First-generation paclitaxel- vs. second-generation zotarolimus-eluting stents in small coronary arteries: the BASKET-SMALL Pilot Study.

INTRODUCTION: Event rates after percutaneous coronary interventions (PCI) are higher in small than large coronary vessels but may vary between different drug-eluting stent (DES) types. AIM: To assess the efficacy of two different DES in small vessel disease. MATERIAL AND METHODS: Patients with small vessel PCI were randomised 1 : 1 to a first-generation paclitaxel- vs. a second-generation zotarolimus-eluting stent. The primary endpoint was a composite of cardiac death, non-fatal myocardial infarction, and target vessel revascularisation after 2 years. RESULTS: Overall, 191 patients were enrolled: 100 with a paclitaxel- and 91 with a zotarolimus-eluting stent. Baseline characteristics were similar in both groups. After 2 years, rates of the primary endpoint were numerically higher for zotarolimus- than paclitaxel-eluting stents (9.9% vs. 5.0%, hazard ratio 2.09, 95% confidence interval (CI) 0.7-6.2, p = 0.19), which was mainly driven by higher rates of target vessel revascularisation (6.6% vs. 2.0%, hazard ratio 3.39, 95% CI: 0.68-16.78, p = 0.14). Based on this, a total of 1,019 patients would be necessary to demonstrate at least non-inferiority between the DES used. CONCLUSIONS: In this pilot study, paclitaxel-eluting stents had a favourable efficacy profile in small vessel disease, although the numbers were too small to draw final conclusions. Based on the prohibitively high sample size for a randomized controlled trial between DES, other treatment options should be considered.

Assessment of left atrial functional parameters using a novel dedicated analysis tool for real-time three-dimensional echocardiography: validation in comparison to magnetic resonance imaging.

Real-time three-dimensional echocardiography (RT3DE) is superior to two-dimensional echocardiography in assessing left atrial (LA) parameters, but to date algorithms developed for the left ventricle were applied due to a lack of dedicated LA software. In addition, no data are available on RT3DE assessment of active atrial contraction. The aim of this study was to validate a novel RT3DE analysis tool specifically dedicated to evaluate the LA. Cardiac magnetic resonance imaging (MRI) served as standard of reference. Fifty-five patients scheduled for pulmonary vein isolation underwent cardiac MRI and RT3DE. On ultrasound image datasets, a dynamic polyhedron model of the LA was generated from which LA maximum and minimum volumes (LAmax and LAmin), passive atrial emptying fraction (LAEF), and active atrial ejection fraction (LAEFtrue) were derived and compared to values obtained from cardiac MRI. High intraclass correlations between RT3DE and MRI were found for LAmax (r = 0.94, p < 0.001), LAmin (r = 0.95, p < 0.001), LAEF (r = 0.92, p < 0.001), and LAEFtrue (r = 0.87, p < 0.001). Similarly, Bland-Altman analysis revealed narrow limits of agreement for LAmax (-28.6 to 14.1 ml), LAmin (-26.8 to 12.4 ml), LAEF (-11.2 to 14.9 %), and LAEFtrue (-10.6 to 6.8 %). LAmax, LAmin and LAEFtrue were measured significantly (p < 0.05) lower by RT3DE (111 ± 38 ml vs. 118 ± 39 ml, 73 ± 38 ml vs. 80 ± 41 ml, and 23 ± 14 % vs. 27 ± 14 %, respectively). Interobserver and intraobserver RT3DE measurements correlated closely. RT3DE using a novel dedicated software tool is valid, accurate and reproducible for assessing LA dimensional and functional parameters. This study corroborates previous reports and extends its validity to the assessment of active LA contraction.

Functional assessment of the left atrium by real-time three-dimensional echocardiography using a novel dedicated analysis tool: initial validation studies in comparison with computed tomography.

