Comparison of echocardiographic markers of embolism in atrial flutter and fibrillation: frequency of protruding atherosclerotic plaques in the thoracic aorta.

The potential additional embolic risk of protruding aortic plaques > or = 4 mm and left atrial abnormalities such as thrombus, spontaneous echocardiographic contrast (SEC), low left atrial appendage velocity, recently has been shown in patients with atrial fibrillation (AF). However, the presence and potential role of transesophageal echocardiographic (TEE)-detected protruding aortic plaques > or = 4 mm have not been systematically evaluated in patients with atrial flutter. Among 2493 patients evaluated by TEE, 271 consecutive patients with atrial flutter (n = 41) and AF (n = 230) > or = 2 days duration were included in the study. Clinical and echocardiographic characteristics in consecutive patients with atrial flutter were compared to those in patients with AF, especially atrial morphology and function and atherosclerotic disease of the thoracic aorta. Clinical characteristics of patients with atrial flutter and AF were similar with regard to age (68 +/- 13 and 67 +/- 12, P = 0.628), sex ratio (men, 66% and 54%, P = 0.212), and previous embolic events (5% and 15%, P = 0.126), respectively. The frequency of protruding atherosclerotic plaques > or = 4 mm (12% and 11%, P = 0.919) and SEC (15% and 14%, P = 0.847) in the thoracic aorta was similar in patients with atrial flutter and AF. Left atrial appendage area was smaller (3.1 +/- 0.7 and 6.0 +/- 3.0 cm(2), P = 0.001), left atrial appendage SEC was less frequent (17% and 37%, P = 0.024), and left atrial appendage emptying velocity was higher (47 +/- 10 and 30 +/- 10 cm/s, P = 0.030) in patients with atrial flutter as compared to those with AF. There was no difference between the two groups regarding left ventricular fractional shortening (30 +/- 10% and 33 +/- 13%, P = 0.630), rheumatic valvular disease (5% and 12%, P = 0. 301), left atrial diameter (43 +/- 7 and 45 +/- 8 mm, P = 0.134), right atrial area (16 +/- 4 and 17 +/- 6 cm(2), P = 0.384), left atrial SEC (39% and 53%, P = 0.124), or atrial thrombus ( 2% and 3%, P = 0.888) respectively. Our results point to the high prevalence of protruding atherosclerotic plaques in the thoracic aorta in patients with atrial flutter.

Usefulness of pulmonary regurgitation Doppler tracings in predicting in-hospital and long-term outcome in patients with inferior wall acute myocardial infarction.

Right ventricular (RV) involvement is frequent during inferior wall acute myocardial infarction (AMI) and has been reported as a risk factor for in-hospital morbidity and mortality. The objectives of the present study were: (1) to evaluate in-hospital events in patients with and without RV involvement as diagnosed by abnormal flow characteristics derived from pulmonary regurgitation (PR) analysis (pressure half-time of PR, PHT(PR) < or = 150 ms and the lowest mid-diastolic to peak early diastolic velocity ratio, Vmin/Vmax < or = 0.5); and (2) to determine the influence of RV involvement in complications at long-term follow-up. Among 126 consecutively admitted patients with inferior wall AMI (mean age, 58 +/- 13 years), 101 had PR. We determined the prognostic significance of in-hospital and long-term events for the following variables: age > or = 65 years, ST-segment elevation > or = 1 mm in lead V4R, RV dilation, PHT of PR < or = 150 ms and Vmin/Vmax < or = 0.5, thrombolytic therapy, 3-vessel disease, and diabetes mellitus. We found that the PR derived Doppler index (PHT of PR < or = 150 ms and Vmin/Vmax < or = 0.5) was the only predictor of overall in-hospital clinical events (hazards ratio, 2.7, 95% confidence interval, 1.2 to 6.1, p = 0.016). At long-term follow-up (mean: 20 +/- 12 months, range 12 to 69), event-free survival analysis showed that age > or = 65 years was the only predictor of any event (relative risk, 3.7, 95% confidence interval, 2.1 to 6.3, p < 0.0001). Thus, RV involvement diagnosed with the use of PR flow-derived variables is an accurate and independent predictor of in-hospital complications. However, RV involvement does not influence long-term prognosis.

Is dobutamine stress echocardiography useful for noninvasive differentiation of ischemic from idiopathic dilated cardiomyopathy?

Dobutamine stress echocardiography was performed in 56 consecutive patients, mean age: sixty-two +/- twelve years. Twenty-two patients had an idiopathic dilated cardiomyopathy (group 1) and 34 had angiographically proven ischemic dilated cardiomyopathy (group 2). Wall motion score index and left ventricular ejection fraction were determined at baseline, 5 micrograms/kg/min, peak, and ten minutes after stepwise dobutamine infusion. Worsening or no change in global wall motion score was observed in 9 group 2 patients (26%) and 1 group 1 patient (5%, P = .07). No significant difference was observed with regard to wall motion score index decrease between baseline and peak dose. Left ventricular ejection fraction increase during dobutamine infusion was comparable in both groups. Thus, an ischemic response was observed more often in the coronary artery disease group, yielding a good specificity and positive predictive value although sensitivity was low. However, left ventricular function improvement did not help to discriminate patients with or without significant CAD.

[Clinical, echocardiographic and Doppler outcome in ischemic right ventricular dysfunction associated with inferior wall infarction]. / Evolution clinique, échocardiographique et Doppler de la dysfonction ischémique ventriculaire droite associée à un infarctus inférieur.

