Usefulness and limitations of dobutamine-atropine stress echocardiography for the diagnosis of coronary artery disease in patients with left bundle branch block. A multicentre study.

BACKGROUND: Patients with left bundle branch block exhibit abnormal septal motion which may limit the interpretation of stress echocardiograms. This study sought to assess the diagnostic value of dobutamine-atropine stress echocardiography in left bundle branch block patients. METHODS AND RESULTS: Sixty-four left bundle branch block patients (mean age 59 years, 24 men) with suspected coronary artery disease underwent dobutamine-atropine stress echocardiography and coronary arteriography. Myocardial ischaemia was defined as new or worsening wall thickening abnormalities. Coronary artery disease was quantitatively defined as a diameter stenosis >/=50% in a major epicardial artery. Rest septal motion was normal (apart from the early systolic septal notch) in 34 patients (53%) and abnormal in 30 patients (47%). Rest septal thickening was normal in 32 patients (50%) and abnormal in 32 patients (50%). All seven patients with a QRS duration >/=160 ms and an abnormal QRS axis had abnormal rest septal motion and thickening. Inter-observer agreement for ischaemia was 88%. In all but one patient disagreement was in the septum. For the anterior and posterior circulation, respectively, sensitivity was 60% (9/15) and 67% (8/12), specificity was 94% (46/49) and 98% (51/52), and accuracy was 86% (55/64) and 92% (59/64). Sensitivity for the anterior circulation tended to be better in patients with normal rest septal thickening (83% vs 44%). CONCLUSIONS: Dobutamine-atropine stress echocardiography has excellent diagnostic specificity in left bundle branch block patients with suspected coronary artery disease. In patients with abnormal rest septal thickening, however, dobutamine-atropine stress echocardiography may lack good sensitivity for detection of coronary artery disease in the anterior circulation. Left bundle branch block patients who potentially most benefit from dobutamine-atropine stress echocardiography may initially be selected by their resting electrocardiogram.

Comparison of steerable continuous-wave versus pulsed-wave Doppler ultrasonography to renal artery angiography in diagnosing renal artery stenosis.

Pulsed-wave Doppler ultrasonography is widely used to noninvasively diagnose renal artery stenosis. The use of steerable continuous-wave Doppler has never been tested. We compared pulsed and steerable continuous-wave Doppler ultrasonography, demonstrating that although both methods are highly sensitive for severe stenoses, continuous-wave Doppler shows a better sensitivity for mild to moderate stenoses.

[Doppler flow-velocity analysis of the renal arteries in left ventricular dysfunction]. / Analisi della curva di flusso-velocità doppler delle arterie renali nella disfunzione ventricolare sinistra.

AIM OF THE STUDY: Chronic heart failure leads to renal hypoperfusion. Clinical methods for monitoring renal artery flow have several limitations. We analyzed the renal artery flow-velocity in patients with left ventricular dysfunction and normal controls by pulsed-wave (PW) color-guided Doppler technique. The relation between PW Doppler quantitative indexes and left ventricular ejection fraction (LVEF), creatinine clearance, and age, was also assessed. METHODS: We studied 53 patients with left ventricular dysfunction (LVEF by 2D echo < or = 40%) and no systemic hypertension, diabetes, parenchymal nephropathy, serum creatinine levels > 150 mmol/l, nor renal artery stenosis. Five patients were excluded for suboptimal renal artery PW Doppler recordings. Thus, the study group was constituted of 48 patients (mean age: 64 +/- 13 years). Twenty-eight normal subjects (mean age: 61 +/- 9 years) were the control group. By PW Doppler we measured the maximum (Vmax), the minimum (Vmin) and the mean (Vmean) velocities of both renal arteries. The resistivity index (RI), obtained from the formula (Vmax-Vmin)/ Vmax, and the pulsatility index (PI), obtained from the formula (Vmax-Vmin)/Vmed were calculated. Creatinine clearance was determined in each patient. RESULTS: RI and PI were greater in patients with left ventricular dysfunction than in normal controls. In normal controls, RI and PI were related to age (r: 0.63, p < 0.001; and r: 0.45, p < 0.05) and creatinine clearance (r: -0.44 and -0.40, respectively; both: p < 0.05), not to LVEF. In patients with left ventricular dysfunction, RI and PI were related to LVEF (r: -0.67 and -0.59; both: p < 0.001), other than to age (r: 0.57 and 0.55; both: p < 0.001) and creatinine clearance (r: -0.59, p < 0.001, and r = -0.46, p < 0.01, respectively). In this group, however, there was no sharp separation of RI and PI between patients with different degree of left ventricular dysfunction (LVEF < or = 30% and > 30%). CONCLUSIONS: In patients with left ventricular dysfunction, by renal artery PW Doppler analysis it is possible to detect noninvasively a reduction in regional flow-velocity and an increase in Doppler-derived vascular resistance indexes. These Doppler changes mainly depend on severity of left ventricular dysfunction and less on age of patients.

Regional wall motion analysis by dobutamine stess echocardiography to distinguish between ischemic and nonischemic dilated cardiomyopathy.

