Un incremento exagerado de la presión arterial con el ejercicio no predice mortalidad ni eventos cardiovasculares graves en mujeres referidas a ecocardiografía de ejercicio por razones clínicas / An exaggerated increase in blood pressure with exercise does not predict mortality or severe cardiovascular events in women referred for exercise echocardiography for clinical reasons

FUNDAMENTO Y OBJETIVOS: La asociación entre un incremento exagerado de la presión arterial sistólica con el ejercicio (IEPASE) y la probabilidad de eventos cardiovasculares es controvertida y poco estudiada en población femenina. Nuestro propósito fue determinar la posible asociación de un IEPASE con mortalidad y eventos cardiovasculares en mujeres referidas a ecocardiografía de ejercicio por enfermedad coronaria conocida o sospechada. PACIENTES Y MÉTODOS: Se realizó ecocardiografía de ejercicio a 3.942 mujeres con enfermedad coronaria conocida o sospechada. El IEPASE se definió como un incremento de la presión arterial sistólica con el ejercicio ≥70mmHg. Los objetivos fueron mortalidad global y cardíaca, infarto agudo de miocardio (IM), accidente cerebrovascular (ACV) e intervenciones de revascularización coronaria. RESULTADOS: Trescientas treinta y dos mujeres desarrollaron IEPASE durante los test. En el seguimiento se registraron un total de 458 muertes (162 de origen cardíaco), 212 IM, 89 ACV y 345 intervenciones de revascularización coronaria. La tasa anual de mortalidad global y cardiaca fue inferior en el subgrupo de pacientes con IEPASE (0,15% vs. 2,3%, p = 0,02 y 0,01% vs. 0,2%, p = 0,015, respectivamente). No observamos diferencias significativas en las tasas de IM, ACV y de intervenciones de revascularización coronaria, que fueron, respectivamente, del 1,1%, 0,43% y 2,24% en pacientes con IEPASE y del 0,09%, 0,05% y 0,13% en aquellas mujeres sin IEPASE (p = 0,66; p = 0,57; p = 0,19, respectivamente), Tras un ajuste multivariante el IEPASE no resultó predictor de mortalidad ni de eventos cardiovasculares. CONCLUSIONES: El IEPASE no se asoció con mortalidad ni eventos cardiovasculares graves en mujeres con enfermedad coronaria conocida o sospechada

BACKGROUND AND OBJECTIVES: The association between an exaggerated systolic blood pressure increase with exercise (EBPIE) and the probability of cardiovascular events is controversial and poorly studied in the female population. Our aim was to determine the possible association between EBPIE on one hand and mortality and cardiovascular events on the other in women referred for exercise echocardiography due to known or suspected coronary artery disease. PATIENTS AND METHODS: A total of 3942 women with known or suspected coronary artery disease underwent exercise echocardiography. We defined EBPIE as a ≥70mm Hg increase in systolic blood pressure with exercise. The study endpoints were overall and cardiac mortality, acute myocardial infarction (MI), stroke and coronary revascularisation procedures. RESULTS: A total of 332 women developed EBPIE during the test. During the follow-up, 458 deaths (162 of cardiac origin), 212 MIs, 89 strokes and 345 coronary revascularisation procedures were recorded. The annual rates of overall and cardiac mortality were lower in the patient subgroup with EBPIE (0.15% vs. 2.3%, P=.02 and 0.01% vs. 0.2%, P=.015, respectively). There were no significant differences in the rates of MI, stroke and the need for coronary revascularisation procedures, which occurred in 1.1%, 0.43% and 2.24% of the patients with EBPIE, respectively, and occurred in 0.09%, 0.05% and 0.13% of the women without EBPIE (P=.66; P=.57; P=.19, respectively). After a multivariate adjustment, EBPIE was not a predictor of mortality or cardiovascular events. CONCLUSIONS: EBPIE is not associated with mortality or severe cardiovascular events in women with known or suspected coronary artery disease

An exaggerated increase in blood pressure with exercise does not predict mortality or severe cardiovascular events in women referred for exercise echocardiography for clinical reasons. / Un incremento exagerado de la presión arterial con el ejercicio no predice mortalidad ni eventos cardiovasculares graves en mujeres referidas a ecocardiografía de ejercicio por razones clínicas.

