Duchenne muscular dystrophy: preliminary experience with sacubitril-valsartan in patients with asymptomatic left ventricular dysfunction.

OBJECTIVE: Duchenne muscular dystrophy (DMD) is an inherited X-linked recessive neuromuscular disease caused by mutations of the dystrophin gene, leading to early and progressive muscle deterioration and dilated cardiomyopathy. The aim of this investigation was to assess whether treatment with sacubitril/valsartan (S/V) is well tolerated and may have beneficial effects in DMD patients with left ventricle (LV) dysfunction. PATIENTS AND METHODS: We administered S/V to 3 DMD patients (19-29 yeard old) with LV ejection fraction <35% at echocardiography but no symptoms of heart failure. All patients were on optimal medical therapy. S/V was initiated at a very low dose of 12/13 mg/die, after withdrawal of angiotensin-converting enzyme inhibitor therapy, and slowly titrated to the dose of 49/51 mg twice daily or the maximally tolerated dose. Clinical and echocardiographic follow-up was performed after 3, 6 and 12 months. RESULTS: At baseline, the LV ejection fraction was 32±1%. A significant improvement of LV ejection fraction was observed at 3 months (44.0±6.0%; p<0.05), which was maintained at 6 (45.7±5.0%) and 12 (43.3±3.2%) months (p<0.05 for both). No relevant side effects were reported throughout the period of the study. CONCLUSIONS: Our preliminary data suggest that, in DMD patients with reduced LV ejection fraction, S/V is safe and may improve LV function.

Diagnostic role of echocardiography in patients admitted to the emergency room with suspect no-ST-segment elevation acute myocardial infarction.

OBJECTIVE: We investigated whether echocardiography may help identify, among patients admitted with a suspect of non-ST-segment elevation acute myocardial infarction (NSTEMI), those with athero-thrombotic coronary artery disease (CAD). PATIENTS AND METHODS: We studied consecutive patients admitted with a clinical suspect of first NSTEMI. Echocardiography was assessed within 24 hours from admission. Patients were divided into two groups, according to the results of coronary angiography: 1) patients with obstructive stenosis (≥ 50%) and/or images of thrombosis in one or more coronary arteries (CAD group); 2) patients with no evidence of obstructive coronary arteries (NOCAD group). RESULTS: Of 101 patients enrolled in the study, 53 (52.5%) showed obstructive CAD and 48 (47.5%) NOCAD. At echocardiographic examination, regional wall motion abnormalities were found in 52.8% of patients in the CAD group and 43.7% in the NOCAD group (p=0.43). Left ventricle ejection fraction was 56.4±6.8 vs. 54.7±9.8% (p=0.30) and wall motion score index was 1.16±0.26 vs. 1.21±0.32 (p=0.39) in the two groups, respectively. A multivariable logistic regression independent predictors of obstructive CAD included age, male gender, typical angina, diabetes and hypertension. CONCLUSIONS: Our data showed that, in patients with acute chest pain and increased serum troponin T concentration, routine standard echocardiography does not significantly improve the diagnostic accuracy for the presence of obstructive CAD.

Transesophageal echocardiographic assessment of hemodynamic function during laparoscopic cholecystectomy in healthy patients.

BACKGROUND: This study aimed by means of transesophageal echocardiography, to evaluate hemodynamic changes induced by pneumoperitoneum in patients with normal cardiac performance. METHODS: In this study, 11 ASA I-II patients (mean age, 39 years) with normal cardiac performance undergoing laparoscopic cholecystectomy were evaluated. A 5-MHz transesophageal biplane phased-array transducer connected to an echocardiographer was inserted after induction of anesthesia. Data were collected at three different times: before insufflation (T1), 10 min after insufflation (T2), and 5 min after desufflation (T3). At these same times, heart rate, systolic blood pressure, diastolic blood pressure, end-tidal carbon dioxide (CO(2)), and peak airway pressure were recorded. Statistical analysis was performed using one-way and two-way analysis of variance (ANOVA). A p value less than 0.05 was considered significant. RESULTS: End-systolic and end-diastolic diameters of the left ventricle, contractility, and performance parameters did not change significantly. Conversely, at insufflation, color Doppler area of the mitral backflow increased significantly (p < 0.05) when already present or showed up abruptly (T1: 0.22 +/- 0.28 cm(2); T2: 1.28 +/- 1.02 cm(2); T3: 0.49 +/- 0.53 cm(2)). CONCLUSIONS: Such an event is not interpreted as a mitral insufficiency. It is possibly the result of a "contrast effect" caused by the absorption of CO(2) microbubbles in the blood.

