Análisis comparativo de 2 registros de infarto agudo de miocardio tras una década de cambios. Estudio IBERICA (1996-1998) y Código Infarto-Illes Balears (2008-2010) / Comparative analysis between 2 periods of acute myocardial infarction after a decade in Mallorca. IBERIA Study (996-1998) and Infarction-Code (2008-2010)

OBJETIVO: Investigar las diferencias en la mortalidad a 28 días y otras variables pronósticas en 2 periodos: IBERICA-Mallorca (1996-1998) y Código Infarto-Illes Balears (CI-IB) (2008-2010). DISEÑO: Dos cohortes prospectivas observacionales. Ámbito: Hospital Universitario Son Dureta, 1996-1998 y 2008-2010. PACIENTES: Síndrome coronario agudo con elevación de ST de≤24h, de localización anterior e inferior. Variables principales de interés: Edad, sexo, factores de riesgo cardiovascular, localización, tiempos de actuación, tratamiento de reperfusión con fibrinólisis y angioplastia primaria, administración de ácido acetilsalicílico, betabloqueantes e inhibidores de la enzima conversora de la angiotensina. Se incluyeron el grado de Killip, las arritmias malignas, las complicaciones mecánicas y el fallecimiento a los 28 días. RESULTADOS: Se analizaron 442 pacientes de los 889 incluidos en el IBERICA-Mallorca y 498 de los 847 registrados en el CI-IB. La localización y el Killip fueron similares en ambas cohortes. Las principales diferencias significativas entre el grupo IBERICA y el CI-IB fueron: edad (64 vs. 58 años), infarto previo (17,9 vs. 8,1%), tiempo síntomas-primer ECG (120 vs. 90min), tiempo primer ECG-fibrinólisis (60 vs. 35min), tratamiento fibrinolítico (54,8 vs. 18,7%), pacientes sin reperfusión (45,9 vs. 9,2%), angioplastia primaria (1,0 vs. 92,0%). La mortalidad a los 28 días fue inferior en el CI-IB (12,2 vs. 7,2%; hazard ratio 0,560; IC 95% 0,360-0,872; p = 0,010). CONCLUSIÓN: La mortalidad a los 28 días en el síndrome coronario agudo con elevación de ST en Mallorca ha disminuido en la última década, probablemente debido a un mayor tratamiento de reperfusión con angioplastia primaria y a una reducción de los tiempos de reperfusión

OBJECTIVE: To investigate the differences in mortality at 28 days and other prognostic variables in 2 periods: IBERICA-Mallorca (1996-1998) and Infarction Code of the Balearic Islands (IC-IB) (2008-2010). DESIGN: Two observational prospective cohorts. SETTING: Hospital Universitario Son Dureta, 1996-1998 and 2008-2010. PATIENTS: Acute coronary syndrome with ST elevation of≤24h of anterior and inferior site. Main variables of interest: Age, sex, cardiovascular risk factors, site of AMI, time delays, reperfusion therapy with fibrinolysis and primary angioplasty, administration of acetylsalicylic acid, beta blockers and angiotensin converting enzyme inhibitors. Killip class, malignant arrhythmias, mechanical complications and death at 28 days were included. RESULTS: Four hundred and forty-two of the 889 patients included in the IBERICA-Mallorca and 498 of 847 in the IC-IB were analyzed. The site and Killip class on admission were similar in both cohorts. The main significant difference between IBERICA and IC-IB group were age (64 vs. 58 years), prior myocardial infarction (17.9 vs. 8.1%), the median symtoms to first ECG time (120 vs. 90min), median first ECG to fibrinolysis time (60 vs. 35min), fibrinolytic therapy (54.8 vs. 18.7%), patients without revascularization treatment (45.9 vs. 9.2%), primary angioplasty (1.0% vs. 92.0%). The mortality at 28 days was lower in the IC-IB (12.2 vs. 7.2%; hazard ratio 0.560; 95% CI 0.360-0.872; P=.010). CONCLUSION: The 28-day mortality in acute coronary syndrome with ST elevation in Mallorca has declined in the last decade, basically due to increased reperfusion therapy with primary angioplasty and reducing delays time to reperfusion

Comparative analysis between 2 periods of acute myocardial infarction after a decade in Mallorca. IBERIA Study (996-1998) and Infarction-Code (2008-2010). / Análisis comparativo de 2 registros de infarto agudo de miocardio tras una década de cambios. Estudio IBERICA (1996-1998) y Código Infarto-Illes Balears (2008-2010).

