Normal intima-media thickness on carotid ultrasound reliably excludes an ischemic cause of cardiomyopathy.

BACKGROUND: Coronary artery disease (CAD) is the most common cause of left ventricular systolic dysfunction (LVSD). Patients with ischemia as the cause of LVSD may warrant revascularization. Angiography is the most accurate method of CAD diagnosis but is invasive, expensive, and associated with some risk. Noninvasive imaging for CAD often involves expensive equipment, radiation exposure, medication, and/or contrast administration. Carotid ultrasound with measurement of intima-media thickness (IMT) is safe and inexpensive. Carotid IMT is well correlated with the presence of CAD. We assessed the accuracy of carotid ultrasound for identification of CAD as a potential etiology of LVSD. METHODS: Patients with LVSD (ejection fraction < or =40%) of uncertain etiology referred for angiography underwent carotid ultrasound. Patients with history of myocardial infarction were excluded. Two experienced cardiologists blinded to CAD status determined common carotid artery (CCA) IMT and plaque. Significant CAD was defined as > or =50% stenosis of any major artery. Ischemic LVSD was defined as (1) left main and/or proximal left anterior descending coronary artery > or =75% or (2) > or =2 major arteries with > or =75% stenosis. RESULTS: Mean ejection fraction was 27% +/- 10% in 150 patients. Significant CAD was found in 64 (42.7%) and ischemic LVSD in 40 (26.7%). Carotid plaque was seen in 95 (63.3%). Mean CCA IMT was > or =0.9 mm in 69 (46.0%). The combination of mean CCA IMT <0.9 mm and no plaque had negative predictive value for ischemic LVSD of 98%. CONCLUSIONS: Carotid ultrasound with IMT measurement is a valuable screening tool for excluding an ischemic etiology of LVSD when CAD is suspected.

Echocardiographic manifestations of complications of radiation therapy.

Radiation therapy may affect all of the layers of the heart (epicardial arteries, pericardium, valves, and myocardium). This is especially true after mediastinal or breast irradiation. Coronary artery disease, with resultant myocardial infarction, is the most common cause of death. We present a patient who developed typical constrictive pericarditis as well as valve lesions typical of radiation toxicity (the mitral valve leaflets were thickened at their bases, with the tips spared). The pericardial constriction was manifested by all of the typical echo Doppler findings, namely septal bounce, dilated inferior vena cava, significant respiratory drop in inspiratory mitral E velocity with a normal tissue Doppler e', and expiratory reversal of flow into the hepatic veins.

Amounts of aortic atherosclerosis in patients with aortic stenosis as determined by transesophageal echocardiography.

We quantified the graded amounts of aortic atherosclerosis (AA) in patients with aortic stenosis (AS) to better delineate the need for preprocedural risk stratification. Complex AA is strongly related to embolic events, especially during open heart surgery and catheterization. Despite the frequency of these procedures in patients with AS and the increased prevalence of atherosclerosis, current guidelines do not recommend screening for AA. Patients with concomitant transesophageal and transthoracic echocardiograms were retrospectively identified. AS and AA were graded by expert reviewers as mild, moderate, and severe according to established guidelines. Three hundred sixty patients (212 men, mean age 69 +/- 14 years) were identified, 186 (52%) without AS, 82 (23%) with mild AS, 55 (15%) with moderate AS, and 37 (10%) with severe AS. There was a strong graded positive association between AA and AS (p <0.00001). The prevalence of severe AA increased across grades of AS. Of all patients with severe AS, 54% had severe AA. Of patients with severe AS not referred for an embolic event, 57% had severe AA. The odds ratio for severe AA was 4.9 (95% confidence interval 2.3 to 10.3) in patients with severe AS compared with without AS. In conclusion, AS and AA are closely correlated. The majority of patients with severe AS have severe AA, even without previous thromboembolic events. This significant atherosclerotic burden may warrant preprocedural risk assessment with transesophageal echocardiography.

The effect of transvenous pacemaker and implantable cardioverter defibrillator lead placement on tricuspid valve function: an observational study.

This study assessed the effect of transtricuspid placement of permanent pacemaker (PPM) and implantable cardioverter defibrillator (ICD) leads on tricuspid regurgitation (TR) in 248 patients with echocardiograms before and after placement. Some 21.2% of patients with baseline mild TR or less developed abnormal TR (3.4% mild-moderate, 12.8% moderate, 1.1% moderate-severe, 3.9% severe) after implant. TR worsened by 1 grade or more after implant in 24.2% (20.7% of PPMs vs. 32.4% of ICDs; P < .05). TR worsening was more common with ICDs than PPMs in patients with baseline mild TR or less. After lead implantation, abnormal TR developed in 21.2% and severe TR developed in 3.9% of patients with initially normal TR. TR worsened by at least 1 grade in 24.2%. Patients with ICDs had a higher rate of TR worsening compared with patients with PPMs (32.4% vs. 20.1%; P < .05).