Risk stratification of patients undergoing peripheral vascular revascularization by combined resting and dipyridamole echocardiography.

Patients with advanced peripheral vascular disease have an increased cardiac morbidity and mortality. The aim of this study was to assess the predictive value of rest and stress echocardiography for perioperative and late cardiac events in 110 patients undergoing limb revascularization. All patients underwent preoperative clinical and echocardiographic evaluation at rest and by dipyridamole stress testing to assess cardiac risk. Patients with > or =3 clinical Eagle markers, low left ventricular ejection fraction at rest, or positive dipyridamole stress test results were considered at high cardiac risk. To record adverse cardiac events, all patients were monitored during and after surgery, and followed for at least 1 year after hospital discharge. Cardiac complications occurred in 10 patients (9.7%) perioperatively (2 fatal myocardial infarctions), and in 13 (13%) at 1-year follow-up (7 fatal myocardial infarctions). Echocardiographic evaluation was the best predictor of early (p <0.00003) and late (p <0.0003) cardiac complications. No patient with a negative dipyridamole stress test result and good left ventricular ejection fraction had cardiac complications, either postoperatively or during follow-up. Clinical evaluation does not appear sufficiently sensitive for predicting perioperative cardiac events, but was valuable in predicting late cardiac complications (p <0.0002). Our data show that echocardiographic evaluation of resting dysfunction and of the ischemic response to dipyridamole is a good predictor of perioperative cardiac risk, and is superior to generally available clinical data. Echocardiographic evaluation is useful in defining a low-risk group of patients who can safely undergo limb revascularization, whichever surgical procedure is proposed.

Safety of endovascular treatment in high-cardiac-risk patients with limb-threatening ischemia.

Vascular surgery can be safely performed in approximately 60% of patients with advanced peripheral vascular disease, because of the high frequency of concomitant coronary artery disease and consequent increased risk of perioperative cardiac complications. The aim of this study was to validate the hypothesis that endovascular revascularization could be safely applied to high-cardiac-risk patients with a lower incidence of perioperative cardiac complications. One hundred and fourteen patients with peripheral vascular disease referred for revascularization underwent preoperatively a clinical and echocardiographic evaluation, at rest and under dipyridamole stress test, to assess the cardiac risk. Patients with high clinical score (according to Goldman and Detsky), or low left ventricular ejection fraction at rest, or positive dipyridamole stress test, were considered at high cardiac risk. To record adverse cardiac events, all patients were monitored during surgery, postoperatively, and followed up for 18 months after hospital discharge. Forty-eight patients (42%) were found to be at high cardiac risk. In this high-cardiac-risk group, endovascular surgery was performed in 37/48 patients (77%) (group A), while the remaining 11/48 patients (23%) were bypassed with open surgery (group B). Postoperative cardiac complications occurred in 16% of patients in group A and in 45% of patients in group B with two deaths (p < 0.05). At follow-up, 51% of patients in group A and 44% of patients in group B had suffered late cardiac events (p=ns), with 10 deaths in group A and three deaths in group B (p=ns). Limb salvage rate was similar in the two groups (95% group A, 100% group B; p=ns). These data show that high-cardiac-risk patients with limb-threatening ischemia have significantly less perioperative cardiac complications when treated by endovascular procedures instead of bypass surgery. Follow-up data on cardiac events confirm the severity of concomitant coronary artery disease in patients with peripheral vascular disease.

Contractile reserve of dysfunctional myocardium after revascularization: a dobutamine stress echocardiography study.

OBJECTIVES: We sought to investigate the effects of revascularization on the contractile reserve of dysfunctional myocardium. BACKGROUND: The improvement in dysfunctional but viable myocardium after revascularization is frequently less than expected from the amount of contractile reserve detected on dobutamine stress echocardiography. The fate of the contractile reserve, when it does not result in an adequate contractile recovery, is unknown. METHODS: Basal contraction and contractile reserve of infarct zones were assessed by dobutamine stress echocardiography in 21 postinfarction male patients before and > 3 months after revascularization (30 infarct zones; mean +/- SD left ventricular ejection fraction 35 +/- 8%). An infarct zone wall motion score index (WMSI) was calculated. RESULTS: Before revascularization, contractile reserve was present in 14 infarct zones (12 patients) and absent in 16 (9 patients). After revascularization, ejection fraction increased by 5 +/- 4% (p < 0.01) in patients classified as positive for contractile reserve and remained unchanged in those classified as negative. New York Heart Association classification improved in 58.3% and 22.2% of patients, respectively. Basal contraction improved in eight zones with previous contractile reserve (57.1%) and in one zone without (6.3%) (p < 0.01). Contractile reserve was still evident in 13 zones with previous contractile reserve (93%; 8 with contractile recovery), and it developed in 6 zones without (38%; none with contractile recovery). WMSI values after revascularization were decreased from values before revascularization during low dose dobutamine in zones with and without previous contractile reserve (p < 0.01 and < 0.05, respectively). CONCLUSIONS: After revascularization, contractile reserve is maintained or even increases in viable infarct zones that do not recover as expected. It may also develop in some infarct zones judged not to be viable before revascularization. This increased contractile reserve may play a role in the functional improvement of patients after revascularization.