AIMS: A novel real-time three-dimensional echocardiography (RT3DE) analysis tool specifically designed for evaluation of the left atrium enables comprehensive evaluation of left atrial (LA) size, global, and regional function using a dynamic 16-segment model. The aim of this study was the initial validation of this method using computed tomography (CT) as the method of reference. METHODS AND RESULTS: The study population consisted of 34 prospectively enrolled patients with clinical indication for pulmonary vein isolation. A dynamic polyhedron model of the left atrium was generated using RT3DE. LA maximum and minimum volumes (LA(max)/LA(min)) and emptying fraction (LAEF) were determined and compared with the results obtained by CT. High correlations between RT3DE and CT were found for LA(max) (r = 0.92, P < 0.001), LA(min) (r = 0.95, P < 0.001), and LAEF (r = 0.82, P < 0.001). LA(max) and LA(min) were lower by RT3DE than by CT (95.0 ± 44.7 vs. 119.8 ± 50.5 mL, P < 0.001 and 58.1 ± 41.3 vs. 83.3 ± 52.6 mL, P < 0.001, respectively), whereas LAEF was measured higher by RT3DE (42.8 ± 15.2 vs. 34.2 ± 15.4%, P < 0.001, respectively). RT3DE measurements closely correlated in terms of intra-observer (intra-class correlation r = 0.99, r = 0.99, r = 0.96, respectively) and inter-observer variability (r = 0.97, r = 0.98, r = 0.88, respectively). CONCLUSIONS: LA volumes and EF as assessed by RT3DE correlate highly with CT measurements, albeit there is some bias between the imaging modalities. Most importantly, RT3DE measurements using the novel dedicated LA analysis tool are robust in terms of observer variability and thus suitable for follow-up analyses.

Dynamic assessment of right ventricular volumes and function by real-time three-dimensional echocardiography: a comparison study with magnetic resonance imaging in 100 adult patients.

BACKGROUND: The aim of this study was to validate a novel real-time three-dimensional echocardiographic (RT3DE) analysis tool for the determination of right ventricular volumes and function in unselected adult patients. METHODS: A total of 100 consecutive adult patients with normal or pathologic right ventricles were enrolled in the study. A dynamic polyhedron model of the right ventricle was generated using dedicated RT3DE software. Volumes and ejection fractions were determined and compared with results obtained on magnetic resonance imaging (MRI) in 88 patients with adequate acquisitions. RESULTS: End-diastolic, end-systolic, and stroke volumes were slightly lower on RT3DE imaging than on MRI (124.0 +/- 34.4 vs 134.2 +/- 39.2 mL, P < .001; 65.2 +/- 23.5 vs 69.7 +/- 25.5 mL, P = .02; and 58.8 +/- 18.4 vs 64.5 +/- 24.1 mL, P < .01, respectively), while no significant difference was observed for ejection fraction (47.8 +/- 8.5% vs 48.2 +/- 10.8%, P = .57). Correlation coefficients on Bland-Altman analysis were r = 0.84 (mean difference, 10.2 mL; 95% confidence interval [CI], -31.3 to 51.7 mL) for end-diastolic volume, r = 0.83 (mean difference, 4.5 mL; 95% CI, -23.8 to 32.9 mL) for end-systolic volume, r = 0.77 (mean difference, 5.7 mL; 95% CI, -24.6 to 36.0 mL) for stroke volume, and r = 0.72 (mean difference, 0.4%; 95% CI, -14.2% to 15.1%) for ejection fraction. CONCLUSION: Right ventricular volumes and ejection fractions as assessed using RT3DE imaging compare well with MRI measurements. RT3DE imaging may become a time-saving and cost-saving alternative to MRI for the quantitative assessment of right ventricular size and function.

Three-dimensional echocardiography for quantitative analysis of left-ventricular aneurysm.