Left atrial appendage thrombus outside of a 'successful' ligation.

A 79-year-old woman with severe aortic stenosis underwent aortic valve replacement surgery, and had ligation of the left atrial appendage (LAA) using an epicardial approach. On a post-operative echocardiographic evaluation, the distal portion of the LAA was excluded, leaving no communication with the left atrium. The proximal portion of the LAA, however, was in continuity with the circulation and a large thrombus was present within it. While previous reports of incomplete LAA ligation have involved disruption of the suture line, this present report describes a case of incomplete ligation due to persistence of the proximal portion of the appendage. Thus, thrombus formation occurred despite a 'successful' epicardial exclusion of the distal LAA.

Paradoxical septal motion after cardiac surgery: a review of 3,292 cases.

BACKGROUND: Paradoxical septal motion (PSM) is the systolic movement of the interventricular septum toward the right ventricle despite normal thickening. The PSM is a frequent echocardiographic finding after cardiac surgery. Although it is universally recognized, there has been no large-scale study to correlate PSM with the type of surgical procedure. The cause of PSM is unknown; prevailing theories include: (1) operation on the heart alters the degree to which it is restrained by the pericardium and the chest wall and (2) transient ischemia alters septal motion. HYPOTHESIS: The PSM is related to type of surgery and surgical approach. METHODS: Between 1996 and 2002, 3,292 patients underwent a first cardiac operation and had a postoperative echocardiogram; 313 were excluded due to other explanations for PSM (severe tricuspid regurgitation [TR] cardiac pacing), leaving a study group of 2,979 patients. Univariate and multivariate analyses were performed to determine which surgical characteristics were correlated with postoperative PSM. Septal thickening was assessed in a subset. RESULTS: On multivariate analysis, aortic (p = 0.02) and mitral valve surgery (p < 0.001) and longer cardiopulmonary bypass time (p < 0.001) were independently associated with PSM. Coronary artery bypass grafting (CABG) was less likely to cause PSM than non-CABG surgery (p = 0.003) and off-pump coronary artery bypass (OPCAB) caused less PSM than did on-pump CABG. CONCLUSIONS: 1. Valve surgery is more likely to cause PSM than CABG. 2. Among patients with CABG, OPCAB causes less PSM. 3. Cardiopulmonary bypass time is associated with the development of PSM. 4. The cause of PSM is likely to be multifactorial.

Systolic and diastolic pulsus alternans in severe heart failure.

Pulsus alternans is usually a systolic phenomenon. We present a case of a patient with severe heart failure, and systolic and diastolic pulsus alternans. This case may help clarify the mechanism of pulsus alternans.

Complications of aortic atherosclerosis: atheroemboli and thromboemboli.

Patients with severe aortic atherosclerosis are at high risk for stroke and other embolic complications. Therapy to prevent emboli from aortic plaque is not yet established. Therefore, patients with atherosclerosis or risk factors for embolic disease should be identified and treated aggressively. Aspirin, smoking cessation, and control of blood pressure and glucose are important. Retrospective data in patients with severe aortic plaque support the use of statins to prevent stroke. Iatrogenic embolization can occur as a result of aortic manipulation during invasive vascular procedures or cardiovascular surgery. The risks and benefits of these procedures must be carefully weighed, and alternate approaches should be considered for patients with severe aortic atherosclerosis. For those who require coronary artery bypass graft (CABG) surgery, off-pump CABG is an option. Prophylactic aortic arch atherectomy should not be routinely performed. Aortic filters or stenting have been introduced but have not yet been fully evaluated. For patients who require angiography and have severe descending aortic, aortic arch, or abdominal aortic plaque, it is possible that a brachial (rather than a femoral) approach may avoid embolic complications.

Non-Doppler two-dimensional strain imaging by echocardiography--from technical considerations to clinical applications.

During the past several years, strain and strain rate imaging have emerged as a quantitative technique to accurately estimate myocardial function and contractility. Non-Doppler, 2-dimensional (2D) strain imaging is a new echocardiographic technique for obtaining strain and strain rate measurements. It analyzes motion by tracking speckles in the ultrasonic image in two dimensions. Current available software allows spatial and temporal image processing with recognition and selection of such elements on ultrasound image. The geometric shift of each speckle represents local tissue movement. By tracking theses speckles, 2D tissue velocity, strain, and strain rate can be calculated. Non-Doppler 2D strain imaging is simple to perform. It requires only one cardiac cycle to be acquired; further processing and interpretation can be done after image data acquisition. Because it is not based on tissue Doppler measurements, it is angle independent. Data regarding accuracy, validity, and clinical application of non-Doppler 2D strain imaging are rapidly accumulating. This technique may prove to be of significant clinical value, enabling rapid and accurate assessment of global and segmental myocardial function.