The use of mechanical prostheses in native aortic valve endocarditis.

BACKGROUND AND AIMS OF THE STUDY: The optimal aortic valve substitute in cases of active native valve endocarditis (NVE) remains controversial. This report summarizes our experience with the surgical treatment of active aortic NVE using only mechanical prostheses. METHODS: Between January 1988 and January 1996, 20 patients underwent aortic valve replacement for active NVE. There were 17 men and three women. Mean age was 46.5 years (range eight to 63 years). Thirteen patients were in NYHA class IV and seven in class V. Streptococci were isolated in eight cases, while no causative micro-organism could be identified in seven patients. All operations were performed on urgent (n = 13) or emergency (n = 7) bases. A mechanical valve was implanted in all cases and radical resection of the infected tissues performed using different techniques. All patients were followed up at our institution. Two-dimensional color Doppler studies were performed one month after surgery and at six-month intervals after the first year. Transesophageal echocardiography (TEE) was performed at discharge, six months after surgery and yearly thereafter. RESULTS: No patient died in hospital. Mean follow up was 30.5 months, during which time three patients died, though none from endocarditis-related causes. Endocarditis recurred only one (5%). TEE demonstrated a normally functioning aortic prosthesis in 15 cases and trivial paravalvular leakage in two. CONCLUSIONS: Mechanical prostheses represent a safe aortic valve substitute in cases of acute native valve endocarditis. When radical resection of all the infected areas is performed, the incidence of endocarditis recurrence is acceptable. The concept that homografts are the valve substitute of choice in endocarditis cases cannot be supported by this study.

The use of pulmonary allografts for aortic valve replacement. Short term results and comparative morphometric analysis of the aortic and pulmonary valves.

UNLABELLED: The satisfactory results of aortic valve replacement with pulmonary autograft and the limited availability of aortic allografts prompted us to use the pulmonary valve as an aortic valve substitute and to perform a morphometric analysis of the two valves in cadavers. CLINICAL STUDY: From March 1994 to March 1995 20 patients underwent an aortic valve replacement (AVR) with a pulmonary allograft (PA). Twelve patients were men, 8 women; age ranged from 15 to 58 years. In 4 cases the indication to AVR was an infective endocarditis which was acute in two patients. Functional class was NYHA II in 18 cases and NYHA III in 2 patients with active endocarditis. Left ventricular ejection fraction (LVEF%) was preserved in the majority of patients (mean LVEF=53% range 36% to 65%). End diastolic aortic valve diameters were measured by bidimensional echocardiography in parasternal long axis view and ranged from 18 mm to 29 mm. The diameters of the allografts implanted ranged from 19 mm to 27 mm. Donors age ranged from 19 years to 55 years. We tried to use the allograft from the youngest donor available. The surgical technique was the classic "Ross" coronary freehand implantation in 11 cases, a "Miniroot" implant in 8 instances and a "Miniroot" implant combined with a "Nicks" annular enlargment in 1 case. Aortic cross clamping ranged from 66 mm to 118 m (92m+/-10m). One patient died (5%) of infarction. In this patient the allograft was replaced with a mechanical valve because the echocardiography showed a rapidly increasing aortic regurgitation. At hospital discharge a slight aortic regurgitation was detected in 2 cases. In these two patients, whose annulus diameters were 26 mm and 28 mm respectively, we adopted a classic freehand technique of implantation. Mean postoperative transvalvular gradient was 4 mmHg+/-3 mmHg. The follow-up ranges from 45 days to 14 months (mean 8 months). The aortic regurgitation in the two cases remains stable and no new aortic regurgitations have been detected to date. No embolic or infective episodes occurred during the follow-up. ANATOMIC STUDY: Analysis was performed on 6 couples of valves obtained from cadevers without evidence of previous valvular disease. The normalized Free Edge (FE) dimensions and Leaflet Surfaces (LS) of the pulmonary valve (PV) proved to be larger than the corresponding aortic (AV) measurements (Free edge/Diameter: PV 1.25+/-0.2 vs AV 1.16+/-0.2 p<0.05; Annular Attachment/Diameter PV 1.9+/-0.1 vs AV 1.74+/-0.2 p=NS; Valve Surface/Leaflet Surface PV 0.97+/-0.2 vs AV 0.80+/-0.2 p=0.004) indicating that the PV has a larger coapting surface.

