacy in cancer monitoring in patients. However, their enumeration alone might be inadequate; it might also be critical to understand the viability, the apoptotic state and the kinetics of these cells. Here, we report what we believe to be a new and selective approach to visually detect tumour specific CTCs. Firstly, using labelled human lung cancer cells, we detected a specific density interval in which NSCL-CTCs were concentrated. Secondly, to better characterize CTCs in respect to their heterogeneous composition and tumour reference, blood and tumour biopsy were performed on specimens taken from the same patient. The approach consisted in comparing phenotype profile of CTCs, and their progenitor Tumour Stem Cells, (TSCs). Moreover, NSCL-CTCs were cultivated in short-time human cultures to provide response to drug sensitivity. Our bimodal approach allowed to reveal two items. Firstly, that one part of a tumour, proximal to the bronchial structure, displays a predominance of CD133+. Secondly, specific NSCL-CTCs Epithelial Cell Adhesion Molecule (EpCAM)+CD29+ can be used as a negative prognostic factor as well the high expression of CTCs EpCAM+. These data were confirmed by drug-sensitivity tests, in vitro, and by the survival curves, in vivo.

Accessory mitral valve leaflet in an adult with coronary artery disease

Accessory mitral valve leaflet is a very rare cause of left ventricular outflow tract obstruction. We report a patient presenting this cardiac abnormality who undergone cardiac surgery. A 60-year-old man, presented coronary artery disease and moderate left ventricular tract obstruction due to accessory mitral valve leaflet. The accessory mitral valve leaflet had the typical morphology of a parachute-shaped attached partially to the anterior mitral valve leaflet, with chordae tendinae attached to: 1) an accessory papillary muscle inserted at the free-wall closed to the apex; 2) interconnected with the chordae tendinae of the anterior mitral valve leaflet; 3) a second accessory papillary muscle inserted to the interventricular septum. He underwent successful coronary revascularization of 2 vessels and accessory leaflet excision. A review of 21 cases with accessory mitral valve leaflet is reported.

Predictive value of markers of myocardial reperfusion in acute myocardial infarction for follow-up left ventricular function

This study evaluated recently suggested invasive and noninvasive parameters of myocardial reperfusion after acute myocardial infarction (AMI), assessing their predictive value for left ventricular function 4 weeks after AMI and reperfusion defined by myocardial contrast echocardiography (MCE). In 38 patients, angiographic myocardial blush grade, corrected Thrombolysis In Myocardial Infarction frame count, ST-segment elevation index, and coronary flow reserve (n = 25) were determined immediately after primary percutaneous transluminal coronary angioplasty (PTCA) for first AMI, and intravenous MCE was determined before, and at 1 and 24 hours after PTCA to evaluate myocardial reperfusion. Results were related to global wall motion index (GWMI) at 4 weeks. MCE 1 hour after PTCA showed good correlation with GWMI at 4 weeks (r = 0.684, p <0.001) and was in an analysis of variance the best parameter to predict GWMI 4 weeks after AMI. The ST-segment elevation index was close in its predictive value. Considering only invasive parameters of reperfusion myocardial blush grade was the best predictor of GWMI at 4 weeks (R(2) = 0.3107, p <0.001). A MCE perfusion defect size at 24 hours of > or =50% of the MCE perfusion defect size before PTCA was used to define myocardial nonreperfusion. In a multivariate analysis, low myocardial blush grade class was the best predictor of nonreperfusion defined by MCE. Thus, intravenous MCE allows better prediction of left ventricular function 4 weeks after AMI than other evaluated parameters of myocardial reperfusion. Myocardial blush grade is the best predictor of nonreperfusion defined by MCE and is the invasive parameter with the greatest predictive value for left ventricular function after AMI. Coronary flow parameters are less predictive.

Serial evaluation of perfusion defects in patients with a first acute myocardial infarction referred for primary PTCA using intravenous myocardial contrast echocardiography

AIMS

To investigate whether myocardial contrast echocardiography using Sonazoid could be used for the serial evaluation of the presence and extent of myocardial perfusion defects in patients with a first acute myocardial infarction treated with primary PTCA, and specifically, (1) to evaluate safety and efficacy of myocardial contrast echocardiography to detect TIMI flow grade 0--2, (2) to evaluate the success of reperfusion and (3) to predict left ventricular recovery after 4 weeks follow-up.

METHODS AND RESULTS

Fifty-nine patients underwent serial myocardial contrast echocardiography, immediately before primary PTCA (MCE1), 1 h (MCE2) and 12--24 h after PTCA (MCE3). A perfusion defect was observed in 21 of 24 patients (88%) with anterior acute myocardial infarction. All but one had TIMI flow grade 0--2 prior to PTCA. Nine of 31 patients (29%) with inferior acute myocardial infarction showed a perfusion defect and all had TIMI flow grade 0-2 prior to PTCA. Restoration of TIMI flow grade 3 was achieved in 73% of the patients by primary PTCA. A reduction in size of the initial perfusion defect of at least one segment (16 segment model) or no defect vs persistent defect in patients with anterior acute myocardial infarction was associated with improved global left ventricular function at 4 weeks; mean global wall motion score index 1.29+/-0.21 vs 1.66+/-0.31 (P=0.009). Multiple regression analysis in patients with an anterior acute myocardial infarction revealed that the extent of the perfusion defect at MCE3 was a significant (P=0.0005) independent predictor for left ventricular recovery at 4 weeks follow-up. The only other independent predictor was TIMI flow grade 3 post PTCA (P=0.007).

CONCLUSION

Intravenous myocardial contrast echocardiography immediately prior to primary PTCA seems safe and is capable of detecting the presence of a perfusion defect and its subsequent dynamic changes, particularly in patients with a first anterior acute myocardial infarction. A significant reduction in size of the initial perfusion defect using serial myocardial contrast echocardiography predicts functional recovery after 4 weeks and these findings underscore the potential diagnostic value of intravenous myocardial contrast echocardiography.

Assessment of flow velocity reserve by transthoracic Doppler echocardiography and venous adenosine infusion before and after left anterior descending coronary artery stenting

OBJECTIVES

We sought to evaluate whether coronary flow velocity reserve (CFR) (the ratio between hyperemic and baseline peak flow velocity), as measured by transthoracic Doppler echocardiography during adenosine infusion, allows detection of flow changes in the left anterior descending coronary artery (LAD) before and after stenting.

BACKGROUND

The immediate post-stenting evaluation of CFR by intracoronary Doppler has shown mixed results, due to reactive hyperemia and microvascular stunning. Noninvasive coronary Doppler echocardiography may be a more reliable measure than intracoronary Doppler.

METHODS

Transthoracic Doppler echocardiography during 90-s venous adenosine infusion (140 microg/kg body weight per min) was used to measure CFR of the LAD in 45 patients before and 3.7 +/- 2 days after successful stenting, as well as in 25 subjects with an angiographically normal LAD (control group).