BACKGROUND AND OBJECTIVES: The association between an exaggerated systolic blood pressure increase with exercise (EBPIE) and the probability of cardiovascular events is controversial and poorly studied in the female population. Our aim was to determine the possible association between EBPIE on one hand and mortality and cardiovascular events on the other in women referred for exercise echocardiography due to known or suspected coronary artery disease. PATIENTS AND METHODS: A total of 3942 women with known or suspected coronary artery disease underwent exercise echocardiography. We defined EBPIE as a ≥70mm Hg increase in systolic blood pressure with exercise. The study endpoints were overall and cardiac mortality, acute myocardial infarction (MI), stroke and coronary revascularisation procedures. RESULTS: A total of 332 women developed EBPIE during the test. During the follow-up, 458 deaths (162 of cardiac origin), 212 MIs, 89 strokes and 345 coronary revascularisation procedures were recorded. The annual rates of overall and cardiac mortality were lower in the patient subgroup with EBPIE (0.15% vs. 2.3%, P=.02 and 0.01% vs. 0.2%, P=.015, respectively). There were no significant differences in the rates of MI, stroke and the need for coronary revascularisation procedures, which occurred in 1.1%, 0.43% and 2.24% of the patients with EBPIE, respectively, and occurred in 0.09%, 0.05% and 0.13% of the women without EBPIE (P=.66; P=.57; P=.19, respectively). After a multivariate adjustment, EBPIE was not a predictor of mortality or cardiovascular events. CONCLUSIONS: EBPIE is not associated with mortality or severe cardiovascular events in women with known or suspected coronary artery disease.

Respuesta hipertensiva exagerada al ejercicio e isquemia miocárdica en pacientes con enfermedad coronaria conocida o sospechada / Exaggerated hypertensive response to exercise and myocardial ischaemia in patients with known or suspected coronary artery disease

Objetivos. La asociación entre una respuesta hipertensiva exagerada al ejercicio (RHEE) y la probabilidad de isquemia en las pruebas de esfuerzo es controvertida. Nuestro propósito fue determinar la posible asociación entre una RHEE y el desarrollo de dolor torácico y de isquemia electrocardiográfica o ecocardiográfica con el ejercicio. Pacientes y métodos. Estudio retrospectivo y observacional de 10.047 pacientes con enfermedad coronaria conocida o sospechada referidos para una ecocardiografía de ejercicio. Un análisis de regresión logística evaluó el efecto del desarrollo de una RHEE (definida como una presión arterial sistólica máxima con el ejercicio ≥ 220mmHg) y la aparición de dolor torácico y de cambios electrocardiográficos y ecocardiográficos sugestivos de isquemia. Resultados. Un total de 402 pacientes desarrollaron una RHEE. Los porcentajes de dolor torácico anginoso, isquemia electrocardiográfica y ecocardiográfica entre los pacientes con RHEE fueron del 8,2, 16,2 y 22,6%, frente al 13,8, 14,7 y 27,5%, respectivamente, en pacientes sin RHEE (p=0,001, p=0,4, p=0,032). Tras un ajuste multivariado, la RHEE se asoció con una menor probabilidad de aparición de dolor torácico anginoso inducido por el esfuerzo (OR 0,44; IC 95% 0,30-0,65; p<0,001) y de isquemia ecocardiográfica (OR 0,63; IC 95% 0,48-0,83; p=0,001), pero no con el desarrollo de isquemia electrocardiográfica. Conclusiones. La RHEE se asocia con una menor prevalencia de dolor torácico anginoso e isquemia ecocardiográfica en pacientes con enfermedad coronaria conocida o sospechada (AU)

