In vitro expansion of tumour cells derived from blood and tumour tissue is useful to redefine personalized treatment in non-small cell lung cancer patients.

The clinical development of locally and advanced non-small cell lung cancer (NSCLC) suffers from a lack of biomarkers as a guide in the selection of optimal prognostic prediction. Circulating Tumour Cells (CTCs) are correlated to prognosis and show efficacy in cancer monitoring in patients. However, their enumeration alone might be inadequate; it might also be critical to understand the viability, the apoptotic state and the kinetics of these cells. Here, we report what we believe to be a new and selective approach to visually detect tumour specific CTCs. Firstly, using labelled human lung cancer cells, we detected a specific density interval in which NSCL-CTCs were concentrated. Secondly, to better characterize CTCs in respect to their heterogeneous composition and tumour reference, blood and tumour biopsy were performed on specimens taken from the same patient. The approach consisted in comparing phenotype profile of CTCs, and their progenitor Tumour Stem Cells, (TSCs). Moreover, NSCL-CTCs were cultivated in short-time human cultures to provide response to drug sensitivity. Our bimodal approach allowed to reveal two items. Firstly, that one part of a tumour, proximal to the bronchial structure, displays a predominance of CD133+. Secondly, specific NSCL-CTCs Epithelial Cell Adhesion Molecule (EpCAM)+CD29+ can be used as a negative prognostic factor as well the high expression of CTCs EpCAM+. These data were confirmed by drug-sensitivity tests, in vitro, and by the survival curves, in vivo.

Accessory mitral valve leaflet in an adult with coronary artery disease.

Accessory mitral valve leaflet is a very rare cause of left ventricular outflow tract obstruction. We report a patient presenting this cardiac abnormality who undergone cardiac surgery. A 60-year-old man, presented coronary artery disease and moderate left ventricular tract obstruction due to accessory mitral valve leaflet. The accessory mitral valve leaflet had the typical morphology of a parachute-shaped attached partially to the anterior mitral valve leaflet, with chordae tendinae attached to: 1) an accessory papillary muscle inserted at the free-wall closed to the apex; 2) interconnected with the chordae tendinae of the anterior mitral valve leaflet; 3) a second accessory papillary muscle inserted to the interventricular septum. He underwent successful coronary revascularization of 2 vessels and accessory leaflet excision. A review of 21 cases with accessory mitral valve leaflet is reported.

Predictive value of markers of myocardial reperfusion in acute myocardial infarction for follow-up left ventricular function.

This study evaluated recently suggested invasive and noninvasive parameters of myocardial reperfusion after acute myocardial infarction (AMI), assessing their predictive value for left ventricular function 4 weeks after AMI and reperfusion defined by myocardial contrast echocardiography (MCE). In 38 patients, angiographic myocardial blush grade, corrected Thrombolysis In Myocardial Infarction frame count, ST-segment elevation index, and coronary flow reserve (n = 25) were determined immediately after primary percutaneous transluminal coronary angioplasty (PTCA) for first AMI, and intravenous MCE was determined before, and at 1 and 24 hours after PTCA to evaluate myocardial reperfusion. Results were related to global wall motion index (GWMI) at 4 weeks. MCE 1 hour after PTCA showed good correlation with GWMI at 4 weeks (r = 0.684, p <0.001) and was in an analysis of variance the best parameter to predict GWMI 4 weeks after AMI. The ST-segment elevation index was close in its predictive value. Considering only invasive parameters of reperfusion myocardial blush grade was the best predictor of GWMI at 4 weeks (R(2) = 0.3107, p <0.001). A MCE perfusion defect size at 24 hours of > or =50% of the MCE perfusion defect size before PTCA was used to define myocardial nonreperfusion. In a multivariate analysis, low myocardial blush grade class was the best predictor of nonreperfusion defined by MCE. Thus, intravenous MCE allows better prediction of left ventricular function 4 weeks after AMI than other evaluated parameters of myocardial reperfusion. Myocardial blush grade is the best predictor of nonreperfusion defined by MCE and is the invasive parameter with the greatest predictive value for left ventricular function after AMI. Coronary flow parameters are less predictive.

