Value of dobutamine stress echocardiography [DSE] in assessment of coronary artery disease in high risk obese female patients with normal EF and stable angina pectoris. comparative study to coronary angiography

Study carried to determine the value of DSE in assessment of the presence of CAD in obese female patients with stable angina pectoris and normal EF>55% +/- other risk factors [diabetes mellitus, hypertension, hyperlipidaemia, and/or smoking] versus patients performing coronary angiography. Sensitivity and specificity. Chest pain with suspected CAD may be screened with non-invasive test that has high sensitivity and specificity. We studied 200 female obese patients in the period between 1/1/2007 until 31/12/2008 with stable angina referred to the National Heart Institute with suspected coronary artery disease. Obesity was defined as body weight>110kg in these patients with body waist>44 and body mass index was not considered. Transthoracic echocardiography at rest revealed EF>55% with no segmental wall motion abnormality at rest in 102 +/- 22 patients, paradoxical septal wall motion in 13 +/- 15 patients, left ventricular dilatation in 10 +/- 12 patients, no history of myocardial infarction and variable risk factors [diabetes mellitus, hypertension, hyperlipidaemia, and/or smoking] are present. All patients were subjected to dobutamine stress echocardiography [DSE]: 4 stages; 5 micro g/kg/min, 10 micro g/kg/ml 15 micro g/kg/min and high dose 40ug/kg/min +/- atropine injection 1mg IV in the last stage. Coronary angiography was done in 148 patients. The results are compared to the data obtained from DSE with evaluation of sensitivity and specificity in these classes of patients. Group A: 153/200 patients completed the full dose of DSE with no wall motion abnormality or other factors that necessitate stopping the examination as chest pain, angina equivalent, hypotension or life threatening arrhythmia. Their tests were considered negative. 124/153 patients of them has done coronary angiography and revealed no coronary artery disease. 25/153 patients had one vessel disease or minimal 2or3 vessel that does not recommend any intervention. 4/153 patients had one vessel disease or significant 2or3 vessel that does recommend intervention or CABG. Group B: 40/200 patients had equivocal results because positivity of the test can not be proved after full dose of DSE and recommended coronary angiography to further evaluate coronary arteries. 31/40 patients had one vessel disease or minimal 2or3 vessel that does not recommend any intervention. 9/40 patients had one vessel disease or significant 2 or 3 vessel that does recommend intervention or CABG. Group C: 7/200 patients had positive dobutamine stress echocardiography and coronary angiography revealed significant coronary artery disease. Sensitivity was 84% and specificity 90% with P value 0.0001. Dobutamine stress echocardiography is a simple screening test in high risk obese female patients with suspected CAD compared to invasive coronary angiography with high sensitivity and specificity

Multiplane transoephageal echocardiography [TEE] advantages in assessment of prosthetic mitral and aortic valves intraoperatively [IOTEE], early and late after open surgical replacement follow up of complications

Two-dimensional echocardiography can identify gross [cardiosurgeon] structural abnormalities of a prosthesis, such as dehiscence, vegetation, thrombus, or degeneration of a tissue prosthesis, but its sensitivity for cardiac prosthetic dysfunction is hampered by the difficulty with visualizing structures around and behind the cardiac prosthesis. TEE has become an integral part of cardiovascular surgery for identifying a previously unrecognized abnormality that may affect the surgical procedure or the patient's Outcome and for assessing the result of the operation [1, 3]. lntraoperative transesophageal echocardiography [IOTEE] has become a routine addition to most cardiac operations [12-21]. Although epicardial scanning is still used in a few specific situations[12], IOTEE has become the more commonly used method for visualizing cardiac structures in the operating room. Adults and adolescence undergoing mitral or aortic valve replacement or both were subjected to IOTEE, early or late TEE after surgery to clearly assess the prosthetic valve function and detect complications. Randomized study in 25 cases 13 females and 12 males with mean age 31 years youngest 19 years old and eldest 41 years old, referred to the National Heart Institute for surgical replacement of the mitral or aortic valve or both. Patients with resistant heart tailure were excluded from the study. 6 patients had atrial fibrillation. All patients were excluded from rheumatic activity or infective endocarditis. Transthoracic echocardiography was used to assess the mitral and aortic valves by apical 4 chamber, apical 2 chamber, parasternal and subcostal views, and blood flow by Doppler. Transoephageal echocardiography was done before surgery in all patients to further assess the valves [valve stenosis and valve regurge], absence of thrombi or vegetations. IOTEE was done during surgery and prosthetic valve was assessed for valve opening and valve closure, paravalvular leak. TEE [early 6 weeks and late 6 months] is useful in the evaluation of dehiscence, endocarditis, abscess, and intracardiac [especially atrial] mass or thrombi in the presence of a prosthetic valve. Intra-operatively the prosthetic valve is considered successful with good opening and closure and absence of paravalvular leak. Early after surgery [6 weeks], success was considered if there is no or minute paravalvular leak and no thrombi, vegetations, valvular leak or obstruction. Late after surgery [6 months] success considered no or minute paravalvulaj leak and no thrombi, vegetations, valvular leak or obstruction beside we searched for dehiscence, endocarditis, abscess, and intracardiac [especially atrial] mass or thrombi in the presence of a prosthetic valve, All patients have done IOTEE and no complications were detected during surgery namely valvular or paravalvular leak and prosthetic valve obstruction. After 6 weeks, 3/25 significant paravalvular leak, 2/25 fresh thrombus, 0/25 vegetations, 0/25 valvular leak, and 0/25 prosthetic valvular obstruction. Late after surgery [6 months], 5/25 significant paravalvular leak, 2/25 fresh thrombus, 1/25 vegetations, 1/25 valvular leak, and 4/25 prosthetic valvular obstruction, 3/25 valve dehiscence, 0/25 abscess, and 2/25 intracardiac [especially atrial] mass or thrombi in the presence of a prosthetic valve. All results were statistically non significant p>0.001, however, all complications must be considered and correlated to medical treatment especially anticoagulation. Multiplane TEE remains the gold standard in proving efficacy of prosthetic valve function and detection of complications both intraoperatively [IOTEE], early and late alter surgery. All complications may be related to anticoagulation

Efficacy of balloon valvuloplasty using multi-track technique for 50 cases with tight mitral stenosis at national heart institute and follow up one year

Mitral balloon valvuloplasty is the treatment of choice for severe mitral stenosis in young patients with a minimally calcified and pliable mitral valve. The Multi-Track system, devised by Bonhoeffer et al. in 1995, simplifies the Double Balloon technique. With this system, one of the balloons is a rapid exchange balloon, while the other has a conventional design, enabling both to be aligned in the mitral valve orifice over a single guide wire. The main advantage of such technique is lower cost, not only regarding the balloon, but also because they can be reused after resterilization with ethylene oxide. [Links et al., 2000] The study was designed to assess the efficacy of balloon valvuloplasty using multi-track technique for 50 cases of tight mitral stenosis [MVA 1.8 cm[2] in 82% of cases which is statistically significant and