Objectives. The association between an exaggerated hypertensive response to exercise (EHRE) and the probability of ischaemia in stress tests is controversial. Our purpose was to determine the possible association between an EHRE and the development of chest pain and electrocardiographic or echocardiographic ischaemia with exercise. Patients and methods. A retrospective observational study was conducted of 10,047 patients with known or suspected coronary artery disease referred for exercise echocardiography. A logistic regression analysis assessed the effect of developing an EHRE (defined as a maximum systolic blood pressure with exercise ≥220mmHg) and the onset of chest pain and electrocardiographic and echocardiographic changes suggestive of ischaemia. Results. A total of 402 patients developed an EHRE. The rates of angina, electrocardiographic ischaemia and echocardiographic ischaemia among the patients with an EHRE were 8.2, 16.2 and 22.6% versus 13.8, 14.7 and 27.5%, respectively, for patients without an EHRE (p=.001, p=.4, p=.032). After a multivariate fit, EHRE was associated with a lower probability of exercise-induced angina (OR, 0.44; 95% CI 0.30-0.65; p<.001) and echocardiographic ischaemia (OR, 0.63; 95% CI 0.48-0.83; p=.001) but not with the onset of electrocardiographic ischaemia. Conclusions. EHRE is associated with a lower prevalence of angina and echocardiographic ischaemia in patients with known or suspected coronary artery disease (AU)

Exaggerated hypertensive response to exercise and myocardial ischaemia in patients with known or suspected coronary artery disease. / Respuesta hipertensiva exagerada al ejercicio e isquemia miocárdica en pacientes con enfermedad coronaria conocida o sospechada.

OBJECTIVES: The association between an exaggerated hypertensive response to exercise (EHRE) and the probability of ischaemia in stress tests is controversial. Our purpose was to determine the possible association between an EHRE and the development of chest pain and electrocardiographic or echocardiographic ischaemia with exercise. PATIENTS AND METHODS: A retrospective observational study was conducted of 10,047 patients with known or suspected coronary artery disease referred for exercise echocardiography. A logistic regression analysis assessed the effect of developing an EHRE (defined as a maximum systolic blood pressure with exercise ≥220mmHg) and the onset of chest pain and electrocardiographic and echocardiographic changes suggestive of ischaemia. RESULTS: A total of 402 patients developed an EHRE. The rates of angina, electrocardiographic ischaemia and echocardiographic ischaemia among the patients with an EHRE were 8.2, 16.2 and 22.6% versus 13.8, 14.7 and 27.5%, respectively, for patients without an EHRE (p=.001, p=.4, p=.032). After a multivariate fit, EHRE was associated with a lower probability of exercise-induced angina (OR, 0.44; 95% CI 0.30-0.65; p<.001) and echocardiographic ischaemia (OR, 0.63; 95% CI 0.48-0.83; p=.001) but not with the onset of electrocardiographic ischaemia. CONCLUSIONS: EHRE is associated with a lower prevalence of angina and echocardiographic ischaemia in patients with known or suspected coronary artery disease.

WITHDRAWN: Accuracy of Peak Treadmill Exercise Echocardiography to Detect Multivessel Coronary Artery Disease: Comparison with Post-exercise Echocardiography.

The publisher regrets that this was an accidental duplication of an article that has already been published in Eur. J. Echocardiogr., 4 (2003) 182-190, . The duplicate article has therefore been withdrawn.

Accuracy of peak treadmill exercise echocardiography to detect multivessel coronary artery disease: comparison with post-exercise echocardiography.