Clinical and instrumental diagnosis of pulmonary embolism.

Pulmonary embolism shows a high mortality especially for the difficulty in establishing an early correct diagnosis. The pathophysiology and thus the clinical manifestations of pulmonary embolism (PE) are essentially conditioned by three factors: the size of the embolus, the pre-existing cardiorespiratory condition, the release caused by the embolus, of some substances or the activation of reflexes which tend to worsen the purely mechanical consequences of PE. The clinical manifestations resulting from the combination of these factors result in three clinical patterns: acute cor pulmonare, pulmonary infarction, acute dyspnea. PE symptoms may be absent in a moderate percentage of cases and if present, they are nonspecific. Some laboratory tests were shown to be of no diagnostic accuracy, as enzyme determination, a sign of necrosis, blood gas analysis, and determination of alveolar arterial oxygen gradient. Among blood coagulation tests, D-dimer determination was shown to be of some relevance. However, at present, it cannot be used to confirm the diagnostic suspicion of PE. Among the instrumental cardiologic procedures, while ECG has a poor diagnostic reliability, transesophageal echocardiography in central embolism may be able to visualize the embolus and to accurately assess the hemodynamic effects, supplying sufficient information for PE therapy. Even if imaging procedures as pulmonary angiography and more recently CT or MRI are the most reliable diagnostic tools, the diagnostic suspicion of PE in subjects at risk, the use of the examined methods and the search in these patients for the presence of lower limb deep vein thrombosis, often asymptomatic, may increase the number of treated patients thus decreasing the mortality of this disease.

Significance of transient ST-T segment changes during dobutamine testing in Q wave myocardial infarction.

OBJECTIVES: We evaluated dobutamine stress electrocardiography for detecting potentially reversible contractile dysfunction or residual ischemia in the infarct-related area. BACKGROUND: ST-T segment changes in pathologic Q wave leads during stress testing may reflect contractile reserve, inducible ischemia or passive mechanical stretching. Dobutamine echocardiography allows detection of contractile reserve at low doses and inducible ischemia at high doses. METHODS: We used low (5 to 10 microg/kg body weight per min) and high doses (20 to 40 microg/kg per min) of dobutamine in 49 patients with a previous Q wave myocardial infarction and analyzed the relation between ST-T segment changes in pathologic Q wave leads and regional contraction. RESULTS: At low dose dobutamine, regional contraction improved in the infarct-related area in 23 patients. New or further ST segment elevation and pseudonormalization of negative T waves developed at low doses more frequently in patients with than without contractile reserve (both p < 0.001), giving a sensitivity of 43.5% and 60.9% and a specificity of 100% and 96.2%, respectively. At high dose dobutamine (43 patients), new or further ST segment elevation and pseudonormalization of negative T waves, occurring beyond those observed at low doses, had a low predictive accuracy for contractile reserve (sensitivity of 9.5% and 14.3% and specificity of 68.2% and 81.8%, respectively). Pseudonormalization of negative T waves at high dose dobutamine was 100% specific (but only 25% sensitive) for homozonal ischemia. CONCLUSIONS: ST segment elevation or pseudonormalization of negative T waves, or both, is indicative of contractile reserve in the infarct-related area when either develops at low dose dobutamine, but may be associated with worsening or no change in contractile function at high doses.

Variable response of the peripheral circulation to acetylcholine in patients with coronary artery disease.