RESULTS

Adequate Doppler spectra were obtained in 96% of the patients. Pre-stent CFR was significantly lower in patients than in control subjects (diastolic CFR: 1.45 +/- 0.5 vs. 2.72 +/- 0.71, p < 0.01; systolic CFR: 1.61 +/- 1.02 vs. 2.41 +/- 0.68, p < 0.01) and increased toward the normal range after stenting (diastolic CFR: 2.58 +/- 0.7 vs. 2.72 +/- 0.75, p = NS; systolic CFR: 2.43 +/- 1.01 vs. 2.41 +/- 0.52, p = NS). Diastolic CFR was often damped, suggesting coronary steal in patients with > or =90% versus <90% LAD stenosis (0.86 +/- 0.23 vs. 1.69 +/- 0.43, p < 0.01). Coronary stenting normalized diastolic CFR in these two groups (2.45 +/- 0.77 and 2.64 +/- 0.69, respectively, p = NS), even though impaired diastolic CFR persisted in three of four patients with > or =90% stenosis. Stenosis of the LAD was better discriminated by diastolic (F = 49.30) than systolic (F = 12.20) CFR (both p < 0.01).

CONCLUSIONS

Coronary flow reserve, as measured by transthoracic Doppler echocardiography, is impaired in LAD disease; it may identify patients with > or =90% stenosis; and it normalizes early after stenting, even in patients with > or =90% stenosis.

Imaging of the posterior descending coronary artery. The last frontier in echocardiography

BACKGROUND

Non-invasive color Doppler imaging of the left anterior descending coronary artery has been described, but imaging of the posterior descending coronary artery (PD) has never been reported. The aim of this paper was to describe color Doppler imaging and flow reserve of the PD, regardless of its origin from the right or circumflex coronary artery, in different settings such as acute myocardial infarction or coronary stenting.

METHODS

A C256 Acuson Sequoia ultrasound system connected to a standard 3.5 MHz transducer was used. Neither a contrast agent nor harmonic or power Doppler imaging was used. However, the Nyquist limit of color Doppler was reduced to 12 cm/s. Patients were examined in the apical 2-chamber view, with the coronary sinus ostium imaged in the short axis until a diastolic flow signal close to the epicardial layer was detected. Pulsed Doppler confirmed an anterograde, doming systolic and monophasic decrescendo diastolic flow. Adenosine was intravenously infused at the standard dose of 140 microg/kg/min over 90 s in order to elicit maximal microcirculatory dilation. The resting and hyperemic peak diastolic flow velocities were measured and the coronary flow reserve was calculated as the ratio between hyperemic and resting peak diastolic flow velocities.

RESULTS

This simple bedside technique provided crucial information about several important issues: 1) arterial patency after thrombolysis; 2) evaluation of the physiologic impact of a coronary stenosis, with implications on the detection of a critical stenosis; 3) reperfusion imaging of perforating branches after myocardial infarction; 4) post-stent assessment of coronary flow reserve.

CONCLUSIONS

This paper shows, for the first time, that non-invasive imaging of the PD by non-contrast transthoracic Doppler is feasible and that the coronary flow reserve is measurable even in critical conditions. More studies are needed to assess the feasibility of PD imaging in different clinical settings and the potential benefit of contrast agents in improving the evaluation of coronary flow.

Non-invasive assessment of coronary flow velocity reserve before and after angioplasty in a patient with mammary graft stenosis

We report the diagnosis of mammary artery graft dysfunction by high-resolution transthoracic Doppler and venous adenosine infusion. The patient was treated by percutaneous balloon angioplasty, with optimal angiographic results. Coronary flow reserve in the distal left anterior descending artery was abnormal before angioplasty, and recovered soon after the procedure. The utility of this new non-invasive technique in the diagnosis of flow-limiting stenoses and follow-up of coronary angioplasty is described.

Detection of false lumen perfusion at the beginning of cardiopulmonary bypass in patients undergoing repair of aortic dissection

OBJECTIVE

In patients undergoing surgical repair of aortic dissection, false lumen perfusion during cardiopulmonary bypass may produce central nervous system damage, myocardial ischemia, aortic rupture, and death. We describe a method to detect false lumen perfusion at the beginning of retrograde aortic perfusion that may prevent these complications.

DESIGN

Sonicated albumin microbubbles (8 mL) were injected through a side branch of the extracorporeal circulation line to detect true lumen and/or false lumen perfusion of the thoracic aorta at the beginning of cardiopulmonary bypass. Transesophageal echocardiography was used to image aortic perfusion.

SETTING

The study was performed in a cardiac surgery theater.

PATIENTS

A total of 27 consecutive patients undergoing operation for Type I aortic dissection were studied.

INTERVENTIONS

All patients underwent surgical repair of aortic dissection and retrograde aortic perfusion through one femoral artery.

MEASUREMENTS AND MAIN RESULTS

Patients were divided into three groups: Group I, those having adequate true lumen perfusion: brisk appearance and washout of contrast in the true lumen with no, poor, or delayed opacification of the false lumen; Group II, those having mixed true lumen and false lumen perfusion: simultaneous opacification of both lumens; Group III, those having inappropriate false lumen perfusion: same criteria as for adequate true lumen perfusion applied to the false lumen. The true lumen was perfused in 13 patients, both lumens in 11 patients, and false lumen alone in three patients. In these three patients, cannulation was repeated through the contralateral femoral artery with restoration of true lumen perfusion; the first patient died of diffuse cerebral ischemic damage and renal failure, another one experienced temporary postoperative monoparesis, and the last had no neurologic sequelae.

CONCLUSIONS

Contrast echocardiography allows immediate detection of retrograde aortic perfusion during cardiopulmonary bypass and may help prevent neurologic complications and death in patients with Type I dissection.

Assessment of myocardial reperfusion by intravenous myocardial contrast echocardiography and coronary flow reserve after primary percutaneous transluminal coronary angioplasty [correction of angiography] in patients with acute myocardial infarction

BACKGROUND

This study investigated whether the extent of perfusion defect determined by intravenous myocardial contrast echocardiography (MCE) in patients with acute myocardial infarction (AMI) treated by primary percutaneous transluminal coronary angioplasty (PTCA) relates to coronary flow reserve (CRF) for assessment of myocardial reperfusion and is predictive for left ventricular recovery.

METHODS AND RESULTS

Twenty-five patients with first AMI underwent intravenous MCE with NC100100 with intermittent harmonic imaging before PTCA and after 24 hours. MCE before PTCA defined the risk region and MCE at 24 hours the "no-reflow" region. The no-reflow region divided by the risk region determined the ratio to the risk region. CFR was assessed immediately after PTCA and 24 hours later. Left ventricular wall motion score indexes were calculated before PTCA and after 4 weeks. CFR at 24 hours defined a recovery (CFR >/=1.6; n=17) and a nonrecovery group (CFR <1.6; n=8). Baseline CFR did not differ between groups. MCE ratio to the risk region was smaller in the recovery group compared with the nonrecovery group (34+/-49% vs 81+/-46%, P=0.009). A ratio to the risk region of </=50% defined an MCE reperfusion group. It was associated with improvement of CFR from 1.67+/-0.47 at baseline to 2. 15+/-0.53 at 24 hours (P<0.001) and of regional wall motion score index from 2.6+/-0.5 to 1.9+/-0.5 at 4 weeks (P<0.001).