OBJECTIVE: To investigate the differences in mortality at 28 days and other prognostic variables in 2 periods: IBERICA-Mallorca (1996-1998) and Infarction Code of the Balearic Islands (IC-IB) (2008-2010). DESIGN: Two observational prospective cohorts. SETTING: Hospital Universitario Son Dureta, 1996-1998 and 2008-2010. PATIENTS: Acute coronary syndrome with ST elevation of≤24h of anterior and inferior site. MAIN VARIABLES OF INTEREST: Age, sex, cardiovascular risk factors, site of AMI, time delays, reperfusion therapy with fibrinolysis and primary angioplasty, administration of acetylsalicylic acid, beta blockers and angiotensin converting enzyme inhibitors. Killip class, malignant arrhythmias, mechanical complications and death at 28 days were included. RESULTS: Four hundred and forty-two of the 889 patients included in the IBERICA-Mallorca and 498 of 847 in the IC-IB were analyzed. The site and Killip class on admission were similar in both cohorts. The main significant difference between IBERICA and IC-IB group were age (64 vs. 58 years), prior myocardial infarction (17.9 vs. 8.1%), the median symtoms to first ECG time (120 vs. 90min), median first ECG to fibrinolysis time (60 vs. 35min), fibrinolytic therapy (54.8 vs. 18.7%), patients without revascularization treatment (45.9 vs. 9.2%), primary angioplasty (1.0% vs. 92.0%). The mortality at 28 days was lower in the IC-IB (12.2 vs. 7.2%; hazard ratio 0.560; 95% CI 0.360-0.872; P=.010). CONCLUSION: The 28-day mortality in acute coronary syndrome with ST elevation in Mallorca has declined in the last decade, basically due to increased reperfusion therapy with primary angioplasty and reducing delays time to reperfusion.

Biphasic response to dobutamine predicts improvement of left ventricular dysfunction after revascularization: correlation with positron emission and rest-redistribution 201Tl tomographies.

BACKGROUND: Dobutamine echocardiography (DSE), positron emission tomography (PET) and 201Tl-single photon emission computed tomography (SPECT) have been used to identify myocardial viability. There are few reports, however, that compare high doses DSE with myocardial metabolic and perfusion imaging techniques in the same patient population. The aim of this study was to determine the correlation between high doses DSE, metabolic PET and 201Tl-SPECT imaging to predict the recovery of function after revascularization in patients with severe left ventricular (LV) dysfunction. METHODS: Twenty-five patients underwent DSE (up to 40 microg/kg/min), rest and 4-hour redistribution 201Tl SPECT, rest 13N-ammonia and 18fluoro-deoxy-glucose PET imaging and coronary angiography 7-10 days before surgical revascularization. A follow-up 2D-echocardiography was performed 6 weeks after surgery. RESULTS: Of the 109 successfully revascularized segments with severe dysfunction, 62 (57%) improved. LV ejection fraction increased from 30 +/- 10% to 42 +/- 13 at follow-up (p < 0.05). 201Tl SPECT, PET and the presence of contractile reserve determined by DSE had a similar sensitivity (77-87%) to predict recovery of function, but specificity was higher for the PET mismatch pattern and biphasic DSE (85-89%) than for any of the 201Tl viability patterns (19-64%). The highest positive predictive values were obtained by biphasic DSE and PET mismatch pattern (78-79%) compared to all other criteria (54-67%). In a multivariate model, which included evidence of viability by all imaging modalities, biphasic response was the best predictor of regional recovery of function (Odds ratio, OR: 9.9, 95% confidence intervals, 95% CI: 3.5-27.8). CONCLUSIONS: Although DSE and PET had overall comparable results, the presence of contractile reserve by the biphasic response to dobutamine was a best predictor for the improvement of LV contractile function in this group of patients.

[Thallium-201 scintigraphy and dobutamine echocardiography in the assessment of myocardial viability]. / Gammagrafía con talio-201 y ecocardiografía con dobutamina en la valoración de viabilidad miocárdica.