The purpose of this study was to assess endothelium-mediated vasodilation in the peripheral circulation of patients with coronary artery disease who are free from hypertension, hypercholesterolemia, diabetes mellitus, and congestive heart failure. The vascular response of the superficial femoral artery to an endothelium-dependent (i.e., acetylcholine 10-7, 10-6, and 10-5 mol/L) and to an endothelium-independent (i.e., nitroglycerin 10-8 and 10-6 mol/L) dilator was compared in 13 patients with angiographically documented coronary artery disease and in 7 patients with normal coronary angiograms. Vascular response was assessed by Doppler ultrasonography. Whereas the vascular responses to nitroglycerin in patients with abnormal and normal findings on coronary angiograms were similar, the responses to acetylcholine were clearly different. The ratio of mean blood flow velocity (+/-SD) measured during administration of acetylcholine 10-6 mol/L and mannitol was significantly lower in patients with abnormal versus normal results of coronary angiography (1.15 +/- 0.35 vs 2.20 +/- 1.06; p < 0.05). The vascular response to acetylcholine 10-5 mol/L in patients with an abnormal finding on their coronary angiogram was highly variable when compared with that in patients with normal results. Thus, in patients with angiographically proven coronary artery disease, the response of the peripheral circulation to acetylcholine is characterized by a great variability and a reduced sensitivity, when compared with that in patients with normal findings on coronary angiography.

Color Doppler study of mitral regurgitation during percutaneous transluminal coronary angioplasty.

Mitral regurgitation (MR) was evaluated by color Doppler echocardiography during percutaneous transluminal coronary angioplasty (PTCA) in 28 patients with one-vessel artery disease (left anterior descending artery in 11, right coronary artery in 8, and circumflex artery in 9) and normal left ventricular function. In all three groups, left ventricular ejection fraction (LVEF) and wall motion score index (WMSI) decreased significantly during artery occlusion in comparison with baseline values (no differences among various groups). Anterior and inferior akinesia/dyskinesia was observed in all patients during left anterior descending and right coronary artery occlusion, respectively. Lateral akinesia/dyskinesia was induced by occlusion of the circumflex artery in six patients (all with proximal lesions [p < 0.05 vs the other two groups]) and the right coronary artery in one. Only the six patients with circumflex artery occlusion showed PTCA-related MR (> 2+ in two). LVEF and WMSI were similar during artery occlusion in patients with and without MR. Neither mitral leaflet prolapse nor anulus dilation occurred during PTCA in any of the patients. Our data show that during brief occlusion of the proximal circumflex artery, functional MR (usually mild) frequently occurs in relation to specific lateral akinesia/dyskinesia.

Doppler analysis of portal vein flow in tricuspid regurgitation.

Portal and hepatic vein flow-velocity profiles were examined by pulsed Doppler in 66 patients with tricuspid regurgitation (color Doppler grading: severe: 37, moderate: 18; mild: 11) and 20 normal subjects to determine if portal vein flow analysis is useful in the evaluation of tricuspid regurgitation. Portal vein flow was defined as one of the following categories: subcontinuous (dependent on respiration), pulsatile systolic (not inverted), inverted after systole, and continuous (not dependent on respiration). An index of portal vein flow pulsatility was also calculated. Standard classification of hepatic vein flow pattern was performed. Portal vein flow was pulsatile in 20% of normals subjects, and in 27.3% 44.5% and 51.3% of patients with respectively mild, moderate and severe tricuspid regurgitation; portal vein flow was inverted after systole in further 32.4% of patients with severe tricuspid regurgitation. Portal vein pulsatility index correlated with color Doppler grading of tricuspid regurgitation (r:0.63; p < 0.001) and right ventricle-atrium pressure gradient (r:0.39; p < 0.01). However, when compared with hepatic vein flow, both sensitivity and specificity of quantitative portal vein flow analysis was less reliable in diagnosing and grading tricuspid regurgitation. In particular, in patients with severe tricuspid regurgitation, the portal vein flow pattern was quite variable (pulsatile in 19 patients, inverted after systole in 12, and continuous in six). Liver biopsy was performed in nine patients, four of them with severe tricuspid regurgitation and continuous portal vein flow. Histology showed severe liver fibrosis in all four.(ABSTRACT TRUNCATED AT 250 WORDS)

Abnormal intraventricular flow patterns in left ventricular dysfunction determined by color Doppler study.