CONCLUSIONS

Intravenous MCE can be used to define perfusion defects after AMI. Assessment of microcirculation by MCE corresponds to evaluation by CFR. Serial intravenous MCE has the potential to identify patients likely to have improved left ventricular function after AMI.

Successful weaning from cardiopulmonary bypass with central venous prostaglandin E1 and left atrial norepinephrine infusion in patients with acute pulmonary hypertension

OBJECTIVE

Postoperative pulmonary hypertension increases the mortality risk in cardiac surgery. We have used central venous prostaglandin E1 (PGE1) and left atrial norepinephrine (NE) infusion to wean from cardiopulmonary bypass (CPB) patients with refractory postoperative pulmonary hypertension.

DESIGN

Observational, nonrandomized study.

SETTING

Department of Cardiac Surgery in a university hospital.

PATIENTS

We studied 10 nonconsecutive American Society of Anesthesiologists III and New York Heart Association class III-IV patients with postoperative pulmonary hypertension and low cardiac output syndrome preventing separation from CPB.

INTERVENTIONS

Patients received right atrial PGE1 (31.5 +/- 6.26 ng/kg/min) and left atrial NE (0.11 +/- 0.02 microg/kg/min) infusion. Hemodynamic data were obtained before CPB (T0), after CPB under maximal inotropes and vasodilator infusion (T1), 10 mins (T2) and 12 hrs (T3) after PGE1 and NE infusion, and 48 hrs after withdrawal of PGE1 and NE (T4).

MEASUREMENTS AND MAIN RESULTS

All patients were successfully weaned from CPB and survived. The biatrial infusion of PGE1 and NE caused a dramatic reduction in mean pulmonary artery pressure (from 42.8 +/- 5.1 mm Hg at T1 to 28.5 +/- 2.6 mm Hg at T2 and 20.5 +/- 2.0 mm Hg at T4), pulmonary vascular resistance index (from 1158 +/- 269 dyne x sec/cm5 x m2 at T1 to 501 +/- 99 dyne x sec/cm5 x m2 at T2 and 246 +/- 50 dyne x sec/cm5 x m2 at T4), and pulmonary-to-systemic vascular resistance index ratio (from 0.61 +/- 0.17 at T1 to 0.20 +/- 0.04 at T2 and 0.11 +/- 0.03 at T4). Cardiac index increased from 1.7 +/- 0.2 L/min/m2 at T1 to 2.3 +/- 0.2 L/min/m2 at T2 and 2.9 +/- 0.1 L/min/m2 at T4.

CONCLUSIONS

In patients with refractory postoperative pulmonary hypertension, the combined administration of low-dose PGE1 in the right atrium and NE in the left atrium is an effective means to wean patients from cardiopulmonary bypass.

Coronary Doppler intensity changes during handgrip: a new method to detect coronary vasomotor tone in coronary artery disease

OBJECTIVES

This study evaluates whether a quantitative measurement of Doppler intensity during handgrip may disclose coronary vasomotor dysfunction in patients with coronary artery disease (CAD).

BACKGROUND

Atherosclerotic coronary segments show an exaggerated constrictive response to handgrip. The intensity of the scattered Doppler signal is proportional to the number of blood cells flowing through the vessel, and should be reduced during vasoconstriction. Therefore, changes in coronary flow during handgrip may be detected by measuring Doppler intensity rather than velocities.

METHODS

The distal left anterior descending coronary artery (LAD) was imaged by high-resolution transthoracic color Doppler echocardiography during handgrip in 47 patients: 15 with normal coronary arteries and 32 with significant CAD involving the LAD. The Doppler signal was acquired at 70 dB dynamic range at baseline, 30-s handgrip and 5 min recovery. Peak and mean flow velocity, pressure half-time, deceleration time (ms), deceleration rate (cm/s2) and mean gray level intensity (intensity units [IU]) of the Doppler spectrum were measured in diastole. RESULTS The velocity parameters did not change significantly during handgrip both in normal and CAD patients. The Doppler intensity significantly decreased during handgrip (from 87.0 +/- 32.8 to 57.7 +/- 35.3 IU; p < 0.001) in patients with CAD, and it increased or remained unchanged in normals (from 74.1 +/- 27.3 to 85.1 +/- 31.2 IU; p = NS). The sensitivity of Doppler intensity in detecting CAD was 84.4%, specificity 93.3%, negative predictive value 73.7% and positive predictive value 96.4%.

CONCLUSIONS

Doppler intensity measured by transthoracic echocardiography during handgrip allows the detection of CAD and coronary vasomotor dysfunction.

Calcium chloride minimizes the hemodynamic effects of propofol in patients undergoing coronary artery bypass grafting

OBJECTIVE

To assess the hemodynamic effects of propofol and the counteracting effect of calcium chloride (CaCl2) in patients undergoing coronary artery bypass grafting (CABG).

DESIGN

Prospective, randomized study.

SETTING

University hospital, department of cardiac surgery.

PARTICIPANTS

Fifty-eight patients undergoing elective CABG, divided into group A (n = 29) and group B (n = 29).

INTERVENTIONS

Anesthesia was induced with a combination of fentanyl, 7 microg/kg; pancuronium, 0.1 mg/kg; and propofol, 1.5 mg/kg, administered over 60 seconds. A blinded investigator administered saline in group A patients and 10 mg/kg of CaCl2 in group B patients at the same speed and same time as propofol administration through another lumen of the central venous catheter.

MEASUREMENTS AND MAIN RESULTS

Hemodynamic data were obtained at baseline (T0), 2 minutes after anesthesia induction (T1), and 2 minutes after tracheal intubation (T2). Heart rate decreased significantly in group A patients (86.2+/-11.3 beats/min at T0 and 72.8+/-7.5 beats/min at T2; p < 0.001). Mean arterial pressure decreased significantly in patients in both groups (group A, 108.0+/-12.0 mmHg at T0; 74.6+/-14.6mmHg at T2;p < 0.001 and group B, 106.0+/-10.2 mmHg at T0; 90.4+/-10.0 mmHg at T2; p < 0.05). Stroke volume index, cardiac index, and cardiac output decreased in group A patients (39.4+/-4.1 mL/beat/m2 at T0 and 28.8+/-5.2 mL/beat/m2 at T2; p < 0.05; 3.4+/-0.6 L/min/m2 at T0 and 1.9+/-0.3 L/min/m2 at T2; p < 0.001; 5.9+/-0.9 L/min at T0 and 3.4+/-0.4 L/min at T2; p < 0.001, respectively), whereas in group B patients, changes were negligible (38.1+/-7.0 mL/beat/m2 at T0 v 35.7+/-6.6 mL/beat/m2 at T2; (NS) 3.3+/-0.5 L/min/m2 at T0 v 2.7+/-0.3 L/min/m2 at T2; (NS) 5.7+/-0.9 L/min at T0 v 4.7+/-0.5 L/min at T2; (NS), respectively).

