Effects of rotational atherectomy with a reduced burr-to-artery ratio on coronary no-reflow.

AIM: The use of rotational atherectomy in addition to standard percutaneous coronary interventional procedures, although it improves coronary blood flow dynamics by improving vessel geometry, is often associated with distal embolization and the no-reflow phenomenon. We sought to evaluate the safety and effectiveness of a burr size/reference artery diameter (RAD) ratio <0.7 in rotational atherectomy in order to reduce the distal embolization and then to analyze the procedural and peri-procedural no-reflow phenomenon. METHODS: Between March 1999 and May 2003, 50 consecutive patients with a chronic stable angina lasting more than 3 months underwent rotablator atherectomy, adjunctive stent im-plantation (primary coronary stenting, PCS) or plain old balloon angioplasty (POBA) in case of de novo lesions or in stent restenosis, respectively. We analyzed the target vessel myocardial blush grade and the troponin I, creatine kinase and CK-MB values at 1.6 and every 8 h during the first day and then daily until discharge. RESULTS: Procedural success was achieved in all 50 patients (mean age 55+/-11 years; 45 males, 5 females). Quantitative angiography revealed, in the group treated with PCS, an increase in minimal lumen diameter (MLD) from 0.88+/-0.39 mm at baseline to 1.4+/-0.63 mm after rotablator (p<0.01) to 2.85+/-0.9 mm after stent implantation (p<0.01). On the other hand, for the group treated with POBA, the MLD changed from 1.8+/-0.32 mm at baseline to 2.2+/-0.54 mm after rotablator (p=0.6) to 3.28+/-0.91 mm after adjunctive balloon angioplasty (p<0.01). No statistically significant changes have been observed between myocardial blush grade and enzymes between baseline and after the procedure. CONCLUSION: Rotablator atherectomy with a reduced burr size/RAD ratio is a safe and effective interventional procedure without any peri-procedural no-reflow phenomenon.

Perforated aneurysms of left side valves during active infective endocarditis complicating hypertrophic obstructive cardiomyopathy.

The most frequent site of vegetative lesion in patients with hypertrophic cardiomyopathy is anterior mitral leaflet, due to chronic endocardial trauma arising from systolic anterior motion. We describe three cases of serious infective endocarditis complicated lesions (vegetation, aneurysm and perforation) on aortic and mitral valves, in patients with obstructive hypertrophic cardiomyopathy. In particular, we observed how severe valvular damage and dysfunction, combined with particular hemodynamic conditions, are followed by adverse clinical outcome. We performed transthoracic echocardiogram and transoesophageal echocardiography studies to define morphologic and hemodynamic features of infection, deciding the proper therapy and we planned the echocardiographic follow-up.

Current status of three-dimensional echocardiography.

Volume rendered three-dimensional echocardiography (3DE), a rapidly emerging imaging method, offers clinicians and surgeons a new perspective for visualizing the heart. Using both transthoracic and transesophageal approach this new methodology enables qualitative and quantitative information of cardiac disorders to be obtained. 3DE image projections have allowed visualization of intracardiac structures and great vessels and delineation of their pathology in a comprehensive manner. Experimental and clinical studies suggest that 3DE is likely to play a valuable role in the evaluation of various cardiac and flow disorders and in planning interventions and surgery. In addition, 3DE has been applied to derive quantitative measurements of volume, mass and dimensions of the left and right ventricles and also other cardiac lesions, such as atrial and ventricular septal defects. Every aspect of 3DE is in continuous evolution. Faster and more highly automated image processing could make the technique more easily applicable in the clinical scenario.

Harmonic imaging with Levovist for transthoracic echocardiographic reconstruction of left ventricle in patients with post-ischemic left ventricular dysfunction and suboptimal acoustic windows.

BACKGROUND: Attempts to perform transthoracic 3-dimensional echocardiography (3DE) are often encumbered by poor definition of chamber borders in adult patients who have technically suboptimal acoustic windows. METHODS: To assess whether harmonic imaging (HI) and contrast agents can facilitate transthoracic 3DE assessment of the left ventricle, we used fundamental imaging (FI), HI alone, and HI coupled with the echo-enhancing contrast agent Levovist in 15 consecutive patients with post-ischemic left ventricular (LV) dysfunction and technically difficult windows. Dynamic 3DE image data sets were obtained at 5-degree angles (36 slices) from a transthoracic apical view. From these data a total of 240 myocardial segments were analyzed with the use of dynamic short-axis paraplane slices at basal, middle, and apical LV levels (standard 16 segment model). For border definition, each segment was scored in random sequence on the following scale by 2 independent investigators: 0 = not seen, 1 = suboptimal visualization, and 2 = well defined. RESULTS: Our results showed a significant increase in the number of well-visualized segments when harmonic mode combined with Levovist injection was compared with FI and HI alone. CONCLUSION: Harmonic imaging alone improves LV assessment by 3DE when compared with FI. Contrast imaging in which Levovist is added to HI further improves the capability of transthoracic tomographic 3DE in the visualization of LV myocardial segments. This could allow 3DE by transthoracic windows to be used more widely in adults for the evaluation of LV volume and function.