Quantification of myocardial area at risk in the absence of collateral flow: the validation of angiographic scores by myocardial perfusion single-photon emission computed tomography.

OBJECTIVES: Our study aimed to compare the area at risk (AAR) determined by single-photon emission computed tomography (SPECT) with the Bypass Angioplasty Revascularization Investigation (BARI) and modified Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease (APPROACH) angiographic scores in the setting of patients undergoing coronary angioplasty for either unstable angina or an STEMI. BACKGROUND: Radionuclide myocardial perfusion imaging prior to reperfusion has classically been the most widely practised technique for assessing the AAR and has been successfully used to compare the efficacy of various reperfusion strategies in patients with an ST-segment elevation myocardial infarction (STEMI). The BARI and modified APPROACH scores are angiographic methods widely used to provide a rapid estimation of the AAR; however, they have not been directly validated with myocardial perfusion single-photon emission computed tomography (SPECT). METHODS: Fifty-five patients with no previous myocardial infarction who underwent coronary angioplasty for single-vessel disease (unstable angina: n = 25 or an STEMI: n = 30) with no evidence of collaterals (Rentrop Collateral Score <2) were included in a prospective study. In STEMI patients, the (99m)Tc-tetrofosmin was injected prior to opening of the occluded vessel and, in patients with unstable angina after 10-15 seconds of balloon inflation. Acquisition was performed with a dual-head gammacamera with a low-energy and high-resolution collimator. A total of 60 projections were acquired using a non-circular orbit. No attenuation or scatter correction was used. Maximal contours of hypoperfusion regions corresponding to each coronary artery occlusion were delineated over a polar map of 17 segments and compared with the estimated AAR determined by two experienced interventional cardiologists using both angiographic scores. RESULTS: Mean AAR percentage in SPECT was 35.0 (10.0%-56.0%). A high correlation was found between BARI and APPROACH scores (r = 0.9, P < .001). Furthermore, a high correlation was also observed between BARI versus SPECT and APPROACH versus SPECT to estimate the AAR (r = 0.9, P < .001 and r = 0.8, P < .001, respectively). Better correlations were observed when the left anterior descending artery (LAD) was revascularized (r = 0.8, P < 0.001 with BARI; r = 0.8, P = .001 with APPROACH) compared to other territories (r = 0.8, P = .001 with BARI; r = 0.7, P = .001 with APPROACH). Also, better correlations were observed in patients who underwent an elective rather than a primary percutaneous revascularization procedure. CONCLUSIONS: In the absence of collateral flow, BARI and APPROACH scores constitute valid methods for AAR estimation in current clinical practice, with more accurate results when used for the LAD territory; both are useful not only in STEMI patients but also in patients with unstable angina.

Immediate and long-term outcome of left-sided infective endocarditis. A 12-year prospective study from a contemporary cohort in a referral hospital.

The aim of this study was to describe the immediate and long-term prognosis of a contemporary cohort of patients with left-sided infective endocarditis (LSIE). A prospective observational cohort study was conducted in a referral centre. Between January 2000 and December 2011, all consecutive adult patients with LSIE were followed-up until death, relapse, recurrence, need for late surgery, or last control. During the active phase of IE, 174 of 438 patients underwent surgery (40% overall; 43% native valve (NVIE), 30% prosthetic valve (PVIE)) and 125 died (29% overall; 26% NVIE, 39% PVIE). The median follow-up in survivors was 3.2 years (interquartile range (IQR) 1.0-6.0 years). Relapses occurred in seven patients (2.2%; 95% CI, 1.1-4.5) and recurrences in eight (2.6%; 95% CI, 1.3-5.0), with an incidence density of 0.0067 per patient-year (95% CI, 0.0029-0.0133) and high mortality (75% of recurrences). Only four of 130 survivors (3.1%; 95% CI, 1.2-7.6) who were treated surgically during the active phase of the disease, and 14/183 (7.7%; 95% CI, 4.6-12.4) of those not undergoing surgery needed operation during follow-up (p 0.09). In the 313 survivors, actuarial survival was 86% at 1 year (87% NVIE, 83% PVIE), 79% at 2 years (81% NVIE, 72% PVIE) and 68% at 5 years (71% NVIE, 57% PVIE). At 1 year, 115 of 397 patients (29.0%; 95% CI, 24.7-33.6) remained alive, with no surgery requirement, relapse or recurrence. LSIE is associated with considerable in-hospital and long-term mortality, especially PVIE. However, relapses, recurrences and the need for late surgery are uncommon.