CONCLUSION

Simultaneous administration of CaCl2 during the induction of anesthesia minimizes the potential negative effect of propofol on cardiac function in cardiac patients.

[Natural harmonic echocardiography]

The acquisition of echocardiographic images in harmonic mode (a frequency double than the transmitted, or fundamental) improves imaging quality. We assessed whether harmonic imaging improves the detection of endocardial borders, evaluation of ventricular function and diagnostic confidence in the clinical arena. We have studied in fundamental and harmonic imaging 45 patients (age 20-89 years, mean 53 years) using a multifrequency transthoracic probe transmitting at 1.75 MHz and receiving at 3.5 MHz (Acuson Sequoia). In 34 low echogenic patients we assessed left ventricular function. The remaining 11 patients represented selected cases (i.e. atrial septal aneurysm, aortic dissection, endocarditis and atrial septal defect). The echocardiographic images were recorded on a magneto-optical disk and analyzed by two blinded observers. Endocardial definition has been semiquantitatively evaluated assigning a 0-4 score for each of the 16 segments of the left ventricle. A score of 0 was allotted to the non-visualizable segments and a score of 4 to the best detectable segments. Ejection fraction was calculated in each patient from the apical 4-chamber view. We compared endocardial border definition and ejection fraction at rest, in fundamental and harmonic mode, and assessed the interobserver agreement in the calculation of ejection fraction. Harmonic images always showed a better definition and lower noise compared to fundamental. Endocardial border definition was significantly improved in all segments (from 1.3 +/- 1.1 fundamental to 2.9 +/- 1.0 harmonic). Forty-two segments were non detectable in fundamental (score 0) compared to 5 in harmonic. Of these 42 segments, 37 were detectable in harmonic, with a score of 2.0 +/- 1.0. Conversely, none of the 5 segments non detectable in harmonic could be visualized in fundamental. The interobserver agreement in calculating ejection fraction was improved by harmonic imaging compared to fundamental (r = 0.91 and r = 0.67, respectively). In the selected clinical cases the diagnosis was easier and faster by harmonic imaging. The harmonic mode drastically improves echocardiographic imaging, it may be used routinely and reduce the need for more invasive techniques such as transesophageal echocardiography.

Flail tricuspid valve in a patient with history of stab chest wound

Cardiac sequelae of stab chest wounds may be various and dramatic, and the right ventricle is the most commonly injured chamber. Correct diagnosis of cardiac damage may be done up to many years after the trauma. We describe a rare case of isolated, unexpected flail tricuspid valve detected by transthoracic echocardiography in a young patient with remote history of stab chest wound.

Imaging of the distal left anterior descending coronary artery by transthoracic color-Doppler echocardiography

Two-dimensional echocardiography evaluates the effect of myocardial ischemia on left ventricular wall motion, but a direct measure of coronary flow by this method is still lacking. The aim of the present study is to evaluate the efficacy of new, high-resolution ultrasound equipment designed to image by color Doppler transthoracic echocardiography the epicardial and intramural coronary vessels. We have studied 33 consecutive patients in apical projections, to detect by color Doppler > or = 1 segments of the middle-distal tract of the left anterior descending coronary artery. In 25 of 33 patients (76%), the middle-distal tract of the left anterior descending coronary artery was imaged by color Doppler. In 15 of 33 patients (46%), the periapical tract of the left anterior descending was imaged along with its perforating branches. In 2 of 4 patients who had coronary artery bypass grafting, the anastomosis between the left internal mammary artery and the left anterior descending coronary artery was imaged. Once the coronary artery was imaged, pulsed Doppler was used to measure coronary blood flow velocity at rest. Peak and mean flow velocity, as well as the deceleration time (msec) and deceleration rate (cm/sec2), were measured on the diastolic phase of the Doppler tracing. In all 25 patients, it was possible to measure by pulsed Doppler the coronary flow velocity pattern characterized by a typical prevalent diastolic component. Peak diastolic flow velocity was 50 +/- 17 cm/sec and mean diastolic flow velocity was 37 +/- 12 cm/sec. The deceleration time was 916.2 +/- 429.1 msec and the deceleration rate was 86.3 +/- 69.3 cm/sec2. The Doppler pattern of the grafted mammary artery was different from the native mammary flow. This new noninvasive imaging technique of the coronary arteries promises to expand the field of diagnostic and experimental echocardiography and brings new insight into the pathophysiology of ischemic heart disease.

The complex relation between myocardial viability and functional recovery in chronic left ventricular dysfunction

Preserved myocardial viability and recurrent symptomatic ischemia are the most widely accepted criteria indicating that coronary revascularization should take place in patients with postischemic left ventricular dysfunction. However, the presence of viable myocardium within the infarct zone does not necessarily imply recovery of function after coronary revascularization. The complex relation between the extent of transmural necrosis and the degree of residual perfusion within the infarct area plays an important role. However, independently of functional recovery, cell viability may have important clinical implications, since it may improve long-term prognosis by attenuating left ventricular remodeling processes. Several different methods are used to detect hibernating myocardium. Mounting evidence suggests that thallium-201 scintigraphy is most sensitive in identifying tissue viability, whereas dobutamine echocardiography is most specific in predicting functional recovery after revascularization. In between, myocardial contrast echocardiography is the only technique able to evaluate the microvascular integrity that is a condition sine qua non for both cell viability and later functional recovery. Combined information derived from these 3 different approaches might be considered as the best way to understand how the combination of contractile, viable but noncontractile, and dead tissue affect resultant function and prognosis.

[Visualization of native internal mammary arteries and aorto-coronary graft by means of high resolution color Doppler ultrasonography]

The internal mammary artery is routinely used for coronary artery bypass grafting because of its optimal long-term patency profile. This vessel can be imaged by angiography, but only the proximal tract at the origin from the succlavian artery can be imaged by conventional echography. The aim of our study was to visualize the intrathoracic course of the native and grafted internal mammary arteries by a new ultrasound equipment which allows high-resolution transthoracic color Doppler imaging of the chest wall vessels and coronary arteries. We studied 35 patients, 16 non operated and 19 operated of coronary surgery with the internal mammary artery grafted to the left anterior descending coronary artery. We used a multifrequency 3.5-7 MHz transducer with a small insonating surface, placed at the second-fifth intercostal space at the left and right sternal border, to image the native mammary arteries. The grafted mammary artery was detected at the fourth-fifth left intercostal space 2-4 cm lateral to the sternal border. The native left internal mammary artery was visualized in all 16 non operated patients, and the right internal mammary artery in 14/16 (87%). The native left internal mammary artery peak flow velocity was 41-160 cm/s (mean 81 +/- 34 cm/s), and the mean flow velocity was 28-89 cm/s (mean 45 +/- 17 cm/s). The right internal mammary artery peak flow velocity was 35-153 cm/s (mean 82 +/- 36 cm/s), and mean flow velocity was 21-82 cm/s (mean 46 +/- 22 cm/s). The grafted left internal mammary artery was visualized in 16/19 patients (84%), evaluated at 6 days to 36 months after surgery. Peak diastolic flow velocity ranged from 24 to 80 cm/s (mean 48 +/- 17 cm/s), and mean diastolic flow velocity ranged from 13 to 57 cm/s (mean 33 +/- 11 cm/s). The left anterior descending peak flow velocity distal to the anastomosis was 22-62 cm/s (mean 37 +/- 15 cm/s) and mean flow velocity was 18-53 cm/s (mean 29 +/- 12 cm/s). We conclude that transthoracic color Doppler echocardiography allows to image the native and grafted mammary arteries, with potential clinical applications in the management of patients with coronary artery disease.

