Cardiac myxoma originating from areas of ventricular akinesia.

We present a case of large pedunculated myxoma (61×39 mm) in the left ventricular cavity with anterior-septal and anterior free wall akinesia. Angiographic study showed normal coronary arteries, but the clinical signs strongly suggested a previous myocardial infarction. We cannot exclude the possibility that the ventricular akinesia results from embolization of tumor fragments. For a time, cardiac myxomas were believed to arise from mural thrombi. In this case the presence of blood stasis or low-velocity blood flow related to wall motion abnormalities may have played a role in improving tumor growth.

Early administration of verapamil after thrombolysis in acute anterior myocardial infarction. Effect on left ventricular remodeling and clinical outcome. VAMI Study Group. Verapamil Acute Myocardial Infarction.

BACKGROUND: The administration of verapamil during the reperfusion phase of acute myocardial infarction can reduce the extent and severity of microvessel damage and limit myocardial dysfunction. We aimed at investigating the effect of early verapamil administration on left ventricular remodeling and the clinical evolution after myocardial infarction. METHODS: Eighty-eight patients with first acute anterior myocardial infarction thrombolysed < 4 hours from symptom onset were enrolled in a multicenter, randomized, double-blind, controlled study of verapamil administration (5 mg i.v. + 2 microg/kg/min over 24 hours). Echocardiographic end-diastolic (EDV) and end-systolic (ESV) left ventricular volumes were assessed by biplane Simpson's rule. RESULTS: At 90 days, EDV in the verapamil and placebo groups was respectively 88.9 +/- 27.8 and 95.8 +/- 30.7 ml (p = 0.11), ESV was 52.6 +/- 22.7 and 57.7 +/- 25.4 ml (p = 0.18). There was no change over time in the verapamil group (day 3 vs day 90: EDV 85.0 +/- 17.7 vs 88.9 +/- 27.8 ml, p = NS; ESV 48.7 +/- 14.1 vs 52.6 +/- 22.7 ml, p = NS) while left ventricular volume increased in the placebo group (day 3 vs day 90: EDV 87.6 +/- 21.1 vs 95.8 +/- 30.7 ml, p = 0.03; ESV 52.0 +/- 16.9 vs 57.7 +/- 25.4 ml, p = 0.08). NYHA functional classes were differently distributed at 30 and 90 days (chi2 = 0.009 and 0.07), with a lower prevalence of classes II and III in the verapamil group (p = 0.03). CONCLUSIONS: The early intravenous administration of verapamil in thrombolysed patients can reduce left ventricular remodeling and NYHA functional class after acute anterior myocardial infarction.

Multiplane transesophageal echocardiography to detect effectiveness of selective pulmonary recombinant tissue-type plasminogen activator thrombolysis in pulmonary embolism and patent foramen ovale.

A functionally patent foramen ovale can create a relevant right-to-left shunt during massive pulmonary embolism. This associated feature, although maintaining adequate cardiac output, may explain both the paradoxic embolism and the uneffectiveness of peripherally administered drugs. This case demonstrates the potential of transesophageal echocardiography in monitoring the hemodynamic findings of such patients and, consequently, the effectiveness of thrombolytic treatment.

[Diagnosis of coronary disease using multiplane transesophageal echocardiography and atrial pacing]. / Diagnosi di malattia coronarica mediante ecocardiografia transesofagea multiplanare e pacing atriale.

The diagnostic value of echo-pacing has been previously report. Recently, monoplanar transesophageal echocardiography (TEE) has been used to improve the reliability of this stress procedure. Therefore, in 40 consecutive patients undergoing coronary angiography for suspected coronary artery disease (CAD) we tested the accuracy of atrial pacing (TAP) during multiplane TEE as a stress procedure. TAP was performed during TEE using a circular, adhesive electrode installed at the tip of the echoscope and connected to the pulse generator. In all patients TAP was firstly attempted by positioning the TEE probe in the esophagus and, if not successful, in the stomach. Left ventricular wall motion was monitored by means of 4, 2 chamber and long axis views from the esophagus and short axis scan from the stomach, in baseline conditions, at peak pacing and immediately after maximal heart rate. The test was considered positive if wall motion abnormalities developed during TAP. Stable capture of the atrium was obtained in 28 patients from the esophagus and in 6 patients from the stomach. Thus, TEE-TAP was performed in 34/40 patients (feasibility 85%). Wall motion abnormalities were detected during TAP in 20/24 with and in 2/10 patients without CAD. Thus, sensitivity and specificity of TEE-TAP were 83% and 80% respectively. The sensitivity of the test in single and multivessel disease resulted 72% and 92%. The 12 lead electrocardiogram during TAP showed a sensitivity of 66% and a specificity of 40% (p < 0.01 vs TEE-TAP). In conclusion, TEE-TAP is a new approach for CAD evaluation providing a complete and accurate imaging of left ventricular wall motion.