BACKGROUND: The possibility of differentiating viable from non-viable tissue among patients with severe coronary artery disease and severe left ventricular impairment entails relevant clinical and therapeutic implications since it may influence the indication of patient revascularization. To evaluate the presence of myocardial viability two techniques are available in the clinical setting: echocardiography with intravenous infusion of dobutamine and scintigraphy with myocardial perfusion with thalliem-201 by means of single-photon emission tomography. OBJECTIVE: To compare prospectively the value of these techniques for detecting viable myocardium. MATERIAL AND METHODS: Thirty-five patients with severe coronary disease and severe left ventricular dysfunction were included in the study. All patients underwent an echocardiogram using incremental doses of dobutamine, from 5 up to 40 micrograms/kg/min in three-minute periods. For thallium-201 scintigraphy the rest redistribution protocol with delayed images at 4 hours was used. The criteria for detecting viability were: a) for thallium-201, the presence of redistribution in delayed images and normal uptake at rest, and b) for dobutamine echocardiography, a sustained improvement in regional motion, biphasic response, and worsening. RESULTS: By considering the segmental improvement post-revascularization as "gold standard" of viability, the statistically significant variables in a logistic regression model and, therefore, predictors of segmental functional recovery were the biphasic response and the sustained response for dobutamine echocardiography and normal uptake at rest and redistribution in the delayed images for thallium-201. Taken together, the result was significant for the biphasic response of dobutamine echocardiography. CONCLUSIONS: The biphasic response with dobutamine echocardiography is the echocardiographic pattern that best predicts the functional recovery of the ischemic myocardium. A normal uptake and redistribution at four hours is the only scintigraphic pattern that can predict functional improvement. Of both patterns, the biphasic response is the best predictor of the functional recovery of the dysfunctional myocardium.

Gammagrafía con talio-201 y ecocardiografía con dobutamina en la valoración de viabilidad miocárdica / Thallium-201 scintigraphy and dobutamine echocardiography in the assessment of myocardial viability

Introducción y objetivo. La posibilidad de diferenciar el tejido viable del no viable en pacientes con enfermedad coronaria severa y disfunción ventricular izquierda tiene implicaciones clínicas y terapéuticas importantes, pues puede influir en la indicación de revascularización del paciente. Para poder evaluar la presencia de viabilidad miocárdica disponemos en la práctica clínica de dos técnicas: la ecocardiografía con infusión intravenosa de dobutamina y la gammagrafía de perfusión miocárdica con talio-201 mediante tomografía por emisión de fotón único. El objetivo de este estudio fue comparar de forma prospectiva el valor de estas dos técnicas en la detección de miocardio viable. Material y métodos. Se incluyeron en el estudio 35 pacientes con enfermedad coronaria y disfunción ventricular severa. A todos ellos se les realizó una ecocardiografía utilizando dosis progresivas de dobutamina desde 5 hasta 40 µg/kg/min en estadios de tres minutos. Para el talio-201 se escogió el protocolo de reposo-redistribución con imágenes tardías a las cuatro horas. Los criterios para la detección de viabilidad fueron: para el talio-201, presencia de redistribución en las imágenes tardías y la captación normal en reposo; para la ecocardiografía con dobutamina, mejoría mantenida del movimiento regional, respuesta bifásica y el empeoramiento. Resultados. Considerando como patrón oro de viabilidad la mejoría segmentaria postrevascularización, las variables que resultaron estadísticamente significativas en un modelo de regresión logística y, por tanto, predictoras de la recuperación funcional segmentaria fueron para la ecocardiografía dobutamina la respuesta bifásica y la respuesta mantenida y para el talio-201 la captación normal en reposo y redistribución en las imágenes tardías. Cuando valoramos estos patrones juntos el resultado fue significativo para la respuesta bifásica de la ecocardiografía con dobutamina. Conclusiones. La respuesta bifásica de la ecocardiografía con dobutamina es el patrón ecocardiográfico que mejor predice la recuperación funcional del miocardio isquémico. La captación normal y redistribución a las cuatro horas es el único patrón gammagráfico con capacidad de predecir mejoría funcional. De los dos patrones, la respuesta bifásica es la que mejor predice la recuperación funcional del miocardio disfuncionante (AU)

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[Comparison of dobutamine echocardiography and rest-redistribution 201-thallium SPECT in the assessment of myocardial viability taking PET as gold standard]. / Comparación entre la eco-dobutamina y talio-201 SPECT reposo-redistribución en la valoración de la viabilidad miocárdica considerando el PET como patrón oro.