Neuromuscular relaxants in non-cardiac surgery after cardiomyoplasty

PURPOSE

Dynamic cardiomyoplasty is a therapeutic alternative to heart transplantation in irreversible cardiac insufficiency. Little information exists about the use of muscle relaxants in patients with cardiomyoplasty. In particular, it is not clear if the muscle flap is responsive to neuromuscular blockers. The purpose of this report is to describe the safe use of vecuronium in a patient with cardiomyoplasty.

CLINICAL FEATURES

A 59-yr-old man, after cardiomyoplasty for dilated cardiomyopathy two years earlier, underwent general anaesthesia with fentanyl, propofol and vecuronium during surgery for intestinal ischaemia. Intraoperative transthoracic echocardiography showed that vecuronium did not affect muscle flap motion. Two days after surgery he died in septic shock. Post-mortem histological and immunohistochemical examination showed nervous degeneration of the flap probably as a result of the chronic low frequency pacing. There was also an increase in extrajunctional receptors and an alteration in junctional receptors, as demonstrated by the negative reaction to anti-synaptophysin antibodies, used to identify the neuromuscular plate.

CONCLUSION

In patients undergoing non-cardiac surgery after previous cardiomyoplasty, muscle relaxants, such as vecuronium, may be used safely. Depolarising agents, such as succinylcholine, should probably be avoided because of the possible exaggerated actions on extrajunctional receptors.

Tissue-type plasminogen activator therapy versus primary coronary angioplasty: impact on myocardial tissue perfusion and regional function 1 month after uncomplicated myocardial infarction

OBJECTIVES

This study sought to compare the impact of primary coronary angioplasty and thrombolytic therapy for acute myocardial infarction (AMI) on 1-month infarct size and microvascular perfusion.

BACKGROUND

The effect of the reperfusion strategies of primary coronary angioplasty and thrombolytic therapy on microvascular integrity still remains to be determined.

METHODS

Sixty-two consecutive patients with a first AMI, undergoing intravenous tissue-type plasminogen activator (t-PA) therapy (32 patients, Group I) or primary angioplasty (30 patients, Group II), were studied. Only patients with 1-month Thrombolysis in Myocardial Infarction (TIMI) flow grade 2 or 3 were selected for the study. Patients in whom primary angioplasty was unsuccessful or those with clinical evidence of failed reperfusion were excluded. Microvascular perfusion was assessed at 1 month by intracoronary injection of sonicated microbubbles. Contrast score index (CSI) and wall motion score index (WMSI) were derived using qualitative methods.

RESULTS

At baseline there were no significant differences between groups for age, risk factors, time to hospital presentation, Killip class on admission, prevalence of multivessel disease or anterior infarct site, infarct area extension before reperfusion, peak creatine kinase levels and postinfarction treatment. Conversely, significant differences between groups were found at follow-up for percent residual infarct related-artery (IRA) stenosis (70 +/- 12 vs 36 +/- 14 [mean +/- SD], p = 0.0001), CSI (1.02 +/- 0.4 vs. 1.49 +/- 0.5, p = 0.0003) and WMSI (1.67 +/- 0.3 vs. 1.45 +/- 0.3, p = 0.015). In particular, in the subset of patients with TIMI grade 3 flow, a perfusion defect occurred in one or more segments subtended by the IRA in 72% of Group I versus 31% of Group II patients (p < 0.00001) and in 27% of Group I versus 8% of Group II segments (p < 0.00001).

CONCLUSIONS

The present study shows, in a highly selected cohort with successful IRA recanalization, that primary angioplasty is more effective than thrombolysis in preserving microvascular flow and preventing extension of myocardial damage at 1-month after AMI.

Cor triatriatum associated with degenerative aortic insufficiency in an adult patient

Cor triatriatum is a rare cardiac anomaly which can be congenital or acquired in origin. Congenital cor triatriatum is due to an alteration of the common pulmonary vein resorption and therefore the left atrium is divided into two chambers, a proximal one, in communication with the pulmonary veins, and a distal one, in communication with the mitral valve orifice. The diagnosis is usually made at birth, but in rare cases, when the communication between the two chambers is wide and the patient is asymptomatic, the lesions may be diagnosed incidentally during a routine echocardiographic examination. We report a 32-year-old man, admitted to our hospital with a diagnosis of aortic insufficiency, in whom echocardiography revealed the presence of cor triatriatum. The patient underwent aortic valve replacement and resection of the atrial membrane. Histology of the aortic valve revealed myxoid degeneration of the spongiosa.

Cardiac involvement in Behçet's disease

To assess the prevalence and the extent of cardiac involvement in patients with Behçet's disease and to investigate the possible causes that may predispose to this involvement, 30 patients affected by Behçet's disease and 30 normal control subjects were submitted to M-mode, two-dimensional, and Doppler echocardiographic evaluation. Moreover, antinuclear and anticardiolipin autoantibodies were determined in the sera of both patients and control subjects. Finally, HLA-B51 positivity was assessed in the patients and in a historical control group. Mitral valve prolapse was observed in 50% and proximal aorta dilatation in 30% of the patients. There was a significant difference in the rate of these abnormalities in comparison with the control group. Left ventricular function parameters were similar between the two groups. The positivity rate of antinuclear and anticardiolipin autoantibodies was very low (7%), without differences between the groups. HLA-B51 was detected in 82.7% of the patients versus 21.7% in the control group (p < 0.00001). In conclusion, this study demonstrates a high rate of cardiac abnormalities in patients with Behçet's disease.

[Study of the coronary flow with high resolution transthoracic echocardiography and nondirectional Doppler]

Two-dimensional echocardiography allows to evaluate the effect of myocardial ischemia on left ventricular wall motion, but a direct measure of coronary flow by this method is still lacking. The aim of the present study was to evaluate the efficacy of a new, high-resolution echocardiographic equipment designed to image the epicardial and intramural coronary vessels by non directional Doppler. We studied 33 consecutive patients by transthoracic echocardiography in apical projections, to detect one or more segments of the left anterior descending coronary artery by non directional Doppler. Once the coronary artery has been imaged, pulsed Doppler was used to measure coronary blood flow velocity at rest. Peak and mean flow velocities were measured on the diastolic phase of the Doppler spectrum. In 25/33 patients (75.7%) the middle-distal tract of the left anterior descending coronary artery was imaged by non directional Doppler. In 15/33 patients (45.5%) the periapical tract of the left anterior descending coronary artery was imaged along with its perforating branches. In 2 out of 4 patients operated of coronary artery bypass grafting, the anastomosis between the left internal mammary artery and the left anterior descending coronary artery was imaged. In all 25 patients it was possible to measure by pulsed Doppler the coronary velocity flow pattern, characterized by a typical prevalent diastolic component. Peak diastolic flow velocity was 49.98 +/- 17.30 cm/s and mean diastolic flow velocity was 36.52 +/- 11.91 cm/s. The Doppler pattern of the grafted mammary artery was different from the native mammary flow. This new non invasive imaging technique of the coronary arteries promises to expand the field of diagnostic and experimental echocardiography and brings new insight into the pathophysiology of ischemic heart disease.