BACKGROUND: Quantitative analysis of left-ventricular (LV) aneurysms after myocardial infarction is prognostically relevant and assists in planning surgery. Three-dimensional (3D) echocardiography facilitates clear visualization of cardiac anatomy and accurate assessment of functional parameters. The aim of the present study was to determine the ability of 3D echocardiography to quantify LV aneurysms. METHODS: Ten patients with a known LV-aneurysm after myocardial infarction underwent 3D echocardiography and cardiac magnetic resonance (CMR) imaging at 1.5 Tesla within 3 days. For 3D echocardiography, a multiplanar transesophageal examination was performed with full LV coverage and the 3D dataset was analyzed offline. The LV-aneurysm was defined by a wall thickness <5 mm. The following quantitative parameters were determined: left ventricular end-diastolic and end-systolic volumes, LV myocardial mass (LV-mass) and mass of the LV-aneurysm. LV ejection fraction and percentage of aneurysm mass (%-aneurysm) were calculated. RESULTS: LV volumes and ejection fraction showed a strong correlation between 3D echocardiography and CMR (r = 0.94-0.97; P < 0.01). Importantly, the mass and percentage of mass of the LV-aneurysm demonstrated a high correlation as well (r = 0.94 and r = 0.86, respectively; P < 0.01). For all parameters, the calculated bias between both methods was found to be minimal (0.8-7.6%). CONCLUSIONS: Three-dimensional echocardiography proved to be a reliable tool for quantitative analysis of LV volumes, ejection fraction and aneurysm size in patients with prior myocardial infarction. In addition, 3D visualization of the complex cardiac anatomy in patients with LV-aneurysm may assist surgical procedure planning.

Patent foramen ovale and cryptogenic stroke: a matter of age?

A patent foramen ovale (PFO) enables a right-to-left shunt in about a quarter of the population. The marked association between cryptogenic stroke and PFO supports the hypothesis that paradoxical embolism could be a relevant cause of stroke. Although this association has been described in several studies for patients <55 years of age, only limited data are available on the role of PFO in older patients. Recent studies, however, have also shown a significant association between cryptogenic stroke and PFO in patients >55 years of age. The relationship is especially marked in the presence of atrial septum aneurysm (ASA). This finding is in accordance with previous reports indicating that PFO and concomitant ASA is a high-risk feature. Factors promoting paradoxical embolism, such as deep vein thrombosis (DVT) and elevated right-heart pressure, are more frequently encountered in older than in younger patients. Independent of age, contrast-enhanced transthoracic and transesophageal echocardiography are the methods of choice for the detection and imaging of PFO and atrial septal aneurysm. Transcranial Doppler can be used as a screening method in patients with cryptogenic stroke to detect a right-to-left shunt. Proof of DVT strongly supports the suspicion of paradoxical embolism and should lead to oral anticoagulation. If paradoxical embolism is suspected without proof of DVT, both drug therapy with aspirin or warfarin and percutaneous closure of the PFO are available as therapeutic options. Recent studies have shown that percutaneous closure can be performed safely and with a low rate of recurrence both in older and younger patients. Thus far, however, there is no clear-cut evidence of superiority for either therapeutic strategy.

Drug-eluting stents compared with bare metal stents improve late outcome after saphenous vein graft but not after large native vessel interventions.

OBJECTIVES: To define long-term efficacy of different stent types in saphenous vein graft (SVG) interventions. METHODS: In BASKET (Basel Stent Cost Effectiveness Trial), major adverse cardiac events (MACE), i.e. cardiac death, myocardial infarction and symptom-driven target vessel revascularization (TVR) were assessed after 18 months comparing drug-eluting stents (DES) versus bare metal stents (BMS), and SVG and large native vessels (> or =3.0 mm). RESULTS: Large vessel interventions were performed in 605 patients. Patients with SVG interventions (n = 47, 8%) were older and had more often hypertension, prior myocardial infarction, prior revascularization and multivessel disease and less frequent ST-elevation myocardial infarction than patients with large native vessel interventions (n = 558, 92%). Stent number and length were higher in SVG than in large native vessel interventions. Baseline characteristics were similar for DES and BMS. In SVG stenting, long-term outcome was better in DES- than in BMS-treated patients (MACE 21 vs. 62%, p = 0.007, mainly due to TVR 18 vs. 46%, p = 0.045), but for large native vessel stenting, no significant difference was noted (MACE: 13 vs. 16%, p = 0.40). CONCLUSIONS: Among patients with SVG disease, treatment with DES resulted in a better long-term outcome than treatment with BMS. In contrast, no DES benefit was found in similarly sized native vessels regarding MACE.