Prognosis of left-sided infective endocarditis in patients transferred to a tertiary-care hospital--prospective analysis of referral bias and influence of inadequate antimicrobial treatment.

The aims of this study were to compare the characteristics of adult patients with left-sided infective endocarditis (LSIE) diagnosed and treated in a tertiary-care hospital with those of patients referred from a second-level community hospital, and to establish the accuracy of diagnosis and adequacy of treatment in referred patients and the influence of this factor on outcome. A prospective observational cohort study was conducted at Hospital Universitari Vall d'Hebron, a 1000-bed teaching hospital in Barcelona (Spain) and a referral centre for cardiac surgery. One hundred and fourteen of 337 (34%) episodes of LSIE treated in our hospital occurred in transferred patients. As compared with patients diagnosed in our hospital, transferred patients acquired LSIE within the healthcare system less often (16.7% vs. 38.1%, p <0.001), were in better health (Charlson index 3 (interquartile range (IQR)) 1-4) vs. 4 (IQR 2-6), p <0.001), had more complications (94.7% vs. 78.9%, p <0.001), underwent more operations (69.3% vs. 22.1%, p <0.001), and experienced similar mortality (22.8% vs. 31.4%, p 0.100). Only 52 of 114 (45.6%) referred patients received an antimicrobial regimen included in the American, European or Spanish guidelines at the hospital of origin. After adjustment for congestive heart failure and staphylococcal infection in multivariate logistic regression, inadequate or no antimicrobial treatment at origin was a risk factor for in-hospital mortality (OR 3.3, 95% CI 1.1-10.0, p 0.030). Errors in the initial antimicrobial treatment prescribed for LSIE are associated with greater mortality.

[Usefulness of the new imaging techniques, second harmonic and contrast in endocardial border visualization. Reliability analysis in segmental contraction assessment]. / Utilidad de las nuevas técnicas de imagen, segundo armónico y contraste en la visualización del borde endocárdico. Análisis de la reproducibilidad en la valoración de la contracción segmentaria.

AIM: This study sought to determine if newer techniques significantly improve endocardial border definition in suboptimal acoustic windows, and the reproducibility of the evaluation of wall motion abnormalities according to the different techniques and degrees of expertise. METHODS: We studied a total of 20 consecutive patients with poor ultrasound window, to assess, if the use of tissue harmonic imaging (2H) or contrast with second harmonic (Levovist ; 4 g i.v.), (2HC) improves endocardial border visualization. In order to analyze inter and intraobserver reliability with the different techniques, four observers with different degrees of expertise were each asked to assess the segmental wall motion score of 31 consecutive echocardiograms. RESULTS: The quality of the image was clearly superior with 2H and 2HC compared with 2D. This difference was larger in apex and lateral endocardial border from 0.9 and 1 to 1.5 and 1.64 (p < 0.001) with 2H. 2HC was found to slightly but significantly improve the endocardial definition in apex compared with 2H (1.64 vs 1.81; p = 0.016). The percentage of segments assessed for interobserver variability significantly improve with 2H and 2HC (2D = 50%, 2H = 75% and 2HC = 95%). Interobserver agreement with the different techniques between the experienced observers did not statistically differ. The less experienced observer presented a significantly lower interobserver reliability than those with experience, and did not improve with 2H and 2HC. CONCLUSIONS: a) Native tissue harmonic imaging and second harmonic imaging with contrast (Levovist ) significantly improves endocardial border visualization; b) the newer imaging techniques significantly improve performance (percentage of evaluated segments) without decreasing reliability, and c) experience in assessing wall motion is the main factor in interobserver agreement.

[Rupture of type A aortic dissection into right cardiac cavities]. / Ruptura de disección aórtica tipo A en cavidades cardíacas derechas.

We present three cases of communication between the false channel of an ascending aortic dissection and a right cardiac chamber in three patients that had previously been operated on for aortic valve replacement. In two cases there already was a degree of aortic dissection at the moment of surgery. Diagnosis was confirmed by transesophageal echocardiography and/or aortography. Two patients developed severe cardiac failure and underwent surgery, while the other one is surviving with medical treatment.