AIMS: Although peak exercise echocardiography has been reported for both bicycle and treadmill exercise and has shown higher sensitivity than post-exercise imaging, little is known about its utility for identifying multivessel involvement. We sought to compare feasibility and accuracy of peak treadmill exercise echocardiography vs post-exercise echocardiography for identification of multivessel coronary artery disease and to assess its incremental value when combined with clinical and exercise test variables. METHODS AND RESULTS: The study group included 335 patients (228 men; mean (+/- SD) age 60 +/- 11 years). Two hundred and seventy-nine patients were included on the basis of having had an exercise echocardiography and a coronary angiography within 4 months of the exercise test. To avoid bias to coronary angiography, a subgroup of 56 consecutive non-diabetic patients referred for exercise echocardiography with pretest probability of coronary artery disease <10% and had atypical chest pain or were asymptomatic were also included and considered as having no coronary artery disease. Multivessel coronary artery disease (> or = 50% diameter stenosis in >1 vessel) was confirmed in 170 patients, whereas 165 patients were considered to have one-vessel coronary artery disease or no coronary lesions. Positive exercise echocardiography was defined as ischaemia or necrosis in at least two coronary territories. Post-exercise images were acquired within 125 s after exercise (49 +/- 15). Mean heart rate (bpm) was 139 +/- 19 at peak vs 117 +/- 22 at post-exercise imaging (P<0.001). Interpretable peak and post-exercise images were obtained for all patients. Sensitivity for predicting multivessel disease was higher with peak than with post-exercise imaging (79 vs 55%, P<0.001), with lower specificity (79 vs 88%, P<0.05). Predictive positive value was similar (80 vs 83%). Negative predictive value was again higher with peak imaging (78 vs 66%, P<0.01). Total accuracy was not different (79 vs 72%). A stepwise logistic regression analysis identified peak exercise echocardiography positivity for multivessel coronary artery disease as the strongest independent predictor of multivessel disease (odds ratio (OR): 7.36); also significant were male gender (OR: 4.22), diabetes mellitus (OR: 4.28), previous myocardial infarction (OR: 3.12) and increment of product heart rate x blood pressure (OR: 1.00). CONCLUSIONS: Peak treadmill exercise echocardiography is technically feasible and has higher sensitivity and negative predictive value for predicting multivessel disease than post-treadmill exercise echocardiography. This method adds independent and incremental values to clinical and exercise variables for the diagnosis of multivessel coronary artery disease. Therefore, in the clinical setting, peak exercise echocardiography should be performed to diagnose multivessel coronary artery disease.

Comparison of two-dimensional echocardiography and pulsed Doppler tissue imaging during dobutamine-atropine stress testing to detect coronary artery disease.

In order to compare the diagnostic accuracy of two-dimensional (2-D) echocardiography and pulsed Doppler tissue imaging (pDTI) during dobutamine-atropine stress testing (DAST) to detect significant coronary lesions, 41 patients underwent DAST (up to 40 microg/k/min of dobutamine with additional atropine during submaximal heart rate responses) and coronary angiography. Pulsed Doppler tissue sampling of territories corresponding to the left anterior descending (LAD), left circumflex (LCx), and right coronary arteries (RCAs) were performed in the apical four-chamber plus aorta and two-chamber apical views. The measurements were repeated at rest, at low dose (10 microg/k/min), and at peak stress. Pulsed DTI measurements included peak early systolic (Vs), peak early diastolic (Ve), and peak late diastolic (Va) velocities. Harmonic 2-D echocardiography was recorded at rest, low dose, peak stress, and recovery, and compared with pDTI assessment. Positive 2-D echocardiography was considered as infarction or ischemic response. The results were evaluated for the prediction of significant coronary stenosis (50% luminal narrowing). Feasibility of pDTI was 100%, 95%, and 98% for the LAD, the LCx, and RCA territories, respectively. At rest, Vs in territories supplied by arteries with coronary artery disease (CAD) (6.3 +/- 2.0 cm/sec) was not different from those without (6.6 +/- 2.1 cm/sec). Vs increased less in territories supplied by arteries with than without CAD (75 +/- 107% vs 102 +/- 69%, P = NS). Ve was lower in territories with CAD at rest (6.0 +/- 2.1 cm/sec vs 8.2 +/- 3.4 cm/sec, P < 0.0001) and low dose (7.2 +/- 2.1 cm/sec vs 8.8 +/- 3.6 cm/sec, P < 0.01), but similar at peak stress (7.6 +/- 3.5 cm/sec vs 8.1 +/- 3.3 cm/sec). Ve increase was similar in territories with (36 +/- 74%) than without CAD (15 +/- 6 4%). Va was similar at rest and low dose in territories with and without CAD (9.2 +/- 2.7 cm/sec vs 9.1 +/- 2.3 cm/sec and 10.9 +/- 3.1 vs 10.3 +/- 3.6 cm/sec, respectively), but lower at peak stress in territories with CAD (13.3 +/- 4.6 cm/sec vs 15.3 +/- 4.5 cm/sec, P = 0.05). The Va increase was lower in territories with CAD (43 +/- 37% vs 77 +/- 72%, P < 0.05). In a territory-based analysis, a failure to achieve Vs > or =10.5 cm/sec at peak stress in the LAD and LCx, and > or =10.0 cm/sec in the RCA territory, was found to be the more accurate limit to detect CAD in the corresponding arteries: sensitivity (95% confidence intervals): 63% (55-71), P = NS vs 2-D echocardiography: 59% (51-67); specificity 76% (68-84), P < 0.01 vs. 2-D echocardiography: 95% (89-100); and accuracy 69% (63-75), P = NS vs 2-D echocardiography: 76% (70-82). Thus, pDTI is feasible during DAST but not more accurate than 2-D echocardiography for the detection of significant CAD in a territory-based study.

