Using mitral 'annulus reversus' to diagnose constrictive pericarditis.

AIMS: To characterize mitral medial and lateral annular velocities in constrictive pericarditis or restrictive cardiomyopathy compared with normal subjects. METHODS AND RESULTS: Tissue Doppler imaging peak systolic velocity (S'), peak early diastolic annular velocity (e'), and timing difference between mitral early flow and early annular movement were measured in 14 patients with constrictive pericarditis, 10 with restrictive cardiomyopathy, and 17 normal subjects using the apical four-chamber view lateral and medial mitral annulus. In controls, mitral lateral e' velocity was 25% higher than medial e' velocity (13.0 +/- 3.1 vs. 10.7 +/- 2.8 cm/s; P = 0.02), whereas with constrictive pericarditis, averaged lateral e' velocity was 2% lower than medial e' velocity (10.7 +/- 2.5 vs. 11.2 +/- 3.1 cm/s; P > 0.05). This relationship represented a reversal of lateral and medial e' velocities compared with normal subjects (P = 0.004). Differences in S', E/e', and timing intervals between normal subjects and patients with constrictive pericarditis were not statistically significant; however, restrictive cardiomyopathy could be distinguished from constrictive pericarditis and controls with all other parameters (S', E/e', medial and lateral e' velocities, and timing interval differences; all P < 0.05). CONCLUSION: Practical applications of tissue Doppler imaging for evaluation of possible constrictive pericarditis include reversal of the relationship between lateral and medial e' velocities (i.e. 'annulus reversus').

Preoperative dobutamine stress echocardiographic findings and subsequent short-term adverse cardiac events after orthotopic liver transplantation.

Cardiovascular (CV) complications are the leading cause of non-graft-related death in orthotopic liver transplant (OLT) patients. Pretransplant cardiac evaluation using dobutamine stress echocardiography (DSE) is commonly utilized for risk stratification of OLT candidates. To determine if clinical and echocardiographic variables identify patients with increased CV risk, we performed a retrospective chart review of all 284 patients that underwent OLT at our institution between June 1999 and August 2005. Of these patients, 157 had a DSE prior to their OLT. Serious adverse CV events occurring during surgery and up to 4 months post-transplantation were defined as cardiac-related death, myocardial infarction (MI), new heart failure, or asystole or unstable ventricular arrhythmia requiring acute treatment. Sixteen of 157 patients (10%) had an adverse CV event with 2 deaths. These included ventricular tachycardia (n = 8), asystole (n = 2), MI (n = 5), and new heart failure (n = 1). Nine of the 16 CV events occurred at the time of surgery (including both deaths), 5 occurred postoperatively, and 3 occurred after hospital discharge. Variables that correlated with increased CV events were inability during DSE to achieve >82% of the maximum predicted heart rate (22% versus 6%, P = 0.01), a peak rate pressure product during DSE of <16,333 (17% versus 5%, P = 0.02), and a Model for End-Stage Liver Disease (MELD) score of >24 at the time of OLT. A multivariate model calculated from the DSE maximum achieved heart rate (MAHR) and MELD score (result = 3.78 + 0.07 MELD - 0.05 MAHR) identified a 47% risk for a value > 0 versus a 6% risk for a value < 0 (P < 0.001). In conclusion, the maximum heart rate achieved during DSE together with the MELD score may be a predictor of adverse CV events up to 4 months post-OLT. A large prospective study is needed to more decisively support this conclusion.

Effect of echocardiographic contrast on velocity vector imaging myocardial tracking.

BACKGROUND: Two-dimensional speckle tracking is an evolving ultrasound technology that allows objective evaluation of left ventricular function. The effect of echocardiographic contrast with 2-dimensional speckle tracking image processing is poorly defined. METHODS: A total of 11 patients undergoing clinically indicated transthoracic echocardiography who also required echocardiographic contrast for left ventricular endocardial border enhancement were prospectively studied. Offline velocity vector imaging analysis was performed to calculate global and regional longitudinal strain from the apical 4-chamber view while corresponding circumferential strain was obtained from the parasternal short-axis view at the papillary muscle level. Images were isochronally normalized and the systolic phase was studied precontrast and postcontrast opacification. RESULTS: Intraclass correlation coefficients were high for global circumferential strain in the short-axis view (0.77) and global longitudinal strain in the apical 4-chamber view (0.87) precontrast and postcontrast. Significant regional variability was present, more pronounced in the apical 4-chamber view (intraclass correlation coefficient 0.24-0.64) versus short-axis view (intraclass correlation coefficient 0.64-0.68). CONCLUSIONS: Velocity vector imaging is able to quantify global and regional strain with and without contrast. There is, however, wide interindividual variability in regional strain quantification with and without contrast, potentially limiting the clinical applicability.

Three methods for evaluation of left atrial volume.