BACKGROUND AND AIM: To compare Tl-201 SPECT and dobutamine stress echocardiography for the detection of myocardial viability in patients with severe left ventricular dysfunction using metabolic imaging by positron emission tomography as the standard reference. MATERIAL AND METHODS: We studied 25 consecutive patients with severe coronary artery disease and left ventricular dysfunction that underwent two different diagnostic modalities for evaluating myocardial viability: stress echocardiography with incremental doses of dobutamine from 5 up to 40 g/kg/min in 3 min stages, and 201 Tl SPECT using a rest-redistribution protocol with delayed images obtained at 4 hours. Fluorodeoxyglucose uptake by PET was used as the gold standard. Viability criteria were as follows, for 201Tl SPECT imaging: normal uptake at rest and presence of redistribution in the delayed images, for dobutamine stress echocardiography: sustained improvement and biphasic response. RESULTS: Sensitivity of thallium redistribution was 46%, for normal uptake, plus redistribution 82%, 34% for dobutamine biphasic response and 58% for sustained improvement plus biphasic response. Specificity of biphasic response was 82% and that of redistribution 67%. Stepwise logistic regression indicated that biphasic wall motion response during dobutamine stress echocardiography (2.01 CI 95%; 1.10 to 3.99) and the presence of redistribution plus normal uptake at rest with thallium imaging (2.68 CI 95%; 1.42 to 5.13) were the best predictors of viability. These results were the same when both techniques were analyzed together. CONCLUSIONS: Biphasic wall motion response during dobutamine stress echocardiography and the normal uptake plus presence of redistribution with thallium imaging were the best pre

Clinical, anatomic, and echocardiographic characteristics of aneurysms of the mitral valve.

This study describes the clinical, anatomic, echocardiographic, and Doppler features of 13 patients with mitral valve aneurysms. Eleven patients had definitive criteria for infective endocarditis. Transesophageal echocardiography was superior to conventional echocardiography in detecting and assessing aneurysms. Patients with heart failure required surgery. Echocardiographic detection of this lesion should not be, by itself, an immediate surgical indication.

[Early percutaneous revascularization in patients with unstable angina. Current results and comparison with conservative medical treatment]. / Revascularización precoz percutánea en los pacientes con angina inestable. Resultados actuales y comparación con el tratamiento médico conservador.

In patients with ongoing angina, despite optimal medical therapy, the best therapeutic alternative is coronary angiography followed by emergency coronary revascularization with surgery or angioplasty. However, whether or not all patients should have early angiography and revascularization is a matter of debate. This paper reviews the advantages of modern medical therapy in this setting and the problems associated with early coronary revascularization. In particular, it analyses the data from the main clinical trials that have specifically compared an early invasive procedure with a conservative strategy in unstable coronary syndromes. Finally, it assesses the impact of the new antithrombotic agents, such as glycoprotein IIb/IIIa receptor blockers, particularly during coronary percutaneous interventions. The data reviewed suggest that early invasive intervention should be reconsidered, and that patients should be controlled (if possible) under medical treatment until non invasive stratification tests allow the identification of those patients who would benefit most from revascularization.

Arteriovenous fistula as a complication of lumbar disc surgery: case report.

Arteriovenous fistula (AVF) is a rare, late complication of lumbar disc surgery. It is often not suspected and the symptoms are diagnosed as heart failure or deep venous thrombosis. We report a case in which the patient developed leg swelling and high-output congestive heart failure due to a left ilioiliac AVF after lumbar laminectomy.

Prevalence and relevance of a septal diastolic notch during dobutamine stress echocardiography.

BACKGROUND: Dobutamine stress echocardiography has become an accepted simple and inexpensive method of detecting coronary artery disease. In this pharmacological stress test, particular attention has been paid to transient systolic wall motion abnormalities. Our group has noted an abnormal diastolic ventricular septal motion, a 'diastolic notch', during dobutamine stress echocardiography that has not been previously described. METHODS AND RESULTS: To find out whether this anomalous septal motion is related to coronary artery disease we have analysed the stress studies of 125 patients (69 men, age 61 +/- 9 years) with chest pain, no previous myocardial infarction and no left bundle branch block, who underwent a dobutamine stress test. Dobutamine was infused up to 40 mu.kg.l-1 min-1 in 3 min stages. A positive stress test was defined as the appearance of transient asynergy. Dobutamine time was the time from the infusion of dobutamine to the appearance of transient asynergy. The diastolic notch time was the time at which diastolic notch was first detected. Diastolic notch was detected in 21 patients with single coronary artery disease, 19 of whom had a severe left anterior descending artery stenosis. Diastolic notch was present in 19 out of 27 patients (70%) with single left anterior descending stenosis. Twenty-six out of 44 patients with multivessel coronary artery disease had evidence of a diastolic notch and 20 of these 26 had severe stenosis of the left anterior descending artery. Finally, all three patients with left main coronary artery disease had a diastolic notch while no patient with angiographically normal coronary arteries had this sign. In patients with a diastolic notch and a positive dobutamine stress test, diastolic notch time was shorter than dobutamine time (9 +/- 4 min vs 11 +/- 3 min, P < 0.05). CONCLUSIONS: In patients without previous myocardial infarction and without left bundle branch block (1) the appearance of a septal diastolic notch during dobutamine stress echocardiography is very specific for the presence of coronary artery disease; (2) the detection of diastolic notch is mostly related to the existence of severe left anterior descending artery stenosis; (3) diastolic notch precedes the development of ventricular asynergy.