[Who are the "non-dippers": an insight from the ambulatory monitoring of arterial pressure in heart transplant patients]

This study was performed in order to define who are the "non-dippers", knowing that their present definition does not imply any explanation about the mechanisms. The investigation was performed on 34 heart transplanted patients, 28 males (mean age 52 +/- 11 years) and 6 women (mean age 35 +/- 14 years), knowing that the "non-dippers" were described as the hypertensives who are devoid of the expected nocturnal fall in blood pressure (BP). The "non-dipping" phenomenon was investigated by exploring the BP 24-h pattern via ambulatory non-invasive BP monitoring, and by applying the rhythmometric analysis for quantifying the BP circadian rhythm. The study provided evidence that the "non-dippers" can be found among the hypertensives as well as the normotensives, suggesting that high BP is not a necessary condition for the "non-dipping" phenomenon, and vice versa. Both the normotensive and hypertensive "non-dippers" were seen to show stereotypic changes in BP circadian rhythm. There are normotensive and hypertensive "non-dippers" with or without the BP circadian rhythm. The "rhythmic non-dippers" show a BP circadian rhythm which is inverted in phase or demodulated in amplitude. The "non-dippers" are, thus, a heterogeneous category.

Combined use of dobutamine echocardiography and myocardial contrast echocardiography in predicting regional dysfunction recovery after coronary revascularization in patients with recent myocardial infarction

BACKGROUND

Myocardial contrast echocardiography and dobutamine echocardiography have recently emerged as potentially useful clinical tools to detect reversible myocardial dysfunction. However, the relative accuracy of these two techniques in predicting regional wall motion improvement after coronary interventions is still unclear. The aim of the present study was to compare their diagnostic value in predicting functional recovery after coronary revascularization in patients with recent acute myocardial infarction.

METHODS AND RESULTS

Twenty-four patients with acute myocardial infarction underwent myocardial contrast echocardiography and dobutamine echocardiography within 2 weeks of hospital admission. Infarct zone contrast score and wall motion score indexes were derived in each patient. Infarct-related artery revascularization was performed before hospital discharge in all selected patients. Resting echocardiography was repeated 3 months after revascularization, and regional function recovery was analysed. The degree of wall motion score improvement at 3-month follow-up and the percentage of positive responses to dobutamine echo were greater (P < 0.001 and P < 0.002, respectively) in patients with a higher baseline contrast score (> or = 0.50). Conversely, no significant changes were observed either during dobutamine echo or after revascularization in the group of patients without residual perfusion within the infarct area. Diagnostic agreement between both techniques in predicting reversible dysfunction was high (81% of segments). The sensitivity and negative predictive value in predicting functional outcome were 100% (95% confidence interval [CI], 87% to 100%) and 100% (95% CI, 93% to 100%) by contrast echo, and 85% (95% CI, 66% to 96%) and 93% (95% CI, 84% to 98%) by dobutamine echo. The specificity and positive predictive value were 90% (95% CI, 80% to 96%) and 81% (95% CI, 64% to 93%) by contrast echo, and 88% (95% CI, 78% to 95%) and 76% (95% CI, 58% to 90%) by dobutamine echo. The combination of myocardial contrast and dobutamine echocardiography positive responses improved specificity and positive predictive value in detecting functional recovery after revascularization to 100% (95% CI, 94% to 100%) and 100% (95% CI, 85% to 100%), respectively. However, the sensitivity and negative predictive value slightly decreased with the use of both methods (85% [95% CI, 66% to 96%)] and (93%[95% CI, 85% to 98%)], respectively.

CONCLUSIONS

In patients with recent myocardial infarction, reversible dysfunction after coronary revascularization and the response to dobutamine infusion are strictly dependent on microvascular integrity. However, microvascular perfusion does not always imply functional recovery after coronary revascularization. The integration with dobutamine echo results seems particularly helpful to further improve myocardial contrast echo specificity and positive predictive values.

Assessment of left ventricular systolic function in low-echogenic patients by intravenous Infoson injection during dopamine echocardiography. An open, phase III trial

This trial evaluated whether the intravenous injection of an ultrasound contrast agent (Infoson) facilitates the assessment of systolic function in 40 low-echogenic patients undergoing low-dose (4 mcg/kg/min) dopamine echocardiography. Interobserver difference in calculated ejection fraction at entry was > 10%. Echocardiographic monitoring was performed in the apical 4-chamber view at four intervals: baseline, no contrast; first Infoson injection; dopamine infusion, no contrast; dopamine infusion+second Infoson injection. The left ventricle was divided into 5 segments and analysis was performed by two blinded observers. Wall motion abnormalities, ejection fraction and the confidence in detecting the endocardial border, were assessed. Infoson provided adequate left ventricular opacification in 90% of the injections, with a significant improvement in endocardial border detection. The interobserver variability of ejection fraction measurements was significantly reduced. The probability of attaining concordance between the investigators on wall motion assessment improved significantly. These results suggest potential applications in stress echocardiography.

Opacification of the thoracic aorta after venous injection of sonicated albumin microbubbles. Implications for aortic dissection

This study was designed to assess the feasibility of thoracic aorta opacification after intravenous injection of sonicated albumin microbubbles in patients with and without aortic dissection. Twenty-one patients were studied by transesophageal echocardiography. In 11 patients without aortic dissection, the opacification of the left ventricular outflow tract, aortic root and descending aorta was evaluated. Ten patients with aortic dissection were studied to assess perfusion of the true and false lumen. The left ventricular outflow tract, aortic root and descending aorta were opacified in all patients, with a systolic increase in contrast at visual analysis and at videodensitometry. The differentiation between false and true lumen was improved and was crucial in 1 case of type A chronic dissection. The intimal tear was detected in 7/9 cases by color Doppler vs 9/9 cases by contrast echocardiography. The noninvasive ultrasound opacification of thoracic aorta is feasible and may improve the diagnosis of aortic dissection.

Collateral flow prevents unintentional myocardial ischemia during antegrade cardioplegia in patients undergoing coronary artery bypass grafting

OBJECTIVE

We evaluated, in the prevention of perioperative unintentional myocardial ischemia, the role of coronary collateral flow in patients with left anterior descending coronary artery stenosis or occlusion who underwent elective coronary artery bypass grafting.