Accuracy of exercise echocardiography to detect coronary artery disease in left bundle branch block unassociated with either acute or healed myocardial infarction.

To search for the value of treadmill exercise echocardiography in the detection of coronary artery disease in noninfarcted patients with left bundle branch block, we studied 35 patients (17 with coronary artery disease). We found high sensitivity, specificity, and accuracy (76%, 83%, and 80%, respectively).

Comparison of treadmill exercise echocardiography before and after exercise in the evaluation of patients with known or suspected coronary artery disease.

OBJECTIVES: We sought to compare the feasibility and accuracy of peak treadmill exercise echocardiography versus postexercise echocardiography imaging. BACKGROUND: Although peak exercise echocardiography has been reported for both supine and orthostatic bicycle exercise and has shown higher sensitivity than postexercise imaging, acquiring images at peak exercise with treadmill has not been explored. METHODS: Peak and post-treadmill exercise echocardiography and coronary angiography were performed on 89 patients with known or suspected coronary artery disease. Positive exercise echocardiography was defined as necrosis or ischemic response. Positive coronary angiography was defined as >/=1 diseased vessels (>/=50% luminal narrowing). Images were analyzed in a blind manner by an expert observer. RESULTS: Postexercise images were acquired within 80 seconds after exercise (40 +/- 14). Mean heart rate (bpm) was 139 +/- 22 at peak versus 118 +/- 25 at postexercise imaging (P <.001). Interpretable peak and postexercise images were obtained for all 89 patients. Of the 72 classified as having positive exercise echocardiography, 23 had new regional wall motion abnormality at peak (21 with positive angiography), which resolved at postexercise imaging. Sensitivity was higher with peak than with postexercise imaging (94% vs 73%, P <.001). Specificity was similar (68% vs 79%), as was predictive positive value (92% vs 93%). Negative predictive value was again higher with peak imaging (76% vs 44%, P <.05). Total accuracy was higher with peak imaging (89% vs 74%, P <.05). CONCLUSIONS: Peak treadmill exercise echocardiography is technically feasible and has higher sensitivity and accuracy than post-treadmill exercise echocardiography. Therefore in the clinical setting peak exercise echocardiography should be performed to diagnose ischemia.

Labil subaortic obstruction during exercise stress echocardiography.

Exercise-induced subaortic obstruction and/or mitral valve systolic anterior motion causing mitral regurgitation were found in 43 of 2,280 patients (1.8%) assigned to treadmill exercise echocardiography.

[Combined perioperative ultrafiltration in pediatric cardiac surgery. The preliminary results]. / Ultrafiltración combinada perioperatoria en cirugía cardíaca pediátrica. Resultados preliminares.

INTRODUCTION AND OBJECTIVES: Recently, ultrafiltration techniques are used more and more as a treatment for the inflammatory response of cardiopulmonary bypass. It also provides fine control of fluids. The purpose of this study is to present a technique which combines conventional and modified ultrafiltration and to analyze the obtained results. PATIENTS AND METHODS: 22 patients (mean weight 13.1 +/- 8.4 kg) operated on cardiopulmonary bypass. Combined ultrafiltration was performed during cardiopulmonary bypass (conventional) and after pump (modified ultrafiltration). We analyzed cardiopulmonary bypass variables, the first 24-hour hemodynamics, biological variables (arterial blood gases, cell counts, IL-6, adhesion molecules ICAM-1 and VCAM-1, and coagulation profiles). RESULTS: A total amount of 1,399 +/- 680 ml/m2 of mean combined ultrafiltrate volume was obtained (657 +/- 386 ml/m2 during cardiopulmonary bypass and 845 +/- 358 ml/m2 post-cardiopulmonary bypass). After modified ultrafiltration, hematocrit rose from 23 +/- 2.3 to 32 +/- 4.1, arterial systolic blood pressure rose from 74 +/- 13 to 98 +/- 20 mmHg, heart rate decreased from 133 +/- 22 to 126 +/- 23 bpm, and central versus pressure did not change. A statistically significant relationship (multivariable), was shown between modified ultrafiltration time and VCAM-1 post-ultrafiltration levels. Platelet count was lower and diuresis rose related to cardiopulmonary bypass ultrafiltration volume and diuresis increased. CONCLUSIONS: Perioperative combined ultrafiltration is feasible without undue morbidity and provides adequate hemoconcentration and excellent postoperative hemodynamic results. More studies with control groups are necessary to better define the therapeutic influence in antiinflammatory properties of this technique.