Serial evaluation of perfusion defects in patients with a first acute myocardial infarction referred for primary PTCA using intravenous myocardial contrast echocardiography.

AIMS: To investigate whether myocardial contrast echocardiography using Sonazoid could be used for the serial evaluation of the presence and extent of myocardial perfusion defects in patients with a first acute myocardial infarction treated with primary PTCA, and specifically, (1) to evaluate safety and efficacy of myocardial contrast echocardiography to detect TIMI flow grade 0--2, (2) to evaluate the success of reperfusion and (3) to predict left ventricular recovery after 4 weeks follow-up. METHODS AND RESULTS: Fifty-nine patients underwent serial myocardial contrast echocardiography, immediately before primary PTCA (MCE1), 1 h (MCE2) and 12--24 h after PTCA (MCE3). A perfusion defect was observed in 21 of 24 patients (88%) with anterior acute myocardial infarction. All but one had TIMI flow grade 0--2 prior to PTCA. Nine of 31 patients (29%) with inferior acute myocardial infarction showed a perfusion defect and all had TIMI flow grade 0-2 prior to PTCA. Restoration of TIMI flow grade 3 was achieved in 73% of the patients by primary PTCA. A reduction in size of the initial perfusion defect of at least one segment (16 segment model) or no defect vs persistent defect in patients with anterior acute myocardial infarction was associated with improved global left ventricular function at 4 weeks; mean global wall motion score index 1.29+/-0.21 vs 1.66+/-0.31 (P=0.009). Multiple regression analysis in patients with an anterior acute myocardial infarction revealed that the extent of the perfusion defect at MCE3 was a significant (P=0.0005) independent predictor for left ventricular recovery at 4 weeks follow-up. The only other independent predictor was TIMI flow grade 3 post PTCA (P=0.007). CONCLUSION: Intravenous myocardial contrast echocardiography immediately prior to primary PTCA seems safe and is capable of detecting the presence of a perfusion defect and its subsequent dynamic changes, particularly in patients with a first anterior acute myocardial infarction. A significant reduction in size of the initial perfusion defect using serial myocardial contrast echocardiography predicts functional recovery after 4 weeks and these findings underscore the potential diagnostic value of intravenous myocardial contrast echocardiography.

Assessment of flow velocity reserve by transthoracic Doppler echocardiography and venous adenosine infusion before and after left anterior descending coronary artery stenting.

OBJECTIVES: We sought to evaluate whether coronary flow velocity reserve (CFR) (the ratio between hyperemic and baseline peak flow velocity), as measured by transthoracic Doppler echocardiography during adenosine infusion, allows detection of flow changes in the left anterior descending coronary artery (LAD) before and after stenting. BACKGROUND: The immediate post-stenting evaluation of CFR by intracoronary Doppler has shown mixed results, due to reactive hyperemia and microvascular stunning. Noninvasive coronary Doppler echocardiography may be a more reliable measure than intracoronary Doppler. METHODS: Transthoracic Doppler echocardiography during 90-s venous adenosine infusion (140 microg/kg body weight per min) was used to measure CFR of the LAD in 45 patients before and 3.7 +/- 2 days after successful stenting, as well as in 25 subjects with an angiographically normal LAD (control group). RESULTS: Adequate Doppler spectra were obtained in 96% of the patients. Pre-stent CFR was significantly lower in patients than in control subjects (diastolic CFR: 1.45 +/- 0.5 vs. 2.72 +/- 0.71, p < 0.01; systolic CFR: 1.61 +/- 1.02 vs. 2.41 +/- 0.68, p < 0.01) and increased toward the normal range after stenting (diastolic CFR: 2.58 +/- 0.7 vs. 2.72 +/- 0.75, p = NS; systolic CFR: 2.43 +/- 1.01 vs. 2.41 +/- 0.52, p = NS). Diastolic CFR was often damped, suggesting coronary steal in patients with > or =90% versus <90% LAD stenosis (0.86 +/- 0.23 vs. 1.69 +/- 0.43, p < 0.01). Coronary stenting normalized diastolic CFR in these two groups (2.45 +/- 0.77 and 2.64 +/- 0.69, respectively, p = NS), even though impaired diastolic CFR persisted in three of four patients with > or =90% stenosis. Stenosis of the LAD was better discriminated by diastolic (F = 49.30) than systolic (F = 12.20) CFR (both p < 0.01). CONCLUSIONS: Coronary flow reserve, as measured by transthoracic Doppler echocardiography, is impaired in LAD disease; it may identify patients with > or =90% stenosis; and it normalizes early after stenting, even in patients with > or =90% stenosis.