Evaluation of the abdominal aorta and the renal arteries with an intracardiac echocardiography probe placed in the inferior vena cava: a feasibility study.

BACKGROUND: Ultrasound evaluation of the abdominal aorta and its branches is usually performed transabdominally. Not infrequently, the image quality is suboptimal. Recently, an intracardiac echocardiography probe has become commercially available. These probes are usually inserted intravenously and advanced to the right heart for diagnostic and monitoring purposes during procedures such as atrial septal defect closure and pulmonary vein isolation. Because of the close anatomic relation between the abdominal aorta and the inferior vena cava, we hypothesized that these probes would be useful in the evaluation of the abdominal aorta and the renal arteries. METHODS: Sixteen patients with normal renal function and no history of hypertension who were undergoing a pulmonary vein isolation procedure or atrial septal defect closure were studied. In each patient, the intracardiac echocardiography probe was inserted in the femoral vein and advanced to the right atrium for the evaluation of the left atrium and the pulmonary veins during the procedure. At the end of the therapeutic procedure, the probe was withdrawn into the inferior vena cava for the evaluation of the aorta and renal arteries. RESULTS: High-resolution images of the abdominal aorta from the diaphragm to its bifurcation were easily obtained in all patients. These images allowed for the evaluation of arterial size, shape, and blood flow. Both renal arteries were easily visualized in each patient. With the probe in the inferior vena cava, both renal arteries were parallel to the imaging plane and, therefore, accurate measurement of renal blood flow velocity and individual renal blood flow were measured.

Increase in circulating bone marrow progenitor cells after myocardial infarction.

BACKGROUND: Most circulating blood cells expressing the marker CD34 are bone marrow progenitor cells. These cells differentiate into cardiomyocytes, endothelial and smooth muscle cells after myocardial infarction in vivo. Mobilization of bone marrow progenitor cells into the peripheral blood after myocardial infarction may supply these cells to the heart. Rise in CD34+ cell concentrations following myocardial infarction would support the existence of myocardial-initiated mobilization. METHODS: Serial measurements of circulating CD34+ cells were made in 42 consecutive patients presenting with first ST-elevation myocardial infarction. Measurement of serum concentrations of monocyte chemoattractant protein-1, stromal derived factor-1, hepatocyte growth factor, interleukin-17 and thrombopoietin was also performed. Samples were drawn on day 1 after myocardial infarction, and on days 4, 8 and 12. Levels of CD34+ cells and cytokines were also measured in 15 controls. RESULTS: By day 8, the mean concentration of CD34+ cells rose by 74% above mean control level of 2527 cells/ml, and 41% above day 1 mean (P=0.02). This rise was sustained on day 12 (P=0.05). On day 1, there was a 9.3-fold rise in hepatocyte growth factor above the control level of 589 pg/ml (P=0.002). Hepatocyte growth factor levels declined from the day 1 mean of 6061 to 1485 pg/ml on day 12 (P=0.002). No significant change in stromal derived factor-1, interleukin-17, monocyte chemoattractant protein-1 and thrombopoietin was observed. Elevations in CD34+ cells and hepatocyte growth factor were not related to infarction size as estimated on echocardiography. CONCLUSIONS: Elevation in the concentration of circulating CD34+ cells after myocardial infarction suggests that myocardial initiated bone marrow progenitor cell mobilization exists in humans. The cytokines studied in our protocol are not likely to play a direct role in bone marrow progenitor cell mobilization.

Pulmonary vein compression by tumor: an unusual Doppler flow pattern.

Pulmonary venous compression caused by a large lung mass was diagnosed in a 50-year-old female with metastatic renal cell carcinoma. The pulmonary venous flow pattern on Doppler revealed high flow velocity as well as the unusual finding of continued antegrade flow throughout the cardiac cycle (without reversal during atrial contraction). Extracardiac tumors can compress pulmonary veins, mimicking pulmonary vein stenosis. This may cause dyspnea due to elevated pulmonary venous pressures. This report describes an unusual pulmonary vein blood flow pattern in a patient with lung metastases.

Rare flow pattern in a patient with cor triatriatum.

Doppler echocardiography demonstrated a rare flow pattern due to cor triatriatum that is also present in subvalvular or supravalvular mitral stenosis: a forward gradient, in both systole and diastole.