METHODS

Coronary lesions and collaterals were assessed by coronary angiography in 21 patients. Anteroseptal myocardial viability was evaluated by dobutamine echocardiography. Antegrade perfusion of cardioplegic solution was assessed by myocardial contrast echocardiography. Time-intensity curves were generated from the anteroseptal region. Twelve parameters were measured and averaged in the following four groups of patients: those with stenosis of the left anterior descending artery and poor collaterals; those with stenosis of the left anterior descending artery and good collaterals; those with occlusion of the left anterior descending artery and good collaterals; and those with occlusion of the left anterior descending artery and poor collaterals.

RESULTS

Time-intensity curves were significantly different in patients with stenosis versus occlusion of the left anterior descending artery (p < 0.005); multiple comparisons with Bonferroni's correction showed that this difference was mainly a result of the impact of collateral circulation (p < 0.01). However, the role of collaterals was nonsignificant within the groups with stenosis and occlusion of the left anterior descending artery. Patients with occlusion of the left anterior descending artery and good collaterals had perfusion parameters similar to those of patients with stenosis of the left anterior descending artery (p = not significant), except for the ascending slope and time to peak values (p < 0.05 and p < 0.01, respectively), which reflected a higher flow resistance in the collateral circulation. Regional systolic function after coronary artery bypass grafting was depressed in patients with poor collaterals and poor perfusion of cardioplegic solution, as compared with findings in other subgroups.

CONCLUSIONS

Incomplete myocardial protection may impair the early recovery of function after coronary artery bypass grafting.

"Patch-glue" annular reconstruction for mitral valve replacement in severely calcified mitral annulus

Mitral valve replacement in severe annular calcification may be complicated by atrioventricular rupture, left circumflex coronary artery injury, and thromboembolic events. Mitral valve replacement was performed in 2 patients with massive annular calcification, by suturing a Tissucol fibrin glue-treated Teflon patch on the posterolateral atrial wall. After 30 and 34 months, respectively, the valve was normally functioning and the patients were asymptomatic and free from hemorrhagic and thromboembolic events.

Iatrogenic pneumohemomediastinum mimicking cardiac tamponade: a complication of catheter ablation procedure

We describe a patient who developed cardiac tamponade during electrophysiological mapping aimed at ablating an atrioventricular accessory pathway. Transesophageal echocardiography showed compression of the left pulmonary veins due to pneumohemomediastinum secondary to left subclavian vein cannulation.

Anaesthesia for caesarean section in a Marfan patient with recurrent aortic dissection

PURPOSE

We report the anaesthetic management of a 34-yr-old pregnant woman with recurrent aortic dissection and Marfan syndrome for Caesarean section.

CLINICAL FEATURES

She presented at 28 wk gestation with recurrent aortic dissection and had undergone aortic valve replacement and coronary ostia reimplantation (Bentall procedure) in the first trimester of pregnancy. She was treated in hospital with labetalol, anticoagulants and steroids and daily echocardiographic examination until 34 wk when caesarean section was planned. After positioning radial artery and CVP catheters and a transoesophageal echocardiographic probe, general anaesthesia was induced with thiopentone and maintained with isoflurane, and endotracheal intubation was facilitated with vecuronium. The site of incision was infiltrated with lidocaine before surgery which was uneventful. The patient was discharged at 10 days.

CONCLUSIONS

With appropriate preoperative care and monitoring, uneventful general anaesthesia for caesarean section was achieved in a patient with Marfan syndrome in the presence of recurrent aortic dissection.

[Hypertensive cardiac damage in heart transplantation. A noninvasive monitoring study of arterial pressure]

This study is aimed at investigating the relationship between cardiac hypertrophy and blood pressure (BP) 24-h pattern in 34 heart transplanted patients (HTP), 9 out of them (26%) being considered as normotensives, the other ones (74%) being regarded as hypertensives under adequate treatment, via casual sphygmomanometry. The study is an attempt to explain the occurrence of at least one sign of hypertrophic cardiopathy in 20 cases (59%), hypothesizing the presence of false normotensives among the putative normotensives and presumably-cured hypertensives. The ambulatory BP monitoring was able to identify 7 hypertensives (78%) among the putative normotensives, and 17 not well-cured subjects (68%) among the presumably cured hypertensives. At least one sign of cardiac hypertrophy was found in 5 (50%) of the 10 true normotensives, who were all non-dipper, and in 15 (63%) of the 24 hypertensives. The 9 hypertensives without cardiac hypertrophy (37%) had developed hypertension very recently. These findings stress the role of the ambulatory BP monitoring as a diagnostic tool during the follow-up of HTP, in order to identify the false normotensives as well as the not well-treated hypertensives. This role can contribute to optimize the prophylaxis of hypertensive damage for the transplanted heart.

Transesophageal echocardiography in critically-ill patients using a miniaturized probe: feasibility, efficacy and indications

Transesophageal echocardiography (TEE) with standard probes may be unsuccessful in emergencies, and in critically-ill or non collaborative patients. A miniaturized pediatric probe was used to overcome these limitations. Thirty-nine patients (age 18-87 years, height 155-184 cm, weight 45-102 kg) were studied with the pediatric probe, and 21 of them were studied using both the pediatric and adult probes in a random sequence. Feasibility, efficacy and patient's compliance were assessed. The use of the pediatric probe was mandatory in 18 critically-ill and/or non collaborative patients for the following reasons: contraindication to sedation in 15 patients with respiratory failure and/ or with unstable hemodynamics (12 not intubated patients) or patients undergoing electroencephalographic monitoring (3 intubated patients); inability to advance the probe into the esophagus in 1 patient with esophageal compression from intrathoracic struma and in 2 patients with stenosing esophageal cancer. Imaging projections and diagnostic accuracy in a wide range of cardiac, aortic and mediastinal diseases were similar for both the pediatric and adult probes. Patient's compliance was much improved by the pediatric probe. In conclusion, TEE by pediatric probes can be used in critically-ill adult patients when the approach with the standard probe is unfeasible or when sedation is undesirable.

[Describing and interpreting systemic hypertension in heart transplantation with non-invasive arterial pressure monitoring]

This investigation was performed in 34 heart transplanted patients (HTP), 28 males and 6 females, mean age 49 +/- 13 years. The aim of the study was to detect hypertension in HTP by casual sphygmomanometry and non-invasive ambulatory blood pressure monitoring (ABPM). The evaluation of ABPM demonstrated that 71% out of the HTP was hypertensive because of some elevated blood pressure values scattered during the hours of the day and/or of the night. These hypertensives were found within the groups of normotensives as well as of hypertensives considered to be correctly treated. Fifty percent hypertensive HTP did not show the physiologic nocturnal decrease in blood pressure (non-dippers); 25% out of the non-dipper hypertensives showed absence of the blood pressure circadian rhythm, demonstrating that their hypertension was prevalently nocturnal and could not be detected by casual sphygmomanometry-The ABPM is recommended in clinical follow-up of HTP for a correct diagnosis of hypertension, which frequently complicates heart transplantation, and with the aim of avoiding hypertensive damage of the transplanted organ. The ABPM is useful for adjusting the antihypertensive therapy, in order to restore the blood pressure circadian rhythm.