Imaging of the posterior descending coronary artery. The last frontier in echocardiography.

BACKGROUND: Non-invasive color Doppler imaging of the left anterior descending coronary artery has been described, but imaging of the posterior descending coronary artery (PD) has never been reported. The aim of this paper was to describe color Doppler imaging and flow reserve of the PD, regardless of its origin from the right or circumflex coronary artery, in different settings such as acute myocardial infarction or coronary stenting. METHODS: A C256 Acuson Sequoia ultrasound system connected to a standard 3.5 MHz transducer was used. Neither a contrast agent nor harmonic or power Doppler imaging was used. However, the Nyquist limit of color Doppler was reduced to 12 cm/s. Patients were examined in the apical 2-chamber view, with the coronary sinus ostium imaged in the short axis until a diastolic flow signal close to the epicardial layer was detected. Pulsed Doppler confirmed an anterograde, doming systolic and monophasic decrescendo diastolic flow. Adenosine was intravenously infused at the standard dose of 140 microg/kg/min over 90 s in order to elicit maximal microcirculatory dilation. The resting and hyperemic peak diastolic flow velocities were measured and the coronary flow reserve was calculated as the ratio between hyperemic and resting peak diastolic flow velocities. RESULTS: This simple bedside technique provided crucial information about several important issues: 1) arterial patency after thrombolysis; 2) evaluation of the physiologic impact of a coronary stenosis, with implications on the detection of a critical stenosis; 3) reperfusion imaging of perforating branches after myocardial infarction; 4) post-stent assessment of coronary flow reserve. CONCLUSIONS: This paper shows, for the first time, that non-invasive imaging of the PD by non-contrast transthoracic Doppler is feasible and that the coronary flow reserve is measurable even in critical conditions. More studies are needed to assess the feasibility of PD imaging in different clinical settings and the potential benefit of contrast agents in improving the evaluation of coronary flow.

Non-invasive assessment of coronary flow velocity reserve before and after angioplasty in a patient with mammary graft stenosis.

We report the diagnosis of mammary artery graft dysfunction by high-resolution transthoracic Doppler and venous adenosine infusion. The patient was treated by percutaneous balloon angioplasty, with optimal angiographic results. Coronary flow reserve in the distal left anterior descending artery was abnormal before angioplasty, and recovered soon after the procedure. The utility of this new non-invasive technique in the diagnosis of flow-limiting stenoses and follow-up of coronary angioplasty is described.

Detection of false lumen perfusion at the beginning of cardiopulmonary bypass in patients undergoing repair of aortic dissection.

OBJECTIVE: In patients undergoing surgical repair of aortic dissection, false lumen perfusion during cardiopulmonary bypass may produce central nervous system damage, myocardial ischemia, aortic rupture, and death. We describe a method to detect false lumen perfusion at the beginning of retrograde aortic perfusion that may prevent these complications. DESIGN: Sonicated albumin microbubbles (8 mL) were injected through a side branch of the extracorporeal circulation line to detect true lumen and/or false lumen perfusion of the thoracic aorta at the beginning of cardiopulmonary bypass. Transesophageal echocardiography was used to image aortic perfusion. SETTING: The study was performed in a cardiac surgery theater. PATIENTS: A total of 27 consecutive patients undergoing operation for Type I aortic dissection were studied. INTERVENTIONS: All patients underwent surgical repair of aortic dissection and retrograde aortic perfusion through one femoral artery. MEASUREMENTS AND MAIN RESULTS: Patients were divided into three groups: Group I, those having adequate true lumen perfusion: brisk appearance and washout of contrast in the true lumen with no, poor, or delayed opacification of the false lumen; Group II, those having mixed true lumen and false lumen perfusion: simultaneous opacification of both lumens; Group III, those having inappropriate false lumen perfusion: same criteria as for adequate true lumen perfusion applied to the false lumen. The true lumen was perfused in 13 patients, both lumens in 11 patients, and false lumen alone in three patients. In these three patients, cannulation was repeated through the contralateral femoral artery with restoration of true lumen perfusion; the first patient died of diffuse cerebral ischemic damage and renal failure, another one experienced temporary postoperative monoparesis, and the last had no neurologic sequelae. CONCLUSIONS: Contrast echocardiography allows immediate detection of retrograde aortic perfusion during cardiopulmonary bypass and may help prevent neurologic complications and death in patients with Type I dissection.