AIM: To compare and contrast 3 different echocardiographic methods used to measure left atrial (LA) volume: biplane area length (AL), biplane modified Simpson (SIMP), and prolate ellipse (PE) methods. METHODS AND RESULTS: A review of consecutive patients who presented to our outpatient echocardiography laboratory for a resting transthoracic study between April 2006 and May 2006 was performed. Echocardiograms were reexamined and LA volume measured using the AL, SIMP, and PE methods. Of 102 consecutive patients evaluated, 97 had a measure of LA volume using all 3 methods. A significant difference in the measurement of mean +/- SD LA volume was noted among the 3 different methods: 37 +/- 16 mL/m(2) for AL, 34 +/- 14 mL/m(2) for SIMP, and 27 +/- 12 mL/m(2) for PE. The PE method yielded routinely smaller values compared with either the AL or SIMP method (P < 0.001). Differences increased with increased LA volume. The SIMP method derived consistently smaller (<5 mL/m(2)) values than those of the AL method, consistent across the full range of LA volumes. CONCLUSION: Significant differences exist among these 3 commonly used methods for measuring LA volume. Standardization of the measurement of LA volume is recommended.

Isolated left ventricular basal ballooning phenotype of transient cardiomyopathy in young women.

This report describes a variant of transient regional left ventricular dysfunction in which isolated basal left ventricular akinesia with normal mid-ventricular (papillary-level) wall motion and apical hypercontractility were noted in young women (mean age 31 years). This finding was demonstrated in 3 consecutive patients; the first patient was experiencing emotional life-altering events, and the second presented with an acute flare of multiple sclerosis. The third patient presented < 24 hours after methamphetamine use. Coronary angiography demonstrated normal epicardial coronary arteries in all patients. Wall motion abnormalities resolved within 2 to 6 weeks. In conclusion, the entity described in this report is reminiscent of apical ballooning ("Tako-Tsubo"), mid-ventricular ballooning, and apical sparing syndromes; however, isolated basal left ventricular involvement has not been previously described and is a newer variant in the spectrum of transient cardiomyopathies. The pathophysiology of this entity has not been elucidated. A unifying feature between the transient cardiomyopathic syndromes most likely is in the concentration, distribution, and activity of cardiac adrenergic receptors.

Esophageal overtube facilitation of transesophageal echocardiography in patients with previously difficult esophageal intubation.

BACKGROUND: In upper endoscopy, overtubes protect the hypopharynx and esophagus in patients requiring multiple esophageal intubations. Transesophageal echocardiography (TEE) is frequently used in general cardiology practice to provide high-resolution, real-time images of cardiac structures that are often not visualized by transthoracic imaging alone. Patients with a history of esophageal disorders or difficult esophageal intubations may have increased risk for complications from the echoprobe. An esophageal overtube may facilitate TEE in such patients. OBJECTIVE: We sought to evaluate the usefulness of upper endoscopy with placement of an esophageal overtube to facilitate TEE in patients with prior difficult esophageal intubations. METHODS: We performed upper endoscopy, followed by placement of an esophageal overtube, in 4 patients who had an unsuccessful intubation with the TEE probe. The endoscopic procedures were successfully completed, thus, allowing for uneventful subsequent TEE. CONCLUSIONS: Upper endoscopy with placement of an esophageal overtube may allow for safe successful completion of TEE in patients with previously unsuccessful blind esophageal intubation.

Transient midventricular ballooning syndrome: a new variant.

We describe a new variant of transient left ventricular (LV) ballooning in North American Caucasian patients in which only the midventricle is affected. The patients described in this case series initially presented with emotional or physical stress and had similarities to transient apical ballooning syndrome; however, this variant is unique in that the transient ballooning involves the midventricle with hypercontractility of the apical and basal segments. The presentation, clinical features, and transient nature of the reported cases in this series are similar to transient LV apical ballooning and suggest a shared pathophysiologic etiology. Sparing of the apical segment with involvement of midventricle only supports etiologies not related to an epicardial coronary artery distribution. Although the pathophysiologic mechanism of the transient ventricular ballooning syndromes and other cases of catecholamine-associated transient ventricular dysfunction are not well understood, the emergence of this new variant raises further questions in the understanding of the "brain-heart" relationship.

Doppler tissue imaging during supine and upright exercise in healthy adults.

Doppler tissue imaging variables were measured in 18 healthy men and women during supine bicycle stress exercise and upright exercise treadmill testing. From a color Doppler tissue imaging cineloop, tissue velocities in basal and mid segments of the standard 3 apical views during rest and peak exercise were assessed. Compared segments were adjusted for double product, and peak variables were compared using the paired t test. Peak systolic velocity and strain rate increased with both forms of exercise (P < .03). Time to compression-expansion crossover shortened in all segments with exercise and at peak exercise treadmill testing versus peak supine bicycle stress exercise (P < .03). Of all segments, 81% were analyzable for peak systolic velocity, 79% for strain rate. Doppler tissue imaging is a feasible tool for quantitatively assessing left ventricular response to supine and upright exercise.

Endocarditis caused by Coccidioides species.

Endocarditis caused by Coccidioides species has been reported rarely. Herein, we report 2 such cases and summarize 4 published reports. Coccidioidal endocarditis was found in patients who had prolonged or disseminated infection. Vegetations were identified on mitral or aortic valves or valvular rings, and embolic phenomena were observed. Diagnosis was hindered by uniformly negative results from blood cultures. The patients had a wide range of serologic titers for Coccidioides species (1:1-1:2048). The infection was fatal in 4 of the 6 patients whose cases we reviewed. We conclude that coccidioidal endocarditis is an uncommon manifestation of Coccidioides infection that connotes a poor prognosis.