[Elective noninvasive test in the diagnosis of coronary disease in the aged]. / Prueba no invasiva de elección en el diagnóstico de enfermedad coronaria en el anciano.

BACKGROUND AND PURPOSE: The purpose of this study was to determine the best noninvasive test to diagnose coronary artery disease in the elderly. PATTERNS AND METHODS: We conducted a study on 56 elderly patients (> 65 years) with chest pain and no previous history of coronary artery disease. They underwent exercise stress test, dipyridamole echocardiography (0.84 mg/kg), dobutamine echocardiography (up to a total dose of 40 microgram/kg/min and atropine when it was necessary), dobutamine MIBI-SPECT and coronary angiography. RESULTS: Angiography detected significant coronary artery disease in 41 patients. All tests used in this study had a similar sensitivity (conclusive exercise stress test 87%, dipyridamole echocardiography 83%, dobutamine echocardiography 80% and MIBI-SPECT 87%; p = NS). Coronary angiography did not identify significant lesions in 15 patients. Specificity of conclusive exercise stress test, dipyridamole and dobutamine echocardiography was similar (75%, 100% and 93% respectively; p = NS). However, the specificity of stress echocardiography was higher than that of scintigraphy (100% vs 66%; p = 0.02 for dipyridamole echocardiography and 93% vs 66%; p = 0.07 for dobutamine echocardiography). Diagnostic accuracy of each test was similar. CONCLUSIONS: Exercise stress test remains the non invasive diagnostic test of choice to detect coronary disease in the elderly. If this test is inconclusive, both stress echocardiography and isotopic studies are useful, although the specificity of stress echocardiography is higher than that of scintigraphy.

[MIBI-echocardiography with dobutamine: Significance of changes of contractility in patients with changes in perfusion]. / Ecocardiografía-MIBI con dobutamina: significado de las alteraciones de la contractilidad en pacientes con alteraciones de la perfusión.

BACKGROUND AND OBJECTIVES: In the presence of coronary artery disease and with an appropriate stressor, perfusion defects precede contractility abnormalities. Perfusion defects without contractility abnormalities may be due to the absence of ischemia or mild ischemia. Our purpose has been to compare the clinical characteristics, hemodynamic response and severity of perfusion defects in patients with coronary artery disease and perfusion defects with and without wall motion abnormalities during dobutamine infusion. PATIENTS AND METHODS: Eighty two patients with significant coronary artery disease demonstrated by angiography without previous myocardial infarction underwent dobutamine infusion (up to 40 mg/kg/min). Atropine was given when necessary. Stress scientigraphic MIBI-SPECT images were acquired 1 hour after peak stress and rest studies were obtained 24 hours after stress testing. The perfusion score was calculated by dividing the total uptake score between the number of segments affected. RESULTS: Among the 73 patients with perfusion defects, stress echocardiography was positive in 59 (Group A) and was negative in the remaining 14 (Group B). There were more hypertensive patients in Group A (33 vs 4; p = 0.04). There was no significant difference between the two groups with respect to other clinical characteristics. The peak rate-pressure product was similar in both groups (18.520 +/- 5.691 vs 18.680 +/- 5.329; p = NS). The development of electric abnormalities and angina was more common in Group A (42 vs 3, p < 0.001 and 33 vs 1; p < 0.001). Perfusion defects were not more extensive in Group A (abnormal segments 2.15 vs 2.21; p = NS) but they were more severe (segments with severe uptake reduction or no uptake 1.10 vs 0.28; p < 0.05; perfusion score 2.62 vs 2.21; p < 0.05). CONCLUSION: In patients with severe coronary artery disease and perfusion defects during dobutamine-MIBI-SPECT, the presence of wall motion abnormalities defines patients with more severe perfusion defects.