Assessment of myocardial reperfusion by intravenous myocardial contrast echocardiography and coronary flow reserve after primary percutaneous transluminal coronary angioplasty [correction of angiography] in patients with acute myocardial infarction.

BACKGROUND: This study investigated whether the extent of perfusion defect determined by intravenous myocardial contrast echocardiography (MCE) in patients with acute myocardial infarction (AMI) treated by primary percutaneous transluminal coronary angioplasty (PTCA) relates to coronary flow reserve (CRF) for assessment of myocardial reperfusion and is predictive for left ventricular recovery. METHODS AND RESULTS: Twenty-five patients with first AMI underwent intravenous MCE with NC100100 with intermittent harmonic imaging before PTCA and after 24 hours. MCE before PTCA defined the risk region and MCE at 24 hours the "no-reflow" region. The no-reflow region divided by the risk region determined the ratio to the risk region. CFR was assessed immediately after PTCA and 24 hours later. Left ventricular wall motion score indexes were calculated before PTCA and after 4 weeks. CFR at 24 hours defined a recovery (CFR >/=1.6; n=17) and a nonrecovery group (CFR <1.6; n=8). Baseline CFR did not differ between groups. MCE ratio to the risk region was smaller in the recovery group compared with the nonrecovery group (34+/-49% vs 81+/-46%, P=0.009). A ratio to the risk region of

Successful weaning from cardiopulmonary bypass with central venous prostaglandin E1 and left atrial norepinephrine infusion in patients with acute pulmonary hypertension.

OBJECTIVE: Postoperative pulmonary hypertension increases the mortality risk in cardiac surgery. We have used central venous prostaglandin E1 (PGE1) and left atrial norepinephrine (NE) infusion to wean from cardiopulmonary bypass (CPB) patients with refractory postoperative pulmonary hypertension. DESIGN: Observational, nonrandomized study. SETTING: Department of Cardiac Surgery in a university hospital. PATIENTS: We studied 10 nonconsecutive American Society of Anesthesiologists III and New York Heart Association class III-IV patients with postoperative pulmonary hypertension and low cardiac output syndrome preventing separation from CPB. INTERVENTIONS: Patients received right atrial PGE1 (31.5 +/- 6.26 ng/kg/min) and left atrial NE (0.11 +/- 0.02 microg/kg/min) infusion. Hemodynamic data were obtained before CPB (T0), after CPB under maximal inotropes and vasodilator infusion (T1), 10 mins (T2) and 12 hrs (T3) after PGE1 and NE infusion, and 48 hrs after withdrawal of PGE1 and NE (T4). MEASUREMENTS AND MAIN RESULTS: All patients were successfully weaned from CPB and survived. The biatrial infusion of PGE1 and NE caused a dramatic reduction in mean pulmonary artery pressure (from 42.8 +/- 5.1 mm Hg at T1 to 28.5 +/- 2.6 mm Hg at T2 and 20.5 +/- 2.0 mm Hg at T4), pulmonary vascular resistance index (from 1158 +/- 269 dyne x sec/cm5 x m2 at T1 to 501 +/- 99 dyne x sec/cm5 x m2 at T2 and 246 +/- 50 dyne x sec/cm5 x m2 at T4), and pulmonary-to-systemic vascular resistance index ratio (from 0.61 +/- 0.17 at T1 to 0.20 +/- 0.04 at T2 and 0.11 +/- 0.03 at T4). Cardiac index increased from 1.7 +/- 0.2 L/min/m2 at T1 to 2.3 +/- 0.2 L/min/m2 at T2 and 2.9 +/- 0.1 L/min/m2 at T4. CONCLUSIONS: In patients with refractory postoperative pulmonary hypertension, the combined administration of low-dose PGE1 in the right atrium and NE in the left atrium is an effective means to wean patients from cardiopulmonary bypass.