The effect of exercise on ischemic mitral regurgitation.

This study investigated the effect of dynamic exercise on mitral regurgitation (MR) as assessed by color flow Doppler imaging and tested the hypothesis that MR increases in patients with left ventricular (LV) function worsening during exercise. We studied 513 patients (390 men, 123 women:mean age [+/-1 SD] 58+/-11 years) referred for treadmill exercise echocardiography (EE) to evaluate known or suspected coronary artery disease. Normal EE was seen in 182 (36%), necrosis in 131 (25%), and ischemic response (with or without necrosis) in 200 (39%). MR assessment was performed at rest and immediately postexercise, on the basis of the mosaic area. At rest, mild MR (<3 cm2) was seen in 138; moderate (3 to 6 cm2) was seen in 21; and severe (>6 cm2) was seen in 5. Forty-two patients developed new, mild (n=35), moderate (n=6), or severe (n=1) MR during exercise. Patients were assigned to three groups: group 1--new or increased MR from rest to exercise (n=70); group 2--MR at rest unchanged or decreased (n=136); and group 3--no MR at rest and exercise (n=307). At rest, LV ejection fraction (EF) and wall motion score index (WMSI) were similar in group 1 and group 2 but improved in group 3 (EF: group 1, 51+/-11%; group 2, 53+/-10%; group 3, 56+/-8%, p<0.001 vs group 1 and group 2. WMSI: group 1, 1.3+/-0.3; group 2, 1.3+/-0.4; group 3, 1.1+/-0.2, p<0.01 vs group 1, p<0.001 vs group 2). At exercise, EF and WMSI were impaired in group 1 (EF: group 1, 52+/-14%; group 2, 58+/-15%; group 3, 64+/-11%, p<0.001 vs group 1 and group 2; p<0.05 between group 1 and group 2. WMSI: group 1, 1.5+/-0.4; group 2, 1.4+/-0.4; group 3, 1.2+/-0.3, p<0.001 vs group 1 and group 2, p<0.05 between group 1 and group 2). An ischemic response was common in group 1 (67% vs 35% in group 2 and 34% in group 3, p<0.001 between group 1 and group 3 and between group 1 and group 2). Accordingly, in group 1 patients, exercise time was diminished (7.3+/-2.7 vs 8.4+/-2.7 in group 2 and 9.3+/-2.4 in group 3, p<0.01, between group 1 and group 2, p<0.001 between group 1 and group 3, p<0.001 between group 2 and group 3) and the number of severely narrowed coronary vessels greater (2.4+/-0.9 vs 1.7+/-1.0 in group 2 and 1.7+/-1.0 in group 3). In conclusion, MR does not increase in most patients submitted to dynamic exercise echocardiography. However, if MR develops, severe LV function worsening should be suspected.

[The value of exercise echocardiography in the diagnosis of coronary disease in patients with left heart branch block in the bundle of His]. / Valor de la ecocardiografía de ejercicio en el diagnóstico de enfermedad coronaria en pacientes con bloqueo de rama izquierda del haz de His.