Selection of the optimal stress test for the diagnosis of coronary artery disease.

OBJECTIVE: To compare the value and limitations of exercise testing, dipyridamole echocardiography, dobutamine-atropine echocardiography, and MIBI-SPECT (technetium-99m methoxyisobutyl nitrile single photon emission computed tomography) during dobutamine infusion in the diagnosis of coronary artery disease. DESIGN: The performance of these four tests was assessed in random order on a consecutive cohort of patients. The presence or absence of coronary artery disease was confirmed by coronary angiography. SETTING: Two tertiary care and university centres. PATIENTS: 102 consecutive patients with chest pain and no previous history of coronary artery disease. Ten patients with left bundle branch block were excluded for further analysis of exercise testing and scintigraphy results. RESULTS: MIBI-SPECT was the most sensitive (87%) but the least specific test (70%). Exercise stress testing had a sensitivity of 66%, which increased to 80% when patients with inconclusive results were excluded. Dipyridamole and dobutamine echocardiography had similar sensitivity (81%, 78%) and specificity (94%, 88%). All four tests had similar accuracy and positive and negative predictive values. Agreement between the echocardiographic techniques was excellent (detection of coronary artery disease 87%, kappa = 0.72; regional analysis 93%, kappa = 0.72; diagnosis of the "culprit" vessel 95%, kappa = 0.92), and it was good between echocardiographic techniques and MIBI-SPECT (diagnosis of the culprit vessel 90%, kappa = 0.84 with dobutamine and 92%, kappa = 0.85 with dipyridamole). CONCLUSIONS: Exercise stress testing has a sensitivity comparable to other tests in patients capable of exercising and with no basal electrical abnormalities. The greatest sensitivity is offered by MIBI-SPECT and the greatest specificity is obtained with stress echocardiography. Redundant information is obtained with dipyridamole echocardiography, dobutamine echocardiography, and MIBI-SPECT.

Natural history and serial morphology of aortic intramural hematoma: a novel variant of aortic dissection.

BACKGROUND: Acute aortic dissection is a cardiovascular emergency that requires prompt diagnosis and treatment. Transesophageal echocardiography is the current standard diagnostic imaging modality in many medical centers. Aortic intramural hematoma is a variant of aortic dissection whose natural history and prognosis have not been well studied. We performed transesophageal echocardiography in patients with aortic intramural hematoma to determine the echocardiographic characteristics and echocardiographic evolution of this lesion, impact on patient management, and patient outcome. METHODS AND RESULTS: Twenty-one consecutive patients with aortic intramural hematoma confirmed anatomically (four patients) or with an additional diagnostic imaging technique (17 patients) underwent a transesophageal echocardiographic examination. Fifteen patients with longstanding hypertension had chest or back pain, and the intramural hematoma was visualized in the ascending aorta (n = 4), along the whole aorta (n = 4), in the descending aorta (n = 6), or in the aortic arch (n = 1). The thickening of the aortic wall was crescentic. Patients with ascending aortic intramural hematoma had the following results: two patients died suddenly, three patients underwent surgery because of increased aortic wall thickening (one patient) or secondary intimal tear (two patients), and the remaining three patients had regression of the hematoma. Patients with hematoma confined to the descending aorta and the patient with aortic arch involvement (n = 7) had a different result: one patient died from aortic rupture and the remaining six patients did well. Six patients had a traumatic aortic injury, and the intramural hematoma was located along the descending thoracic aorta. The thickening of the aortic wall was circular in five patients and crescentic in one. Three of these patients had normalized thickness of the aortic wall on follow-up transesophageal echocardiographic studies. The other three patients died from multiorgan system failure. Aortography showed a reduction of the diameter of the aortic lumen in four patients; diameter in the remaining 17 patients was normal. CONCLUSIONS: Aortic intramural hematoma can be detected and monitored by transesophageal echocardiography but not by aortography. Two types of aortic intramural hematoma can be distinguished: (1) traumatic of good prognosis and (2) nontraumatic, which can be an early stage of the classic aortic dissection, with bad prognosis in cases involving the ascending aorta.

Retrograde atrial kick in acute aortic regurgitation. Study of mitral and pulmonary venous flow velocities by transthoracic and transesophageal echocardiography.