Strongly neovascularized left atrial myxoma.

During transesophageal echocardiography, a massively vascularized left atrial tumor was found in an 82-year-old woman with transient ischemic attacks. Coronary angiography showed several feeding vessels from the left circumflex artery and right coronary artery, which resulted in marked contrast enhancement of the left atrial tumor. Histological examination after tumor excision confirmed the suspicion of neovascularized myxoma.

Patent foramen ovale and cryptogenic stroke in older patients.

BACKGROUND: Studies to date have shown an association between the presence of patent foramen ovale and cryptogenic stroke in patients younger than 55 years of age. This association has not been established in patients 55 years of age or older. METHODS: We prospectively examined 503 consecutive patients who had had a stroke, and we compared the 227 patients with cryptogenic stroke and the 276 control patients with stroke of known cause. We examined the prevalences of patent foramen ovale and of patent foramen ovale with concomitant atrial septal aneurysm in all patients, using transesophageal echocardiography. We also compared data for the 131 younger patients (< 55 years of age) and those for the 372 older patients (> or = 55 years of age). RESULTS: The prevalence of patent foramen ovale was significantly greater among patients with cryptogenic stroke than among those with stroke of known cause, for both younger patients (43.9% vs. 14.3%; odds ratio, 4.70; 95% confidence interval [CI], 1.89 to 11.68; P<0.001) and older patients (28.3% vs. 11.9%; odds ratio, 2.92; 95% CI, 1.70 to 5.01; P<0.001). Even stronger was the association between the presence of patent foramen ovale with concomitant atrial septal aneurysm and cryptogenic stroke, as compared with stroke of known cause, among both younger patients (13.4% vs. 2.0%; odds ratio, 7.36; 95% CI, 1.01 to 326.60; P=0.049) and older patients (15.2% vs. 4.4%; odds ratio, 3.88; 95% CI, 1.78 to 8.46; P<0.001). Multivariate analysis adjusted for age, plaque thickness, and presence or absence of coronary artery disease and hypertension showed that the presence of patent foramen ovale was independently associated with cryptogenic stroke in both the younger group (odds ratio, 3.70; 95% CI, 1.42 to 9.65; P=0.008) and the older group (odds ratio, 3.00; 95% CI, 1.73 to 5.23; P<0.001). CONCLUSIONS: There is an association between the presence of patent foramen ovale and cryptogenic stroke in both older patients and younger patients. These data suggest that paradoxical embolism is a cause of stroke in both age groups.

Transesophageal real-time three-dimensional echocardiography methods and initial in vitro and human in vivo studies.

OBJECTIVES: The purpose of this study was to develop a transesophageal probe that: 1) enables on-line representation of the spatial structures of the heart, and 2) enables navigation of medical instruments. BACKGROUND: Whereas transthoracic real-time 3-dimensional (3D) echocardiography could recently be implemented, there is still no corresponding transesophageal system. Transesophageal real-time 3D echocardiography would have great potential for numerous clinical applications, such as navigation of catheters. METHODS: The newly developed real-time 3D system is based on a transesophageal probe in which multiple transducers are arranged in an interlaced pattern on a rotating cylinder. This enables continuous recording of a large echo volume of 70 mm in length and a sector angle of 120 degrees . The presentation of the volume-reconstructed data is made with a time lag of <100 ms. The frame rate is up to 20 Hz. In addition to conventional imaging, the observer can obtain a stereoscopic image of the structures examined with red/blue goggles. RESULTS: It was shown in vitro on ventricle- and aorta-form agar models and in vivo that the system enables excellent visualization of the 3D structures. Shape, spatial orientation, and the navigation of various catheters (e.g., EPS-catheter, Swan-Ganz-catheter), stents, or atrial septal defect occluders could be recorded on-line and stereoscopically depicted. The size of the echo sector enables a wide field of view without changing the position of the probe. CONCLUSIONS: Transesophageal real-time 3D echocardiography can be technically realized with the system presented here. The in vitro and in vivo studies show particularly the potential for navigation in the heart and large vessels on the basis of stereoscopic images.