To distinguish between ischemic and nonischemic dilated cardiomyopathy (DCM), we studied 43 patients with left ventricular dysfunction (15 ischemic and 28 nonischemic detected by coronary angiography) by dobutamine stress echocardiography. At rest, there were more normal segments (p<0.001) and a trend toward more akinetic segments (p, not significant) per ischemic than per nonischemic DCM patient. However, either at rest or with low-dose dobutamine, individual data largely overlapped. At peak dose, in ischemic DCM, regional contraction worsened in many normal or dys-synergic regions at rest (in the latter case after improvement with low-dose dobutamine); in contrast, in nonischemic DCM, further mild improvement was observed in a variable number of left ventricular areas. Thus with peak-dose dobutamine, more akinetic and less normal segments were present per ischemic than per nonischemic DCM patient (both, p<0.001). A value of six or more akinetic segments was 80% sensitive and 96% specific for ischemic DCM. Our data show that analysis of regional contraction by dobutamine stress echocardiography can distinguish between ischemic and nonischemic DCM.

[Diagnosis of recent posterolateral myocardial infarction: an electrocardiographic, echocardiographic and scintigraphic study]. / Diagnosi di infarto posterolaterale recente: studio elettrocardiografico, ecocardiografico e scintigrafico.

ECG and 2D echocardiography were studied in 64 patients with previous myocardial infarction and evidence of posterolateral fixed defect at 201 TI scintigraphy. The defect was isolated posterolateral in 47 patients (group 1), and posterolateral + inferoapical in 17 (group 2). Thirty subjects with no history of myocardial infarction and no 201 TI defects constituted the control group. We calculated sensitivity, specificity and predictive value of ECG and 2D echocardiography (pertinent wall motion abnormality) in the recognition of posterolateral infarction. ECG data were also analyzed using multivariate analysis. Among the ECG criteria, a positive T wave in V1 proved to be 100% sensitive and 76% specific both in group 1 and in group 2. At multivariate analysis, a 2-variable model (positive T wave inV1 + R/S ratio greater than or equal to 1 in V1-V2) had a sensitivity of 95 and 100% in group 1 and 2, respectively; the specificity was 80%. A 3-variable model (+ R wave duration in V1-V2 greater than or equal to 0.04 sec) proved to be less sensitive (70 and 88% in group 1 and 2, respectively), with a specificity of 97%. A pertinent dyssynergy at 2D echocardiography was 70% sensitive for posterolateral myocardial infarction in group 1, but only 29% in group 2, with a specificity of 100%. These results indicate: 1) standard ECG is more sensitive but less specific than 2D echocardiography in the recognition of previous postolateral myocardial infarction; 2) the recognition of posterolateral involvement can be frequently missed by 2D echocardiography in patients with associated inferior myocardial infarction.

[Increase of plasma levels of beta-endorphin during maximum bicycle ergometry effort in sedentary and trained subjects]. / Incremento dei livelli plasmatici di beta-endorfina durante sforzo massimale al cicloergometro in sedentari ed allenati.

Plasmatic levels of beta-endorphin during maximal graded bicycle stress test were measured by RIA on extracted plasma in 10 well-trained (A group) and in 8 untrained subjects (C group). Blood samples were obtained at rest, at peak work load and at the third, 10th and 90th min of recovery. For every stress test the following were evaluated: exercise time, maximum work load, total work load, maximum double product and mean K (an index of velocity of heart rate recovery during the first three minutes after the exercise). Both groups A and C showed a significant rise in beta-endorphin activity at the third minute of recovery; the increase was significantly greater in trained rather than in sedentary subjects (p less than 0.01). Beta-endorphin release was closely related to mean K; no relationship was found between exercise time, maximum work load, total work load, maximum double product and beta-endorphin rise. Our data shows that a release of beta-endorphin occurs during the initial phase of recovery after a maximal stress test; beta-endorphin rise is greater in trained subjects and correlates with the speed of heart rate recovery, but has no relationship with the duration and the grade of the effort. Whether beta-endorphin increase plays a role in the rapid decrease of adrenergic tone which occurs after exercise or represents a secondary phenomenon remains to be determined.

[The FG syndrome (McK 30545). Description of 2 cases with subaortic stenosis]. / La "FG syndrome" (McK *30545). Descrizione di due casi con stenosi sottoaortica.

This paper reports on two brothers affected by FG syndrome (a rare X-linked syndrome with multiple congenital anomalies and mental retardation) and subvalvular aortic stenosis of the discrete type. This is a previously unrecognized association. The FG syndrome was firstly described by Opitz and Kaveggia in 1974. Nearly 20 cases have been reported: congenital heart diseases previously reported are atrial septal defect, ventricular septal defect and hypoplastic left heart. The clinical appearance of the two cases we have observed was that of mental retardation and typical features including abnormal facies (dolicocephaly, frontal prominence, poorly modeled auricles, micrognathia, prominent lower lip and lack of expression), anteriorly displaced anal opening, clinodactyly, great broad toes. A chromosome study showed a normal 46 XY constitution. Discrete subvalvular aortic stenosis was diagnosed by typical physical and echocardiographic findings.