We examined the relation between left ventricular (LV) flow dynamics measured by color Doppler, and either global or regional LV function in 19 normal subjects (group 1), in 55 patients with old myocardial infarction (MI) (29 without [group 2] and 26 with LV aneurysm [group 3]), and in 16 with idiopathic dilated cardiomyopathy (group 4). We calculated by M-mode color Doppler a flow persistence index (FPI) (duration of flow directed in systole toward the apex/LV ejection time). Contrast echocardiography was performed as a control method in 14 patients of the four groups. In normal subjects, rapid systolic inversion of flow toward the aorta was evident (FPI: 0.11 +/- 0.16). In all but one patient in group 2, a similar LV flow pattern was observed, but FPI was greater (0.32 +/- 0.26). In groups 3 and 4, a paradoxical antegrade LV flow pattern was evident during the entire period of systole (FPI: 1.13 +/- 0.42 and 1.28 +/- 0.36, respectively). LV flow patterns were reproduced in echo-contrast studies. FPI was related to LV end-diastolic volume (r = 0.77), end-systolic volume (r = 0.82), and ejection fraction (r = -0.84). However, when data were analyzed separately in the different groups, these correlations were significant only in groups 2 and 3. Paradoxical flow pattern is not peculiar to regional LV dysfunction; it also occurs in global LV dysfunction. This LV flow abnormality may develop after MI even in the absence of severe LV dyssynergy or dilation, and is quantitatively related to the degree of LV dysfunction.

Acromegalic cardiomyopathy. Left ventricular filling and hypertrophy in active and surgically treated disease.

Myocardial hypertrophy and interstitial fibrosis are common in acromegalic hearts and may induce left ventricular (LV) dysfunction. The transmitral flow pattern was examined by pulsed-wave Doppler in 20 patients with active acromegaly and nine with acromegaly cured by pituitary microsurgery. Control groups consisted of 25 normal subjects and 13 patients with systemic hypertension. We related Doppler indices of LV filling (E and A peak velocities and E/A ratio) to the duration of acromegalic disease, the GH plasma levels and LV mass. The LV mass/BSA was significantly greater in active acromegaly (187 +/- 53 g/sq m) and systemic hypertension groups (161 +/- 48 g/sq m) than in cured acromegaly (125 +/- 35 g/sq m) and the normal control group (109 +/- 36 g/sq m) (p < 0.01 for both). No differences were found in the E peak velocity, A peak velocity, and E/A ratio in the groups with active acromegaly (E/A: 0.9 +/- 0.2), cured acromegaly (E/A: 0.9 +/- 0.3), and systemic hypertension (E/A: 0.8 +/- 0.5). An E/A ratio < 1 was found in 13 patients with active and four with cured acromegaly; (p = NS). In the active acromegaly group, the E/A ratio was related to either LV mass or the duration of disease (r:-0.45 and -0.47, respectively; p < 0.05). In the cured acromegaly group, the E/A ratio was related to the duration of disease before surgery (r:-0.70; p < 0.05) and not to LV mass (r:0.12). In conclusion, an impairment in LV filling may be present not only in the patients with active acromegaly but also in those successfully treated by surgery after a long duration of the disease, despite normal LV mass. These LV filling abnormalities may be in part determined by nonreversible myocardial changes, such as interstitial tissue fibrosis.

Doppler study of precordial musical murmurs.

Using phonocardiography, continuous- and pulsed-wave Doppler, 51 patients with precordial "musical" murmurs (49 with cardiac abnormalities) and 21 patients with noisy murmurs were examined. With M-mode echocardiography, fine fluttering of the structure generating the murmur was evident in 23 patients with musical murmurs and in 5 with noisy murmurs. A continuous-wave Doppler spectral signal characterized by parallel harmonics (Doppler musical signal) was evident in all patients with musical murmurs and in none with a noisy murmur. With pulsed-wave Doppler, the musical signal had less defined spectral features because of range ambiguity. Such a signal was experimentally reproduced by activating a diapason bathed in saline solution. The source of the musical murmur was established in all 51 patients by Doppler. The musical signal was associated with a valvular regurgitation signal in 36 patients and with a ventricular septal defect in 1 patient. The musical signal always disappeared when the pulsed-wave Doppler sample volume was placed 2 cm away from the generating structure. In 11 patients with musical murmur examined by color Doppler, no abnormal bidirectional flow signal was observed in the structures generating the signal. In 6 of the patients without valvular regurgitation, no flow disturbance was found. In conclusion, Doppler is valuable in determining the source of musical murmurs, and musical murmurs are caused by a vibrating structure even in the absence of flow turbulence.

Hypertrophic cardiomyopathy mimicking athlete heart: risk of progression and opportunity for a bioptical approach.

A case of hypertrophic cardiomiopathy (HCM) mimicking athlete heart, is reported. Performing competitive activity was followed by progression of HCM to cardiac dilation and hypokinesis so that transplant was needed at young age. The Authors suggest a more aggressive approach possibly inclusive of cardiac biopsy when doubtful cases of athlete heart require permission for competitive sports.