BACKGROUND AND HYPOTHESIS: The purpose of this study was the comprehensive evaluation of the changes in pulmonary venous and mitral flow velocities of patients with acute and chronic severe aortic regurgitation. Transmitral flow velocities obtained with pulsed-wave Doppler echocardiography have been used to provide information on left ventricular (LV) filling and diastolic function. Pulmonary venous flow tracings are an important adjunct to LV inflow pattern in assessing LV diastolic function. METHODS: Fourteen patients with severe aortic regurgitation (8 chronic and 6 acute) and in sinus rhythm were examined by transthoracic and transesophageal pulsed Doppler echocardiography. Mitral and pulmonary flow velocities were recorded and compared. All patients had ejection fractions > 40%. RESULTS: Early mitral flow peak velocity was higher in patients with acute regurgitation (p < 0.001). The mitral A wave was absent in five patients with acute regurgitation. In contrast, a prominent reverse atrial pulmonary systolic wave AR was demonstrated in these patients. Peak diastolic velocity of the pulmonary venous flow was greater in patients with acute aortic regurgitation (0.76 +/- 0.13) than in patients with chronic aortic regurgitation (0.40 +/- 0.09) (p < 0.001). Peak systolic velocity did not differ significantly between the two groups. The systolic fraction of pulmonary venous flow in patients with acute aortic regurgitation was lower (0.43 +/- 0.05) than that of patients with chronic regurgitation (0.63 +/- 0.1) (p < 0.01). All patients with acute aortic regurgitation had an S/D ratio < 1, while those with chronic regurgitation had an S/D > 1 (p < 0.001) and an E/A < 1. CONCLUSION: Patients with severe acute aortic regurgitation showed a retrograde atrial kick (absence of transmitral A wave with prominent pulmonary AR wave). These patients had an S/D ratio < 1 (restrictive Doppler pattern). Patients with chronic aortic regurgitation exhibited a Doppler pattern of abnormal LV relaxation (E/A < 1, S/D > 1).

Dipyridamole and dobutamine-atropine stress echocardiography in the diagnosis of coronary artery disease. Comparison with exercise stress test, analysis of agreement, and impact of antianginal treatment.

STUDY OBJECTIVES: To compare the usefulness of dipyridamole echocardiography, dobutamine-atropine echocardiography, and exercise stress testing in the diagnosis of coronary artery disease and to analyze the agreement among the tests. DESIGN: Performance of these three tests in random order on a consecutive cohort of patients. SETTING: A tertiary care and university center. PATIENTS: One hundred two consecutive patients with chest pain and no history of coronary artery disease. INTERVENTIONS: Dipyridamole echocardiography, dobutamine-atropine echocardiography, exercise stress testing, and coronary angiography. MEASUREMENTS AND RESULTS: Dobutamine-atropine test was positive in 49 (77%) of 63 patients with coronary artery disease, dipyridamole test in 49 (77%), and exercise stress test in 44 (68%; p = NS). Both echocardiographic tests showed an overall specificity (dipyridamole, 97%; dobutamine, 95%) higher than exercise stress test (79%; p < 0.05). Sensitivity of dipyridamole testing decreased from 93 to 61% (p = 0.002) if patients were receiving antianginal treatment but sensitivity of dobutamine-atropine testing was not affected (77% in patients receiving and not receiving treatment). When results were considered as positive-negative, agreement between dipyridamole and dobutamine-atropine echocardiography was 85% (kappa = 0.70). With regards to regional analysis, concordance was good (93% for segments, kappa = 0.76; and 95% for coronary arteries, kappa = 0.92). Major complications were more frequent during dobutamine-atropine (n = 7) than during dipyridamole infusion (n = 2) (p = 0.06). CONCLUSIONS: Dobutamine-atropine and dipyridamole echocardiography have a similar sensitivity and a higher specificity than that obtained by exercise ECG for the diagnosis of coronary artery disease. Similar information is obtained with dipyridamole and dobutamine-atropine echocardiography. It is our thought that pharmacologic stress echocardiography should be used as a first-step test to rule out coronary artery disease in patients not capable of exercising.

[Echocardiography with dobutamine in hypertensive patients with chest pain]. / Ecocardiografía con dobutamina en pacientes hipertensos con dolor torácico.