Assessment of tricuspid regurgitation by pulsed Doppler ultrasonography of the hepatic veins.

Pulsed Doppler echocardiography was tested to assess the degree of tricuspid regurgitation (TR), classified by right ventriculography, in 47 patients. Forty-eight subjects without TR served as controls (39 with sinus rhythm and 9 with atrial fibrillation). Two Doppler methods were used: the distance of systolic turbulence within right atrium from the tricuspid plane and the quantitative analysis of the flow-velocity traces from the hepatic veins (HVs). Right atrial systolic turbulence was found in 41 of 47 patients with TR and in none of the control subjects, and moderately correlated with the angiographic grading (r = 0.57). In control subjects, TR flow-velocity traces from the HVs showed 2 anterograde flow waves, systolic and diastolic. The ratio of anterograde systolic/anterograde diastolic velocity was more than 0.6 in 38 subjects with sinus rhythm and in 8 with atrial fibrillation. Twenty-two control subjects had a positive wave (designated as "v") coincident with the end of T wave. In 30 patients with TR, a retrograde holosystolic wave was present. Of the remaining patients, 12 had a ratio of anterograde systolic/anterograde diastolic velocity less than 0.6. Fifteen had an end-systolic "v-like" wave, which occurred earlier than the v wave in control subjects (p less than 0.001). In patients with TR, maximal velocities of the anterograde diastolic and retrograde systolic flow correlated with angiographic grading (r = 0.74 and 0.73, respectively). An anterograde diastolic flow velocity more than 26 cm/s and a retrograde systolic flow velocity more than 16 cm/s excluded mild TR. Analysis of Doppler recordings of the HVs is valuable to semiquantitatively assess TR, complementing the right atrial Doppler findings.

[Bidimensional echocardiographic findings in a case of arrhythmogenic dysplasia of the right ventricle]. / Rilievi ecocardiografici bidimensionali in un caso di displasia aritmogena del ventricolo destro.

In a 50-year-old man presenting with dyspnoea and palpitations, cardiomegaly, incomplete right bundle branch block and bursts of ventricular tachycardia, Two-Dimensional Echocardiography revealed an impressive enlargement of the right ventricle, particulary in the outflow tract. Arrhythmogenic right ventricular dysplasia was suggested and confirmed by right ventricular angiography and electrophysiologic study. We emphasize the role of Two-Dimensional Echocardiography in the appropriate planning of cardiac catheterization for a definitive diagnosis of arrhythmogenic right ventricular dysplasia.

Extension of calcific deposits in the anterior mitral valve leaflet and mitral valve stenosis severity. Use of 2D Echo parasternal long-axis view.

To evaluate the role of the extent of calcific deposits on the anterior mitral leaflet in predicting the severity of mitral valve stenosis, two-dimensional echocardiography (2D Echo) and heart catheterization data were analysed in 62 patients with mitral valve stenosis, pure or associated with trivial valve regurgitation. 50 patients had technically adequate 2D Echo. Of these, 28 had pure mitral valve stenosis. The mitral valve area was estimated from the parasternal short-axis 2D Echo projection. Using the parasternal long-axis projection, calcium deposits location and extension on the anterior mitral leaflet was examined. Patients were subdivided into the following groups: Group 0 (absence of calcium deposits = 19 patients), Group 1 (calcium on distal third of the leaflet = 19 patients), Group 2 (calcium on mid and distal segments = 11 patients), Group 3 (calcium on the entire leaflet = one patient). The extension of calcium deposits in long-axis projection was contrasted with 2D Echo mitral valve area in the 50 mitral valve patients. 2D Echo and heart catheterization derived mitral valve area were compared to each other in the 28 patients with pure mitral valve stenosis. 2D Echo mitral valve area was greater in Group 0 patients (1.8 +/- 0.4 cm2) than in Group 1 (1.4 +/- 0.4 cm2) and in Group 2 (1.1 +/- 0.3 cm2) (p less than 0.001 between the three groups). Calcific deposits were present on the anterior mitral leaflet in 30/31 patients with 2D Echo mitral valve area less than or equal to 2 cm2. However, of the 19 patients of Group 0, 13 had moderate and one severe mitral valve stenosis. In the 28 patients with pure mitral valve stenosis, 2D Echo mitral valve area was excellently correlated with Gorlin's derived mitral valve area (r = 0.90). However, in patients with extensive calcification of the anterior mitral valve leaflet (Group 2), 2D Echo mitral valve area was significantly greater than the Gorlin's derived area (1.08 +/- 0.20 cm2 versus 0.68 +/- 0.17 cm2; p less than 0.001). In four patients of Group 2, the mitral valve stenosis was moderate by 2D Echo grading and severe by heart catheterization data. Our data suggest that the study of extension of calcific deposits on the anterior mitral valve leaflet may be a complementary aid in quantifying mitral valve stenosis to the 2D Echo mitral valve area estimate, especially when the valve is severely calcified.