Survival despite almost complete fibrous obstruction of a Sorin tilting disc mitral prosthesis.

We report the case of a 40-year-old woman whose Sorin tilting disc mitral prosthesis was obstructed by fibrous overgrowth to the point of near occlusion. The unusual features of this case are that the patient survived reoperation and that her preoperative symptoms were mild despite an immobile disc and near occlusion of the valve. In most similar cases in the literature, preoperative symptoms have been acute and mortality has been high.

[Assessment of viable myocardium after infarction with transesophageal echocardiography and myocardial echocontrastography]. / Valutazione del miocardio vitale nel postinfarto mediante ecocardiografia transesofagea ed ecocontrastografia miocardica.

Left ventricular recovery of dysfunctioning but viable myocardium can occur only in tissue in which both myocardial contractile reserve and microvascular integrity are preserved. Recent studies have demonstrated that both inotropic stimulating echo tests and myocardial contrast echocardiography can be used to assess myocardial viability in post-myocardial infarction patients. Therefore we performed a transesophageal and myocardial contrast echocardiographic evaluation of post-myocardial infarction patients to assess: the respective accuracy of post-extrasystolic potentiation and low-dose dobutamine (5 and 10 mcg) during transesophageal echocardiography in eliciting contractile reserve, and the potential of myocardial contrast echocardiography in predicting later functional recovery. Results of our studies showed comparable effects of low-dose dobutamine (5 mcg) and post-extrasystolic potentiation in increasing myocardial thickening while low-dose dobutamine (10 mcg) had a greater potential in eliciting residual contractility. Lastly, myocardial contrast echocardiography provided a clear spectrum of intramyocardial perfusion patterns in dysfunctioning areas but did not accurately correlate with later functional recovery as better predicted by low-dose dobutamine in the same segments. In conclusion, these methods represent the preferred choice of studying the perfusion-contraction match in viable myocardium thus playing an important role in prognostic and therapeutic strategies in myocardial infarction patients.

Coronary flow dynamics and reserve assessed by transesophageal echocardiography in obstructive hypertrophic cardiomyopathy.

Myocardial ischemia is frequently associated with left ventricular outflow obstruction. To assess coronary flow impairment in obstructive hypertrophic cardiomyopathy (HC), 10 patients with echo-Doppler-detected obstructive HC and normal coronary arteries underwent transesophageal echo-Doppler examination of both coronary flow velocity (CFV) at rest, recorded in the proximal left anterior descending coronary artery, and coronary flow reserve (CFR) evaluated by means of dipyridamole infusion response. Ten normal patients were similarly studied and served as a control group. Two relevant alterations in coronary flow dynamics were detected in patients with HC: (1) a significantly increased diastolic/systolic CFV ratio, and (2) a significantly reduced dipyridamole/baseline CFV ratio. Compared with normal subjects, the CFV pattern showed a significantly greater diastolic and a significantly lower systolic component at rest (in some patients it was reversed). Diastolic/systolic CFV ratio was significantly higher in patients with HC at baseline (3.1 +/- 1 vs 1.6 +/- 0.5; p < 0.01) and increased further after dipyridamole infusion (4.9 +/- 2 vs 2.2 +/- 0.7; p < 0.01). In addition, CFR was impaired in patients with HC (1.8 +/- 0.3 vs 3.1 +/- 0.5; p < 0.01). Furthermore, a significant correlation between CFR and intraventricular pressure gradient was found. Thus, transesophageal echo-Doppler examination is a useful tool for evaluating CFV dynamics and CFR as demonstrated in patients with obstructive HC.

[Multiplane transesophageal echocardiography in the study of expansive mediastinal processes compressing the right heart: a report of clinical cases]. / Ecocardiografia transesofagea multiplanare nello studio dei processi espansivi del mediastino comprimenti il cuore destro: descrizione di casi clinici.

In order to assess the role of multiplane transesophageal echocardiography in detecting mediastinal masses and in evaluating the manifestations of cardiac compression due to tumoral growth, 3 cases of patients with right ventricular outflow obstruction are presented. In each of these patients transesophageal echocardiography provided an accurate evaluation of the hemodynamic consequences of the tumoral process.

Detection of proximal stenosis of left coronary artery by digital transesophageal echocardiography: feasibility, sensitivity, and specificity.