Right ventricular involvement during inferior wall myocardial infarction does not seem to alter long-term clinical prognosis but its specific outcome has not been clearly studied. We have previously demonstrated that pulmonary regurgitant (PR) flow tracings doppler analysis allows the accurate diagnosis of RV involvement, especially when the pressure half-time of PR was < or = 150 ms and the ratio of the minimal velocity to the maximal velocity was < or = 0.5. We studied 40 patients with acute inferior wall myocardial infarction and with PR flow. Doppler echocardiography was obtained during the first day, before discharge (early control) and between 12 and 24 months follow-up (late control). Among 22 patients with RV involvement defined with PR-derived doppler parameters (RVIPR). 8 had right ventricular enlargement and/or wall motion abnormalities, observed in 6 cases at early control and in 4 at late control. Doppler analysis showed remnant RVIPR parameters in 9 patients at early control and 8 among these at late contorl, with no relation with pulmonary artery pressure or other echocardiographic parameters. No clinical, angiographic or therapeutic data predicted these distinct echocardiographic and doppler patterns and the long-term prognosis was not different. At late control, among 12 RVIPR patients which PR-derived doppler parameters were normal at early control, two patients had still RVIPR pattern at late control and described ischemic recurrence. PR flow doppler analysis is a useful tool for diagnosis and outcome evaluation of RV involvement and shows a remnant diastolic dysfunction in half of the patients with acute RV involvement.

[Dobutamine stress echocardiography; a monocentric experience on 600 consecutive patients. Effect of age]. / Echocardiographie sous dobutamine; expérience monocentrique portant sur 600 patients consécutifs. Influence de l'âge.

The increasing indications of dobutamine stress echo in the investigation of myocardial ischaemia, viability and evaluation of the prognosis of coronary artery disease has made this technique a tool of everyday clinical practice. The authors reviewed the results of 600 investigations in consecutive unselected including patients aged over 75. No significant difference was observed with respect to the causes of interruption of the test between patients aged less than 75 (521 patients) and those older than 75 (79 patients). Attaining the target theoretical maximal heart rate was the commonest reason for stopping the test (47 and 48% respectively). Ventricular arrhythmias were not more common (12 and 10% respectively). Twelve cases of ventricular tachycardia were observed, 8 of which were non-sustained; 9 led to interruption of the test. No cases of ventricular fibrillation were observed. A previous history of cardiac arrhythmias was not associated with a higher frequency of arrhythmia during the test (8% in those with a previous history, 4% in those patients without). Supraventricular arrhythmias were significantly more common in patients over 75 years of age (15 versus 8%, p = 0.046). Dobutamine stress echocardiography' is feasible in a population of unselected patients, including those over 75. Therefore, age does not represent a limitation to the extension of this investigation.

[Morphological study by transesophageal echocardiography and clinical aspects of ruptured chordae tendineae in the elderly]. / Etude morphologique par échocardiographie transoesophagienne et aspects cliniques de la rupture de cordages mitral chez le sujet âgé.

Ruptured mitral chordae tendinae is a classical complication of myxomatous mitral valves or Barlow's syndrome. This complication is controversial in non-myxomatous mitral valve. Of 91 consecutive patients with mitral valve prolapse examined over an 18 months period by transthoracic and transesophageal echocardiography, 42 (18 women and 24 men) with an average age of 76 +/- 8 years (60-93 years) had ruptured mitral chordae tendinae. The thickness of the anterior mitral leaflet measured at the distal third of the valve by transesophageal echocardiography enabled the identification of two groups of patients; group I: > 3 mm (24 patients), average 4.8 +/- 0.8 mm and group II: < or = 3 mm (18 patients), average 2.6 +/- 0.3 mm. The diameter of the mitral ring and left atrium, the length of the anterior mitral leaflet, the left ventricular end diastolic dimensions and fractional shortening, were measured by transthoracic 2D echocardiography (mitral ring) and M mode (other parameters). Ruptured chordae were detected in only 13 cases (31%) by transthoracic echocardiography; 38% were asymptomatic and a chance finding at transesophageal echocardiography. No significant difference was observed between the two groups with respect to age, gender presence of hypertension, dimensions of the cardiac chambers, fractional shortening or localisation of the prolapse related to the ruptured chordae. Fifty-eight per cent of patients in group I were in NYHA functional classes 3-4 as compared to 16% in group II (p < 0.02). The size of the left atrium was significantly greater in group I, 51 +/- 8 mm vs 38 +/- 7 mm (p < 0.001).(ABSTRACT TRUNCATED AT 250 WORDS)

[Value of transesophageal echocardiography in the cardiovascular assessment of an ischemic cerebral accident of suspected embolic origin]. / Intérêt de l'échocardiographie transoesophagienne dans le bilan cardio-vasculaire d'un accident ischémique cérébral présumé d'origine embolique.

Transoesophageal echocardiography (TOE) is a new modality of cardiac investigation allowing examination of cardiac structures and anomalies previously inaccessible to ultrasound. TOE is performed under local anaesthesia after fasting the subject for more than 4 hours and after premedication when the patient is admitted to hospital. In the assessment of an ischaemic cerebral vascular accident, TOE may reveal potential sources of emboli such as intracavitary thrombi and tumours (left atrium and left atrial appendage), atherosclerosis of the aortic arch, vegetations. Certain indirect causes may also be more clearly identified: aneurysm of the interatrial septum, patent foramen ovale for which the causal relationship is more difficult to establish. Intra-atrial blood stasis ("spontaneous echo contrast") is perfectly analysed in the form of intra-atrial "smoke" observed in the presence of atrial dilatation, particularly in the presence of atrial fibrillation and mitral valve obstruction (mitral stenosis, valve prosthesis). The indication for TOE in this context is currently under evaluation, particularly in young patients. It is routinely indicated in patients with known heart disease when peripheral embolism is suspected, looking for intracavitary thrombosis, generally not seen on transthoracic echocardiography.