OBJECTIVE: To assess the diagnostic value of exercise echocardiography in patients with complete left bundle branch block and clinical suspicion of coronary artery disease. MATERIAL AND METHODS: Among 1,176 exercise echocardiograms performed from May of 1994 to November of 1996, 92 showed complete left bundle branch block in the resting electrocardiogram. We retrospectively analyzed data of 23 patients who had coronary angiography performed within 6 weeks of the exercise echo (19 males and 4 females, age 62 +/- 8, resting ejection fraction 52 +/- 10%). Previous acute myocardial infarction was demonstrated in 8 of them. The development of new or worsening regional dysfunction was considered an ischaemic response on exercise echo; whereas we assumed that there was significant coronary artery disease on the coronariography whether there was > or = 1 vessel disease in patients without previous myocardial infarction or > or = 2 vessel disease in patients with previous infarction. RESULTS: Ten patients showed multivessel disease (> or = 2 vessels, 6 with previous infarction); 5 one-vessel disease; and 8 non significant coronary artery disease. Exercise echocardiography sensitivity for ischaemia detection in the entire group was 86% (95% confidence interval 67-100%); the specificity was 67% (36-98%), predictive value of a positive test was 80% and predictive value of a negative test was 75%. Sensitivity for the detection of > 50% stenosis in the left anterior descending coronary territory was 92% (76%-100%) and specificity 64% (35%-92%); for right coronary artery sensitivity was 80% (55%-100%) and specificity 77% (54%-100%); and for left circumflex artery sensitivity was 70% (42%-98%) and specificity 69% (44%-94%). CONCLUSIONS: Exercise echocardiography may be useful in the evaluation of patients with left bundle branch block and clinical suspicion of coronary artery disease; with good sensitivity and low specificity.

Differences in heart transplant physiology according to surgical technique.

A new cardiac transplantation technique that preserves the shape of the left atrium and leaves the right atrium intact has been introduced. To compare the new and the standard techniques, we studied cardiac physiology with Doppler echocardiography and catheterization in 26 patients who underwent operation with the standard technique (group A) and I1 who underwent operation with the new technique (group B). Right atrial dimensions were significantly lower in group B (right atrial area index 8.4 +/- 1.5 vs 14.5 +/- 1.9 cm2/m2, p < 0.001), whereas left atrial dimensions were slightly lower (left atrial area index 10.8 +/- 2.0 vs 16.4 +/- 7.0 cm2/m2, p = 0.07). Right atrial contraction, as reflected by peak late tricuspid velocity, was greater in group B (37 +/- 15 vs 30 +/- 10 cm/sec, p < 0.05). The subsequent systolic vena caval flow-velocity integral was also greater in group B at all respiratory phases (inspiration 10.0 +/- 4.0 vs 5.2 +/- 4.0 cm, p < 0.001; expiration 4.8 +/- 1.9 vs 2.9 +/- 1.4 cm, p < 0.001; apnea 5.3 +/- 2.0 vs 2.9 +/- 1.9 cm, p < 0.001) suggesting better atrial relaxation. Filling pressures on the right side of the heart were lower in group B (mean right atrial pressure 5.5 +/- 2.4 vs 6.6 +/- 2.8 mm Hg, p = 0.1; right atrial A wave 6.0 +/- 3.1 vs 8.3 +/- 3.2 mm Hg, p < 0.01; right atrial V wave 6.8 +/- 3.1 vs 9.2 +/- 3.2 mm Hg, p < 0.01; right ventricular end-diastolic pressure 5.6 +/- 3.2 vs 7.3 +/- 2.9 mm Hg, p < 0.05); however, no significant differences were found in left ventricular end-diastolic pressure or cardiac index. We conclude that patients undergoing the new technique exhibit cardiac physiologic improvements. Follow-up study is indicated to ascertain whether this finding implies improved long-term prognosis.

Unreliability of echocardiographic and Doppler indexes in the diagnosis of heart transplant acute rejection.