To assess feasibility, sensitivity, and specificity of transesophageal echocardiography (TEE) in visualizing proximal left coronary artery segments (entire left main, proximal left anterior descending, and circumflex) and in identifying proximal coronary stenosis, 160 consecutive patients were studied. Each patient underwent TEE before coronary angiography; the echocardiographic images were digitized and reviewed in a continuous cineloop format. The entire proximal left coronary artery was adequately imaged in 111 patients (70%). A stenosis was considered to be present at TEE if hyperreflecting plaques narrowing the coronary lumen were observed. TEE observed the presence of a stenosis in 6 of 6, 50 of 63, and 13 of 24 patients with stenosis detected at angiography on the left main, left anterior descending, and circumflex, respectively, and 2 of 105, 5 of 48, and 14 of 87 patients without angiographically detectable coronary stenosis in corresponding coronary segments. Thus, sensitivity and specificity of TEE in identifying stenosis of the left main coronary artery, proximal left anterior descending artery, and proximal circumflex artery were 100% and 98%, 79% and 89%, 54% and 84%, respectively. In conclusion, TEE identification of the proximal left coronary artery is feasible in most patients. Accuracy in identifying significant proximal stenosis varies from segment to segment and is higher for the left main coronary artery.

Integrated ultrasound evaluation of dissecting aneurysm of the aorta by the combined use of transesophageal echocardiography and intravascular ultrasound.

In order to obtain complete ultrasound imaging of the entire aorta, transesophageal echocardiography and intravascular ultrasound were performed on 3 patients with acute (2 cases) or chronic (1 case) aortic dissection. In each case the integrated use of transesophageal echocardiography and intravascular ultrasound provided an accurate evaluation of the dissection and of its anatomic extension.

Transesophageal Doppler echocardiography evaluation of coronary blood flow velocity in baseline conditions and during dipyridamole-induced coronary vasodilation.

Transesophageal echocardiography allows the evaluation of proximal coronary artery anatomy and coronary blood flow velocity (CBFV). To assess the potential of transesophageal echocardiography in evaluating CBFV and its variations induced by coronary-active drugs, we studied 15 patients by high-quality pulsed wave Doppler recordings of CBFV. In these patients, transesophageal Doppler evaluation of CBFV was performed before, 2 minutes after cessation of dipyridamole infusion (0.56 mg/kg in 4 minutes), and 2 minutes after aminophylline infusion (240 mg injected 4 minutes after cessation of dipyridamole infusion). The following CBFV parameters were evaluated at each of the three steps of the study protocol: maximal and mean diastolic velocities and maximal and mean systolic velocities. Furthermore, the following indexes of coronary flow reserve were evaluated: the ratio between maximal diastolic velocity recorded after and before dipyridamole administration and the ratio between mean diastolic velocity recorded after and before dipyridamole administration. Nine of the 15 patients had a normal left anterior descending coronary artery (group A), whereas the remaining six had significant (less than or equal to 75%) stenosis (group B). In group A patients, all CBFV parameters increased significantly during dipyridamole infusion and returned to near baseline values after aminophylline infusion. In group B patients, on the other hand, none of the CBFV parameters increased after dipyridamole infusion. Dipyridamole/baseline maximal diastolic velocity and mean diastolic velocity ratios were, respectively, 3.22 +/- 0.96 and 3.04 +/- 0.88 in group A and 1.46 +/- 0.45 (p less than 0.01 versus group A) and 1.48 +/- 0.49 (p less than 0.01 versus group A) in group B patients.(ABSTRACT TRUNCATED AT 250 WORDS)

[Evaluation of coronary anatomy and coronary circulation by transesophageal echocardiography]. / Valutazione dell'anatomia e del flusso coronarico mediante ecocardiografia transesofagea.

UNLABELLED: Nowadays the anatomy and coronary flow can be evaluated by means of various methods requiring cardiac catheterization. Transesophageal echocardiography is a new diagnostic method with great potential (excellent technical quality, stable positioning of the transducer, no lung interposition). Because of its potential we have used transesophageal echocardiography on a number of patients undergoing coronary angiography in order to investigate its reliability in estimating the anatomy and coronary flow. From the anatomical point of view 3 aspects were identified: absence of alterations affecting the vessel being explored (Criterion A); presence of non-stenotic calcific wall plaques (Criterion B); presence of stenotic calcific plaques (Criterion C). The percentage of visualization of the left main artery, the left anterior descending and the circumflex was 87%, 78% and 76% respectively. The criteria described showed varying reliability depending on the coronary portion being considered. Using the pulsed Doppler, during the transesophageal study, we obtained an adequate recording of the velocity profile of the left anterior descending in 28/37 patients. After dipyridamole infusion all velocity parameters (diastolic and systolic mean and maximum velocities) increased significantly in those patients with left anterior descending without stenosis, while remaining practically constant in those patients with significant stenosis of the left anterior descending artery. In particular the ratio between the maximum diastolic velocity recorded after dipyridamole and the velocity recorded immediately before infusion was significantly greater in those subjects with normal left anterior descending than in those with significant stenosis of the left anterior descending artery. CONCLUSIONS: transesophageal echocardiography offers new prospects in studying anatomic alterations and flow patterns of the proximal part of the left coronary artery.(ABSTRACT TRUNCATED AT 250 WORDS)