Combined measurement of carotid stiffness and intima-media thickness improves prediction of complex aortic plaques in patients with ischemic stroke.

BACKGROUND AND PURPOSE: We hypothesized that for the prediction or exclusion of aortic thrombi or plaques >or=4 mm, the combination of intima-media thickness (IMT) and distensibility (DC) of the common carotid arteries would be superior to the measurement of IMT alone. METHODS: We prospectively included 208 stroke patients (mean age, 60 years) undergoing transesophageal echocardiography for screening of aortic plaques. IMT and DC were determined by ultrasound, and DC was quantified by measuring blood pressure and the common carotid arteries diameter change on M-mode ultrasound during the cardiac cycle. RESULTS: Negative predictive values of IMT <0.9 mm and DC >or=24x10(-3)/kPa for the exclusion of aortic atheroma >or=4 mm were similar (92.0% and 91.7%, respectively). However, negative predictive values increased to 98.2% and to 100.0% for the exclusion of aortic thrombi when both parameters were combined. Positive predictive values of IMT >or=0.9 mm and DC <24 were lower (46.3%, 41.1%; respectively), but they also increased in combination (54.3%). CONCLUSIONS: Our findings suggest that IMT and DC represent different vessel wall properties and that measuring both parameters provides optimized characterization of carotid atherosclerosis. Combining IMT and DC increases the predictive power of carotid ultrasound, making transesophageal echocardiography dispensable for assessment of the aorta for those with normal carotid arteries and indispensable for those patients with carotid atherosclerosis.

Therapeutic strategies after examination by transesophageal echocardiography in 503 patients with ischemic stroke.

BACKGROUND AND PURPOSE: Transesophageal echocardiography (TEE) is the gold standard in detecting high-risk (ie, aortic thrombi) and potential sources (ie, patent foramen ovale [PFO]) of cerebral embolism. We sought to evaluate the additional information and therapeutic impact provided by TEE in stroke patients and to characterize patients in whom TEE is indispensable. METHODS: We included 503 consecutive patients (mean age 62.2 years) with acute brain ischemia. Each patient received TEE and the following routine diagnostics: ultrasound of brain supplying arteries, ECG or Holter-ECG, transthoracic echocardiography, and brain imaging (computed tomography or MRI). Stroke etiology was classified according to the Trial of Org 10172 in Acute Stroke Treatment (TOAST) criteria. High-risk sources in TEE were: aortic thrombi or plaques > or =4 mm, thrombi in left atrial cavity/left atrial appendage, spontaneous echo contrast, and left atrial flow velocity <30 cm/s. Potential sources in TEE were PFO, atrial septal aneurysm, and aortic plaques <4 mm. RESULTS: Stroke etiology was determined by routine diagnostics in 276 of 503 patients (54.9%). Of the remaining 227 patients (undetermined etiology), 212 (93.4%) were candidates for oral anticoagulation (OA). TEE revealed a high-risk source, with indication for OA in 17 of them (8.0%). A potential source leading to OA was found in an additional 48 patients (22.6%). The remaining 147 patients (69.3%) were treated by platelet inhibitors or statins. CONCLUSIONS: TEE strongly influenced secondary prevention and led to OA in one third of our patients with stroke of undetermined etiology. TEE is indispensable in all patients being candidates for OA when routine diagnostics cannot clarify stroke etiology.

Left atrial appendage flow velocity as a quantitative surrogate parameter for thromboembolic risk: determinants and relationship to spontaneous echocontrast and thrombus formation--a transesophageal echocardiographic study in 500 patients with cerebral ischemia.