OBJECTIVE: To investigate the value of Doppler echocardiography to diagnose heart transplant acute rejection in both patients submitted to the standard surgical technique (Group A), and to a new technique that preserves the size of the left atrium and leaves the right atrium intact (Group B). METHODS: 122 Doppler echocardiographic studies and endomyocardial biopsies were performed on 27 group A and 11 group B patients. Systolic measurements included left ventricular shortening fraction, left ventricular endsystolic stress and tricuspid ring systolic displacement. Diastolic indexes investigated were left and right ventricle filling and superior vena caval flow parameters. RESULTS: As expected, right atrium was smaller in group B(p < 0.01). In group A, peak early to late mitral flow velocity increased, as did the rejection grade; whereas in group B it decreased. Pericardial effusion was seen more frequently in group B rejectors (> or = 3) than non-rejectors (63% vs 27%, p < 0.01). Right heart pressures (right ventricular end-diastolic and right atrial mean) were slightly higher for group A and B rejector patients (p < 0.05 when comparing right ventricular end-diastolic pressure in rejector to non-rejector group B patients). Left ventricular isovolumic relaxation time was reduced during subsequent rejection episodes in the same patient, but sensitivity of 15% left ventricular isovolumetric relaxation time reduction for rejection > or = 3 diagnosis was only 22% with a specificity of 73%. No significant intrapatient changes were found in other Doppler-derived systolic or diastolic indexes. CONCLUSION: Doppler echocardiography does not diagnose heart transplant acute rejection with enough reliability to avoid endomyocardial biopsies.

Spontaneous reversal of a cardiomyostimulator to asynchronous mode.

A patient who underwent dynamic cardiomyoplasty at our institute 10 months earlier was recently found to have asynchronous function of his cardiomyostimulator (model SP1005A, Medtronic, Inc.). This patient had been exposed to metal detection equipment 3 months earlier at an airport security gate, and this equipment was deemed responsible for this change in device programming. Despite the asynchronous function of the device, the patient did not suffer any functional impairment during this 3-month period. Moderate electromagnetic interference is capable of resetting the SP1005A cardiomyostimulator to the asynchronous mode of operation. Muscle stimulation, therefore, will not precisely occur during the systolic phase of the cardiac cycle and systolic augmentation may be lost. Despite asynchronous muscle stimulation, no impairment of this patient's functional Class was observed. This stability may be credited purely to the effect of the muscular wrap around the ventricles in which ventricular wall stress is decreased.

Changes in left ventricular mass and filling after renal transplantation are related to changes in blood pressure: an echocardiographic and pulsed Doppler study.

To examine changes in left ventricular (LV) mass and function (diastolic and systolic) after successful renal allograft transplantation (RT), we prospectively studied 30 patients (19 men, 11 women, aged 37 +/- 13 years) by M-mode, two-dimensional and pulsed Doppler echocardiography at the time of surgery and 10 +/- 1.8 months later. At the time of transplantation all patients had been undergoing dialysis (4 peritoneal dialysis, 26 hemodialysis) for 2.5 +/- 3.2 years. A hematocrit of < or = 30% was present in 26 patients. After RT the mean hematocrit increased from 26 +/- 4 to 40 +/- 7 (p < 0.01), whereas systolic, diastolic and mean blood pressure (BP) remained unchanged. The LV mass index (LVMI) decreased from 201 +/- 56 to 171 +/- 41 g/m2, (p < 0.01); LV diastolic diameter corrected by body surface area (LVDDI) decreased from 298 +/- 38 to 279 +/- 35 (p < 0.01) and the LV end-diastolic volume index (LVEDVI) from 72 +/- 18 to 63 +/- 15 (p < 0.01). There were no changes in LV fractional shortening or LV end systolic wall stress. Peak late transmitral velocity (A wave) decreased from 77 +/- 16 to 68 +/- 12 cm/s (p < 0.01) with no changes in other Doppler-derived indexes of diastolic function. No fistula patency influence on changes in LV mass and function was found. After RT, BP decreased in 21 patients from 150 +/- 20 to 132 +/- 15 (p < 0.001; group I) and increased in 9 patients from 130 +/- 14 to 153 +/- 16 (p < 0.05, group II). Patients in group I suffered a reduction in LVMI (p < 0.001), LV end-diastolic diameter (p < 0.05), LVDDI (p < 0.001); LV end-diastolic volume (p < 0.05); LVEDVI (p < 0.01); cardiac index (p < 0.05), and peak late transmitral velocity (p < 0.01), but no changes in group-II patients were observed. We concluded that BP is a major determining factor with regard to changes in LV hypertrophy and function following RT. LV mass and volumes can be expected to decrease after RT in patients with BP reduction.