[The usefulness of transesophageal echocardiography in the diagnosis of infectious endocarditis and its complications]. / Utilidad de la ecocardiografía transesofágica en el diagnóstico de la endocarditis infecciosa y sus complicaciones.

INTRODUCTION AND AIMS: Transthoracic echocardiography is a technique with high specificity but low sensitivity in the diagnosis of valvular vegetations and infectious endocarditis complications. Recent reports have shown the transesophageal technique to be more sensitive. The aim of this study was to assess the comparative diagnostic roles of transthoracic and transesophageal echocardiography in infectious endocarditis. METHODS: Eighty-eight patients with infectious endocarditis (native valve in 71 and prosthesis in 17) were studied. All underwent transthoracic echocardiogram followed by transesophageal study to detect vegetations and possible complications, particularly paravalvular abscesses. RESULTS: Transthoracic echocardiogram diagnosed vegetations in 33 (46%) of the 71 native valve endocarditis, whereas these were detected by transesophageal study in 67 (94%). In 23 patients vegetations were surgically confirmed. Transthoracic echocardiography failed to diagnose vegetations in any of the prosthetic endocarditis, whereas they were detected by transesophageal study in 11 of the 17 cases (65%). Of the 9 patients who underwent surgery in the acute phase, 5 presented vegetations on transesophageal study which were confirmed at surgery. Transesophageal echocardiography diagnosed 14 abscesses: 11 aortic peri-annular and 3 in the interfibrous. Echocardiography only detected 1 of the peri-annular aortic abscesses. All patients with peri-annular abscess underwent surgery. Transesophageal echocardiography was also more effective than transthoracic in the diagnosis of other complications: 15 vs 4 chordae tendineae mitral valve rupture and 18 vs 13 aortic valve disruption. CONCLUSIONS: Transesophageal echocardiography is more effective than transthoracic echocardiography in the diagnosis of infectious endocarditis and its complications and would therefore be indicated in all cases of absence of vegetations on transthoracic echocardiography and clinical suspicion of endocarditis. Transesophageal echocardiography could be indicated in all cases of clinically suspected aortic endocarditis to rule out peri-annular abscesses.

[Transesophageal echocardiography in the diagnosis of aortic dissection]. / Ecocardiografía transesofágica en el diagnóstico de la disección aórtica.

INTRODUCTION AND OBJECTIVE: Eighty-two patients with suspected aortic dissection were studied to assess the usefulness of transesophageal echocardiography in the diagnosis of this entity. METHODS: All patients underwent transesophageal echocardiogram. The diagnosis of aortic dissection was established in 46 patients by other diagnostic procedures including angiography and computed tomography, surgery and necropsy. RESULTS: The sensitivity and specificity of transesophageal echocardiography were 98% and 97%, respectively. By computed tomography, sensitivity was 92% and specificity 88%. By angiography, sensitivity and specificity were 97% and 93%, respectively. In the diagnosis of the dissection type, transesophageal echocardiography classified correctly in 98%, computed tomography in 89% and angiography 97% of cases. Transesophageal echocardiography visualized the tear in 82% of cases, and angiography in 53%. CONCLUSIONS: Transesophageal echocardiography provides rapid, accurate diagnosis of aortic dissection and permits the initiation of appropriate treatment. Angiography is indicated in non-conclusive cases or those which supra-aortic involvement clinically suspected.

[The usefulness of transesophageal echocardiography in assessing mechanical mitral prostheses. A comparison with transthoracic echocardiography]. / Utilidad de la ecocardiografía transesofágica en la valoración de las prótesis mitrales mecánicas. Comparación con la ecocardiografía transtorácica.