BACKGROUND: Hemostasis in the left atrial (LA) appendage (LAA) is an important cause in the formation of thrombi. Determination of the LAA flow velocity (LAAV) could be a quantitative parameter for estimating thromboembolic risk. The objective of this study was to: (1) determine the relationship between LAAV and qualitative parameters with elevated thromboembolic risk (thrombus/spontaneous echocontrast [SEC]); and (2) define factors that influence LAAV. METHODS: In all, 500 patients with stroke were examined consecutively by transesophageal echocardiography. In addition to measurement of the LAAV, the atrial appendage was examined for the presence of thrombi or SEC. RESULTS: LAAV differed significantly among patients with sinus rhythm (71 +/- 16 cm/s), paroxysmal atrial fibrillation (AF) and in sinus rhythm during transesophageal echocardiography (46 +/- 13 cm/s), paroxysmal AF and AF during transesophageal echocardiography (32 +/- 12 cm/s), and chronic AF (27 +/- 9 cm/s, P < .001). Independent of the rhythm, the risk of thrombus/SEC increased significantly at an LAAV less than 55 cm/s. At an LAAV 55 cm/s or more there is only a minimal risk of thrombus/SEC (negative predictive value 100% and 99%, respectively). Multivariate analysis showed that LAAV is the strongest predictor for the occurrence of thrombus/SEC (P < .0001). Further multivariate analysis showed that left ventricular ejection fraction, LA size, (paroxysmal) AF, age, and sex are independent parameters influencing LAAV. CONCLUSION: Independent of the basic rhythm, there is a close relationship between LAAV and qualitative parameters of elevated thromboembolic risk. LAAV could, therefore, be a quantitative surrogate parameter for risk stratification. It is influenced by both cardiac and extracardiac factors.

Predictors of left atrial spontaneous echocardiographic contrast or thrombus formation in stroke patients with sinus rhythm and reduced left ventricular function.

The objective of the present study was to identify predictors of left atrial spontaneous echocardiographic contrast (SEC) or thrombus in patients with stroke with sinus rhythm and left ventricular dysfunction. Of 500 consecutive patients with stroke, 48 with sinus rhythm and reduced left ventricular ejection fractions (EFs) < or =45% were examined. Ten patients presented with SEC or thrombus. The patients with SEC or thrombus had larger left atrial diameters (47 +/- 4 vs 42 +/- 6 mm, p <0.05), smaller EFs (30 +/- 9% vs 38 +/- 8%, p <0.01), and slower left atrial appendage (LAA) flow velocities (42 +/- 13 vs 61 +/- 17 cm/s, p <0.01). Multivariate analysis identified EF < or =35% and LAA flow velocity < or =55 cm/s as predictors of SEC or thrombus (p <0.05). Patients with stroke with sinus rhythm and moderate- to high-grade reduction of the left ventricular EF represent a risk group for a left atrial source of embolism and should undergo transesophageal echocardiography.

Optimal number of image slices for reliable measurement of left ventricular volumes and ejection fraction by three-dimensional transesophageal echocardiography.

PURPOSE: Quantification of the left ventricular (LV) volume by three-dimensional echocardiography is accurate but time-consuming. To shorten the time required, we sought to determine the minimum number of image planes necessary to measure LV volume reliably. METHODS: We analyzed transesophageal three-dimensional echocardiographic LV data obtained by the rotational scanning method in 16 patients: 11 had ischemic heart disease, and 5 had dilated cardiomyopathy. LV volumes were calculated from 6, 10, and 30 short-axis images using the disk-summation method and from 2, 4, 6, 10, 20, and 30 longitudinal images using the new average rotation method. RESULTS: LV volume varied less with the average rotation method than with the disk-summation method. The 95% limit of agreement between the 30-image and 6-image methods was 0.3% ± 3.7% for the average rotation method, whereas it was -2.0% ± 6.9% for the disk-summation method. The time required for analysis decreased from 12.5 ± 2.8 min with the 30-image method to only 3.3 ± 0.5 min for the 6-image method. CONCLUSIONS: Measurement of six longitudinal images provided reliable LV volume data, even in patients with enlarged or deformed left ventricles. The short measurement time supports the use of three-dimensional echocardiographic LV volume measurement in the clinical setting.