Coronary Doppler intensity changes during handgrip: a new method to detect coronary vasomotor tone in coronary artery disease.

OBJECTIVES: This study evaluates whether a quantitative measurement of Doppler intensity during handgrip may disclose coronary vasomotor dysfunction in patients with coronary artery disease (CAD). BACKGROUND: Atherosclerotic coronary segments show an exaggerated constrictive response to handgrip. The intensity of the scattered Doppler signal is proportional to the number of blood cells flowing through the vessel, and should be reduced during vasoconstriction. Therefore, changes in coronary flow during handgrip may be detected by measuring Doppler intensity rather than velocities. METHODS: The distal left anterior descending coronary artery (LAD) was imaged by high-resolution transthoracic color Doppler echocardiography during handgrip in 47 patients: 15 with normal coronary arteries and 32 with significant CAD involving the LAD. The Doppler signal was acquired at 70 dB dynamic range at baseline, 30-s handgrip and 5 min recovery. Peak and mean flow velocity, pressure half-time, deceleration time (ms), deceleration rate (cm/s2) and mean gray level intensity (intensity units [IU]) of the Doppler spectrum were measured in diastole. RESULTS The velocity parameters did not change significantly during handgrip both in normal and CAD patients. The Doppler intensity significantly decreased during handgrip (from 87.0 +/- 32.8 to 57.7 +/- 35.3 IU; p < 0.001) in patients with CAD, and it increased or remained unchanged in normals (from 74.1 +/- 27.3 to 85.1 +/- 31.2 IU; p = NS). The sensitivity of Doppler intensity in detecting CAD was 84.4%, specificity 93.3%, negative predictive value 73.7% and positive predictive value 96.4%. CONCLUSIONS: Doppler intensity measured by transthoracic echocardiography during handgrip allows the detection of CAD and coronary vasomotor dysfunction.

Calcium chloride minimizes the hemodynamic effects of propofol in patients undergoing coronary artery bypass grafting.

OBJECTIVE: To assess the hemodynamic effects of propofol and the counteracting effect of calcium chloride (CaCl2) in patients undergoing coronary artery bypass grafting (CABG). DESIGN: Prospective, randomized study. SETTING: University hospital, department of cardiac surgery. PARTICIPANTS: Fifty-eight patients undergoing elective CABG, divided into group A (n = 29) and group B (n = 29). INTERVENTIONS: Anesthesia was induced with a combination of fentanyl, 7 microg/kg; pancuronium, 0.1 mg/kg; and propofol, 1.5 mg/kg, administered over 60 seconds. A blinded investigator administered saline in group A patients and 10 mg/kg of CaCl2 in group B patients at the same speed and same time as propofol administration through another lumen of the central venous catheter. MEASUREMENTS AND MAIN RESULTS: Hemodynamic data were obtained at baseline (T0), 2 minutes after anesthesia induction (T1), and 2 minutes after tracheal intubation (T2). Heart rate decreased significantly in group A patients (86.2+/-11.3 beats/min at T0 and 72.8+/-7.5 beats/min at T2; p < 0.001). Mean arterial pressure decreased significantly in patients in both groups (group A, 108.0+/-12.0 mmHg at T0; 74.6+/-14.6mmHg at T2;p < 0.001 and group B, 106.0+/-10.2 mmHg at T0; 90.4+/-10.0 mmHg at T2; p < 0.05). Stroke volume index, cardiac index, and cardiac output decreased in group A patients (39.4+/-4.1 mL/beat/m2 at T0 and 28.8+/-5.2 mL/beat/m2 at T2; p < 0.05; 3.4+/-0.6 L/min/m2 at T0 and 1.9+/-0.3 L/min/m2 at T2; p < 0.001; 5.9+/-0.9 L/min at T0 and 3.4+/-0.4 L/min at T2; p < 0.001, respectively), whereas in group B patients, changes were negligible (38.1+/-7.0 mL/beat/m2 at T0 v 35.7+/-6.6 mL/beat/m2 at T2; (NS) 3.3+/-0.5 L/min/m2 at T0 v 2.7+/-0.3 L/min/m2 at T2; (NS) 5.7+/-0.9 L/min at T0 v 4.7+/-0.5 L/min at T2; (NS), respectively). CONCLUSION: Simultaneous administration of CaCl2 during the induction of anesthesia minimizes the potential negative effect of propofol on cardiac function in cardiac patients.