One hundred and sixty mechanical mitral prostheses were studied by transoesophageal echocardiography to ascertain the role of this technique in their functional assessment. All patients underwent transoesophageal echocardiogram, and, in 83, transthoracic Doppler-echocardiogram had already been performed immediately prior to transoesophageal echocardiogram. Prostheses presenting structural anomaly on bidimensional image and/or areas of regurgitation with predominantly turbulent flow on colour Doppler were considered to be dysfunctional. Of the 160 prostheses, 115 were considered normofunctional, and regurgitation was detected in 85 (94%) by transoesophageal echocardiogram and 10 (9%) by transthoracic echocardiogram; haemodynamic and/or surgical confirmation was obtained in 6 of these prostheses and all proved to be functioning normally. Of the 45 remaining prostheses considered to be dysfunctional, haemodynamic and/or surgical confirmation was obtained in 21 (the non-confirmed 24 were excluded from the study). Seventeen of the dysfunctional prostheses presented with areas of regurgitation of 3.9-24 cm2 (mean: 9.21 + 5.36); in one case, the degree of regurgitation with respect haemodynamic study was over-assessed; transthoracic echocardiogram detected only periprosthetic leaks in 38% of cases, with areas of regurgitation of 1.8-6.3 cm2 (mean: 1.87 + 2.02). The other 4 dysfunctional prostheses presented dysfunction due to thrombosis; all 4 were diagnosed by both transthoracic and transoesophageal echocardiogram. Transoesophageal echocardiogram detected 12 structural anomalies (1 vegetations, 4 thromboses and 7 dehiscencies), whereas transthoracic echocardiogram only detected these anomalies in five of the cases (1 vegetations and 4 thromboses). Transoesophageal echocardiography surpasses transthoracic echocardiography in the assessment of mechanical mitral prostheses and dysfunction diagnosis.(ABSTRACT TRUNCATED AT 250 WORDS)

[The usefulness of Doppler echocardiography in the preoperative assessment of valvulopathies. A comparison with the hemodynamic and surgical findings]. / Utilidad de la ecocardiografía-Doppler en la evaluación prequirúrgica de las valvulopatías. Comparación con los hallazgos hemodinámicos y quirúrgicos.

The Doppler echocardiography and cardiac catheterization studies of all patients who underwent valvular surgery in a three-year period were reviewed to assess the correlation between the estimated severity of valvular disease by both methods. Two-hundred and thirty-five patients (group I: 140 male, age 58 +/- 12; 95 female, age 60 +/- 13) underwent both studies within 6 months. There was agreement on estimation of severity of valve lesions in 140 of 162 patients with aortic valve disease (93% of stenosis, 82% of regurgitations and 79% of mixed lesions), in 58 of 80 patients with mitral valve disease (83% of stenosis, 76% of regurgitations and 33% of mixed lesions) and in 10 of 16 patients with prosthetic valve disfunction. The correlation between both methods was significantly lower in mixed mitral lesions than in the remaining native valve lesions (p < 0.05). Significant disagreement occurred in 4 cases of aortic valve disease, four of mitral valve disease and five of prosthetic disfunction. When disagreement was present, Doppler often underestimated the severity of the disease. Disagreement was more frequent in patients with combined aortic and mitral disease. According to the surgical conclusions cardiac catheterization provided a diagnostic profit in the assessment of the disease severity in 8, 11 and 22% of cases of aortic and mitral valve disease and prosthetic valve disfunction, respectively. Coronary artery disease was present in 19% of patients who underwent coronary arteriography. One-hundred and two patients (group II: 44 m, 48 +/- 15; 58 f, 53 +/- 11) underwent surgery without previous cardiac catheterization.(ABSTRACT TRUNCATED AT 250 WORDS)

[The performance of transesophageal echocardiography in clinical cardiovascular practice]. / Rendimiento de la ecocardiografía transesofágica en la práctica clínica cardiovascular.

The usefulness of transesophageal echocardiography (TEE) in cardiovascular clinical practice is assessed. Seven hundred transesophageal studies were performed between November 1989 and October 1991. One hundred and seventeen studies carried out during the follow-up of treated non-acute pathologies were excluded. The study could not be made in 6 patients. The most frequent indications of TEE were aortic pathology study, 120 (21%), infective endocarditis, 72 (13%), origin of systemic embolisms, 66 (11%), and mitral pre-valvuloplasty and intensive care, 64 (11%). The incidence of pathologic findings on TEE not diagnosed by conventional echocardiography was 32% (182/577). The incidence of pathologic findings with therapeutic implications was 15% (85/577). Indications showing a greater incidence of pathologic findings with therapeutic implications were: 1) thoracic aorta pathology, 42 (35%); 2) mitral prostheses disfunction, 8 (19%), and 3) mitral pre-valvuloplasty, 10 (16%). Infective endocarditis, intensive care studies and congenital cardiopathies had an incidence of 12%. TEE findings in the study of intracardiac masses, the origin of peripheral embolisms and mitral insufficiency had little influence (less than 5%) on the management of the patient.