Three-dimensional echocardiographic determination of cardiac output at rest and under dobutamine stress: comparison with thermodilution measurements in the ischemic pig model.

Determination of cardiac output is a potentially important clinical application of three-dimensional (3-D) echocardiography since it could replace invasive measurements with the Swan-Ganz-catheter. To date, there are no studies available to determine whether cardiac output measured by thermodilution can be predicted reliably under changing hemodynamic conditions. Fifteen pigs with ischemic myocardium were examined under four hemodynamic conditions at rest and under pharmacological stress with 5, 10, and 20 microg/kg/min dobutamine. The 3-D datasets were recorded by means of transesophageal echocardiography. The endocardial definition was enhanced by administering the contrast agent FS069 (Optison). Cardiac output was calculated as the product of stroke volume (end-diastolic - end-systolic volume) and heart rate. The invasive measurements were performed with a continuous thermodilution system. In general, there was moderate correlation between 3-D echocardiography and thermodilution(r = 0.72, P < 0.001). At rest, the 3-D echocardiographic measurements were slightly but significantly lower than the invasive measurements (mean difference 0.6 +/- 0.5L/min,P < 0.001). Under stress with 5, 10, and 20 microg/kg/min dobutamine, there was a marked increase in the deviation (1.3 +/- 0.5L/min,P < 0.001; 1.6 +/- 0.7 L/min,P < 0.001; and 2.1 +/- 1.1L/min,P < 0.001, respectively). The deviation was based on two factors: (1). Under stress, the decreasing number of frames per cardiac cycle acquired with 3-D echocardiography led to imprecise recording of end-diastolic and end-systolic volumes, and thus to an underestimation of cardiac output. At least 30 frames per cardiac cycle are needed to eliminate this effect. (2). There is a systematic difference between 3-D echocardiographic and invasive measurements, which is independent of the imaging rate. This is based on an overestimation of the true values by thermodilution. In conclusion, cardiac output can be determined correctly by 3-D echocardiography for normal heart rates at rest. At elevated heart rates, the temporal resolution of 3-D systems currently available is not adequate for reliable determination. In performing and evaluating future clinical comparative studies, the systematic difference between 3-D echocardiography and thermodilution, based on overestimation by thermodilution, must be taken into account.

In vivo analysis of aortic valve dynamics by transesophageal 3-dimensional echocardiography with high temporal resolution.

OBJECTIVES: Knowledge of aortic valve function has been obtained from experimental studies. The aim of the present study was to investigate characteristics of aortic valve motion in humans. METHODS: Fifty-six patients were studied: 19 with normal valve and good systolic left ventricular function (Group NL), 12 with normal valve and reduced left ventricular function (Group CMP), and 25 with aortic stenosis and good left ventricular function (Group AS). The frame rate was doubled (50 Hz) compared with previous 3-dimensional systems. A mean of 38 +/- 9 images were acquired per cardiac cycle, with 14 +/- 4 images during the systole. The changes in shape and orifice area were analyzed over time. RESULTS: With normal valves, valve movement proceeded in 3 phases: rapid opening, slow closing, rapid closing. Stenotic valves showed a slower opening and closing movement. The times to maximum opening in Groups NL, CMP, AS were 76 +/- 30, 88 +/- 18 (P =.06), and 130 +/- 29 (P <.01) ms, respectively. It was inversely correlated to the maximum orifice area (r = -0.59, P <.001). The opening velocities in Groups NL, CMP, AS were 42 +/- 23, 28 +/- 9 (P <.05), and 5 +/- 2 (P <.001) cm(2)/s, respectively. There was a close correlation between the opening velocity and the maximum orifice area (r = 0.87, P <.001). Slow valve closings occurred at a velocity of 8.0 +/- 5.2, 5.3 +/- 2.0 (P =.21), 2.8 +/- 1.1 (P <.01) cm(2)/s, respectively, and rapid closings in Groups NL and CMP at 50 +/- 23, 29 +/- 8 (P <.01) cm(2)/s. The results show good agreement with experimental data. CONCLUSION: Rapid aortic valve movement can be recorded by 3-dimensional echocardiography and analyzed quantitatively. Time and velocity indices of valve dynamics are influenced by valvular and myocardial factors. A comparable in vivo analysis is not possible with any other imaging procedure.