INTRODUCTION: The exercise stress test shows limited diagnostic accuracy for the detection of coronary artery disease in hypertensive patients. Echocardiography with dobutamine is a useful tool in the assessment of coronary artery disease. PURPOSE: Our purpose has been to compare dobutamine stress echocardiography and exercise stress test for diagnosing coronary disease in hypertensive patients. MATERIAL AND METHODS: Dobutamine stress echocardiography (administered up to 40 micrograms/kg/min, and atropine when necessary), exercise stress test and coronary arteriography were performed on 74 hypertensive patients with chest pain and no previous history of coronary artery disease. RESULTS: Forty-eight (65%) patients underwent a diagnostic exercise stress test and 66 (89%) a diagnostic dobutamine stress echocardiography. Coronary artery disease (> or = 70% stenosis in, at least, one major vessel) was demonstrated in 28 (58%) patients who underwent a diagnostic exercise stress test, and in 39 (59%) patients who completed a dobutamine stress echocardiography. Sensitivity for exercise stress test was 82%, and 79% for dobutamine stress echocardiography (p = NS). Specificity was higher for dobutamine stress echocardiography (100% vs 60%; p < 0.005). CONCLUSIONS: Dobutamine stress echocardiography has high sensitivity and specificity for the detection of coronary artery disease in hypertensive patients. Dobutamine stress echocardiography has higher feasibility and specificity than exercise stress test in this group of patients.

[Identification of intramural aortic hematoma by transesophageal echocardiography]. / Identificación del hematoma intramural aórtico por ecocardiografía transesofágica.

BACKGROUND AND AIM: The usefulness of transesophageal echocardiography in the diagnosis and assessment of patients with aortic dissection has been widely demonstrated. The aim of this study was to evaluate the role of this technique in the detection of intramural aortic hematoma and in the follow-up of these patients. METHODS: The records of 51 patients with aortic dissection by transesophageal echocardiography diagnosed between May 1990 and May 1994 were reviewed. RESULTS: The diagnosis of intramural aortic hematoma was established in 6 patients by transesophageal echocardiography (11%). This diagnosis was confirmed either anatomically (3 patients) or with an additional diagnostic technique (computed tomography or magnetic resonance imaging) and on the basis of echocardiographic follow-up changes (3 patients). CONCLUSIONS: Intramural aortic hematoma represents an infrequent variant of aortic dissection that can be detected by transesophageal echocardiography and is usually unrecognized by aortography.

[Morphological and quantitative analysis of the mechanism of balloon angioplasty. An intravascular ultrasonic study]. / Análisis morfológico y cuantitativo del mecanismo de angioplastia con balón. Estudio con ecografía intravascular.

BACKGROUND AND OBJECTIVES: Intracoronary ultrasound allows to study in vivo the morphology of the arterial wall, the presence and composition of atheroma and the associated lumen encroachment. The objective of our study was to assess the value of intravascular ultrasound to determine the dilatation mechanism after a conventional balloon angioplasty. PATIENTS AND METHODS: Sixteen patients were examined with intravascular ultrasound before and after they had undergone percutaneous transluminal coronary angioplasty. A mechanical intravascular ultrasound system was used. Two different types of imaging catheters were used in this study: a 20 MHz, 4.8 F catheter in 5 patients and a 30 MHz, 3.5 F in 11 patients. RESULTS: Quantitative and qualitative assessments were made from the angiograms and the ultrasound images. Seven out of 16 patients had a calcified plaque, in 8 patients the plaque was fibrotic and in 1 patient soft. Rupture of the plaque was the most common dilatation pattern. Post-PTCA the cross-sectional arterial area was increased from 15.3 +/- 5.2 mm2 to 17.3 +/- 6.2 mm2, the intraluminal area was increased from 2.7 +/- 2.5 mm2 to 7.3 +/- 3.4 mm2, and the plaque area was reduced from 12.3 +/- 4.8 mm2 to 9.7 +/- 3.4 mm2. The quantitative analysis showed that the "most frequent dilatation mechanism" found was the reduction of size plaque, an increase in cross-sectional arterial area was present in only 4 patients (25%). The incidence of depth rupture of the plaque was greater in patients with a calcified plaque than in those without (NS). CONCLUSIONS: 1). Intracoronary ultrasound provides a complete description of plaque composition and geometry before and after coronary balloon angioplasty; 2) several morphologic dilatation patterns were found, and plaque tearing was the most common, and 3) increase in luminal area was most frequently due to a reduction in plaque area. Nevertheless an increase in the cross-sectional arterial area was also common, but less important.