Atrial septal aneurysm and cardiac arrhythmias

Atrial septal aneurysm has been associated with thromboembolic events, interatrial shunting, mitral valve prolapse, and systolic click. An association between atrial septal aneurysm and cardiac arrhythmias has been also described. Twenty patients with atrial septal aneurysm and 19 control subjects performed 24-h Holter monitoring. Frequent (> 10/h) atrial premature beats were observed in seven patients vs. none of the controls (P = 0.008). The mean number of episodes of supraventricular tachycardia and the prevalence of ventricular tachycardia were also higher in the atrial septal aneurysm group (P = 0.044 and P = 0.046, respectively). Left atrial enlargement, mitral valve prolapse and left ventricular hypertrophy were more frequent than in the normal subjects. In conclusion, atrial and ventricular 'complex' arrhythmias occurred more frequently in patients with atrial septal aneurysm than in normal subjects. Further studies in patients with atrial septal aneurysm without other associated echocardiographic abnormalities need to be done to ascertain a potential arrhythmogenicity of this condition.

Diagnosis of persistent left superior vena cava by multiplane transesophageal echocardiography

Persistent left superior vena cava occurs in 2-4% of all congenital cardiac defects. The diagnosis is often missed if the lesion is not accurately looked for. Drainage to the coronary sinus is well tolerated, whereas drainage to the left atrium produces right to left shunt and may be associated with brain abscesses and/or embolization secondary to intravenous therapy administered through the left arm. This paper describes for the first time the diagnosis of persistent left superior vena cava by transesophageal contrast echocardiography. Echocardiography is the method of choice in the diagnosis of persistent left superior vena cava, because it can be used at the patient's bedside and allows easy detection of the drainage site.

Papillary muscle perfusion pattern. A hypothesis for ischemic papillary muscle dysfunction

BACKGROUND

The pathogenesis of posterior papillary muscle dysfunction is poorly understood. We hypothesized that papillary muscle perfusion pattern may explain the higher prevalence of posterior papillary muscle dysfunction after myocardial infarction.

METHODS AND RESULTS

Twenty patients were monitored by transesophageal echocardiography during coronary surgery. Superselective coronary graft injections of 0.2 to 0.5 mL of sonicated albumin microbubbles were performed to assess graft patency and papillary muscle perfusion. Thirty-five graft injections were analyzed: 13 in the right coronary artery, 15 in an obtuse marginal branch, 1 in the left anterior descending coronary artery, and 6 in the first diagonal branch. The posterior papillary muscle was opacified in 16 patients, 11 from the right coronary artery and 5 from one obtuse marginal branch. In 10 of 16 patients (63%), the papillary muscle was perfused by one vessel, while in 6 of 16 (37%), it was perfused by two vessels. The anterior papillary muscle was opacified in 14 patients. Ten patients (71%) had double-vessel and 4 (29%) had single-vessel supply. In the subgroup of 10 patients with old inferior myocardial infarction, mitral regurgitation was present only among those 6 with single rather than double blood supply (P < .05).

CONCLUSIONS

Myocardial infarction may cause papillary muscle dysfunction when the blood supply is provided by one rather than two vessels, as is more frequently the case with the posterior rather than the anterior papillary muscle.

Risk factors of incomplete distribution of cardioplegic solution during coronary artery grafting

Myocardial distribution of cardioplegic solution infused by combined antegrade/retrograde routes was assessed with myocardial contrast echocardiography in 18 patients with chronic stable angina and three-vessel disease undergoing elective coronary artery bypass grafting. Overall myocardial opacification was significantly greater in retrograde than in antegrade cardioplegia (77.7% +/- 13.4% versus 59.1% +/- 15.7%; p = 0.0009). The difference was affected by collateral circulation, as pointed out by the significant interaction between coronary collateral circulation and percent of myocardial opacification after antegrade and retrograde cardioplegia (p = 0.002). When we performed multiple comparisons, in patients with good collaterals the opacification difference between antegrade and retrograde cardioplegia was not statistically significant (66.4% +/- 10.2% versus 76.0% +/- 15.2%; p = not significant), whereas in patients with poor collaterals myocardial opacification during retrograde cardioplegia was significantly greater (44.3% +/- 15.0% versus 81.2% +/- 9.0%; p < 0.02). During antegrade cardioplegia, patients with poor collaterals showed a lower degree of myocardial opacification than patients with good collaterals (44.3% +/- 15.0% versus 66.4% +/- 10.2%; p < 0.01). Our results show that retrograde cardioplegia in patients undergoing elective coronary artery bypass grafting offers no advantage over antegrade cardioplegia when collateral circulation is well developed. On the other hand, conventional aortic root infusion may not provide adequate myocardial protection in the subset of patients with significantly narrowed or occluded coronary arteries and poor collaterals.

Low-dose dobutamine echocardiography predicts the early response of dysfunctioning myocardial segments to coronary artery bypass grafting

Dobutamine echocardiography has recently been introduced for use in identification of viable myocardium in patients with acute myocardial infarction and prediction of the response of dysfunctioning myocardial segments to coronary angioplasty. The aim of this study was to evaluate whether this test may be used to predict the early response of dysfunctioning myocardial segments to surgical revascularization. We studied 30 patients with three-vessel disease and chronic, stable angina pectoris during coronary artery bypass grafting (CABG). Patients were monitored by intraoperative transesophageal echocardiography in the transgastric short-axis view at the papillary muscle level. The left ventricle was divided into eight segments; and 240 myocardial segments were analyzed. Percentage of systolic wall thickening (PSWT) was calculated in each segment at baseline (early after pericardiectomy), before bypass during dobutamine infusion (5 micrograms/kg/min), and after separation from cardiopulmonary bypass. Segments showing PSWT < 30% at baseline were considered dysfunctional. Segments showing an increase in PSWT > 10% during dobutamine infusion were considered responders. Segments showing an increase in PSWT < 10% during dobutamine infusion were considered nonresponders. At baseline, 161 (67%) of 240 segments had PSWT < 30% (dysfunctioning segments). During dobutamine, 98 (60%) of these segments increased PSWT > 10% (from 11.3% +/- 7.6% to 24.2% +/- 12.0%, p < 0.01; responder segments), and 63 (40%) increased PSWT < 10% (from 10.2% +/- 4.9% to 8.3% +/- 5.5%, p value not significant [NS]; nonresponder segments).(ABSTRACT TRUNCATED AT 250 WORDS)

Left ventricular-coronary sinus fistula after mitral valve replacement: diagnosis by transthoracic and transesophageal echocardiography

Repeated mitral valve replacement, particularly in case of heavily calcified mitral annulus, may lead to iatrogenic injury to the posterior atrioventricular groove leading to hematoma, myocardial rupture and/or intracardiac shunt. In this report, the echocardiographic features of left ventricular to coronary sinus fistula developed after repeated mitral valve replacement, are described for the first time. Transthoracic and transesophageal echocardiography allow the early detection of this extremely rare form of iatrogenic injury.