New three-dimensional echocardiographic system using digital radiofrequency data--visualization and quantitative analysis of aortic valve dynamics with high resolution: methods, feasibility, and initial clinical experience.

BACKGROUND: Common 3D systems have only limited spatial and temporal resolution (frame rate of 25 Hz). Thin structures such as cardiac valves are not imaged exactly; rapid movement patterns cannot be precisely recorded. The objective of the present project was to achieve radiofrequency (RF) data transmission to the 3D workstation to improve image resolution. METHODS AND RESULTS: A commercially available echocardiographic system (5-MHz transesophageal echocardiography probe) with an integrated raw data interface enables transmission of RF data (up to 40 megabytes per second). A 3D data set may contain up to 3 gigabytes, so that all of the high-resolution ultrasound information of the 2D image is available. Frame rates of up to 168 Hz result in temporal resolution 6 times that of standard 3D systems. The applicability of the system and the image quality were tested in 10 patients. The structure of the aortic valve and the dynamic changes were depicted by volume rendering. The changes in the orifice areas were measured in frame-by-frame planimetry. The mean number of frames recorded per cardiac cycle was 122+/-16. The improved structural resolution enabled a detailed imaging of the morphology of the aortic cusps. The rapid systolic movement patterns were recorded with up to 51 frames. The high number of frames enabled creation of precise area-time diagrams. Thus, the individual phases of aortic valve movement (rapid opening, slow valve closing, and rapid valve closing) could be analyzed quantitatively. CONCLUSIONS: A 3D system based on RF data enables high-resolution imaging of cardiac movement patterns. This offers new perspectives for qualitative and quantitative analyses, especially of cardiac valves.

Percutaneous aortic valve replacement: an experimental study. I. Studies on implantation.

OBJECTIVE: The purpose of this preliminary study was to devise a new surgical procedure for minimally invasive aortic valve implantation with a transluminal technique. METHODS: The new collapsible heart valve was prepared by mounting a porcine aortic valve, taken from a freshly slaughtered pig, into a self-expandable nitinol stent by means of a suture technique. The outer diameter of the valved stent ranged from 15 to 23 mm, and the length ranged from 21 to 28 mm. Before implantation in vivo, these valved stents were tested in an in vitro circulatory system. Only in vitro-tested valved stents with a pressure gradient of less than 7 mm Hg and regurgitation of I degrees or less were used for transluminal aortic valve implantation in vivo. Six of these valved stents were implanted in the descending aorta and 8 in the ascending aorta of anesthetized pigs. The catheter delivery system (22F) was extraperitoneally inserted through the left iliac artery or the infrarenal aorta. Measurements for transvalvular gradient, valvular opening and closure, blood-flow characteristics, regurgitation, and macroscopic analysis were performed at baseline and after the observation period (164 +/- 48 minutes). RESULTS: This preliminary study contained 14 animals. One animal died of ventricular fibrillation. Technical failure occurred in 2 pigs as a result of stent twisting. At the end of the observation period, the 11 successfully implanted valved stents demonstrated low transvalvular gradients (mean end-systolic Deltarho(max) of 5.4 +/- 3.3 mm Hg for the descending aorta group, 5.4 +/- 1.2 mm Hg for the supracoronary group, and 5.4 +/- 1.1 mm Hg for the subcoronary group), which did not differ from their in vitro gradients. Two-dimensional echocardiography demonstrated complete valvular closure and opening in 5 of 5 cases. Angiography indicated only a physiologic jet of regurgitation (0 degrees ) in 8 animals and mild (I degrees ) regurgitation in 3 animals. Color Doppler ultrasonography indicated no regurgitation in 5 of 5 cases and minor paravalvular leakage in 1 case. CONCLUSION: Aortic valved stents can be successfully implanted without thoracotomy by using a transluminal catheter technique. Long-term function of the valves remains to be established.