[Natural harmonic echocardiography]. / Ecocardiografia in armonica naturale.

The acquisition of echocardiographic images in harmonic mode (a frequency double than the transmitted, or fundamental) improves imaging quality. We assessed whether harmonic imaging improves the detection of endocardial borders, evaluation of ventricular function and diagnostic confidence in the clinical arena. We have studied in fundamental and harmonic imaging 45 patients (age 20-89 years, mean 53 years) using a multifrequency transthoracic probe transmitting at 1.75 MHz and receiving at 3.5 MHz (Acuson Sequoia). In 34 low echogenic patients we assessed left ventricular function. The remaining 11 patients represented selected cases (i.e. atrial septal aneurysm, aortic dissection, endocarditis and atrial septal defect). The echocardiographic images were recorded on a magneto-optical disk and analyzed by two blinded observers. Endocardial definition has been semiquantitatively evaluated assigning a 0-4 score for each of the 16 segments of the left ventricle. A score of 0 was allotted to the non-visualizable segments and a score of 4 to the best detectable segments. Ejection fraction was calculated in each patient from the apical 4-chamber view. We compared endocardial border definition and ejection fraction at rest, in fundamental and harmonic mode, and assessed the interobserver agreement in the calculation of ejection fraction. Harmonic images always showed a better definition and lower noise compared to fundamental. Endocardial border definition was significantly improved in all segments (from 1.3 +/- 1.1 fundamental to 2.9 +/- 1.0 harmonic). Forty-two segments were non detectable in fundamental (score 0) compared to 5 in harmonic. Of these 42 segments, 37 were detectable in harmonic, with a score of 2.0 +/- 1.0. Conversely, none of the 5 segments non detectable in harmonic could be visualized in fundamental. The interobserver agreement in calculating ejection fraction was improved by harmonic imaging compared to fundamental (r = 0.91 and r = 0.67, respectively). In the selected clinical cases the diagnosis was easier and faster by harmonic imaging. The harmonic mode drastically improves echocardiographic imaging, it may be used routinely and reduce the need for more invasive techniques such as transesophageal echocardiography.

Flail tricuspid valve in a patient with history of stab chest wound.

Cardiac sequelae of stab chest wounds may be various and dramatic, and the right ventricle is the most commonly injured chamber. Correct diagnosis of cardiac damage may be done up to many years after the trauma. We describe a rare case of isolated, unexpected flail tricuspid valve detected by transthoracic echocardiography in a young patient with remote history of stab chest wound.

The complex relation between myocardial viability and functional recovery in chronic left ventricular dysfunction.

Preserved myocardial viability and recurrent symptomatic ischemia are the most widely accepted criteria indicating that coronary revascularization should take place in patients with postischemic left ventricular dysfunction. However, the presence of viable myocardium within the infarct zone does not necessarily imply recovery of function after coronary revascularization. The complex relation between the extent of transmural necrosis and the degree of residual perfusion within the infarct area plays an important role. However, independently of functional recovery, cell viability may have important clinical implications, since it may improve long-term prognosis by attenuating left ventricular remodeling processes. Several different methods are used to detect hibernating myocardium. Mounting evidence suggests that thallium-201 scintigraphy is most sensitive in identifying tissue viability, whereas dobutamine echocardiography is most specific in predicting functional recovery after revascularization. In between, myocardial contrast echocardiography is the only technique able to evaluate the microvascular integrity that is a condition sine qua non for both cell viability and later functional recovery. Combined information derived from these 3 different approaches might be considered as the best way to understand how the combination of contractile, viable but noncontractile, and dead tissue affect resultant function and prognosis.