Comprehensive Ultrasound Assessment of the Craniocervical Circulation in Transient Global Amnesia.

OBJECTIVES: Structural changes and metabolic stress have been reported on diffusion-weighted magnetic resonance imaging in the cornu ammonis 1 area of the hippocampus in patients with transient global amnesia (TGA), but a consensus on pathogenesis is still lacking. The aim of our study was to perform a comprehensive ultrasound analysis of the cerebrovascular circulation in our population of patients with TGA. METHODS: One hundred patients with TGA and 50 age- and sex-matched control participants underwent ultrasound examinations of the cervicocranial circulation. RESULTS: The most significant risk factor for TGA was arterial hypertension (P < .01). There were no significant atherosclerotic lesions on the large arteries of the neck (mean internal carotid artery stenosis ± SD, 28.7% ± 11.7%) or on the large intracerebral arteries (good structural and hemodynamic status; P > .05). Rarely detected microembolic signals or a right-left cardiopulmonary shunt excluded an emboligenic mechanism of TGA (P > .05). The internal jugular vein valves were incompetent in 54% of patients with TGA, and this condition was associated with an increased risk of TGA (odds ratio, 4.16; 95% confidence interval, 1.91-9.04). The mean values of the breath holding index and pulsatility index, as parameters of small-vessel function, were within normal ranges and without differences between the TGA and control groups (P > .05). CONCLUSIONS: Our ultrasound examination did not detect significant structural atherosclerotic changes of cervicocranial arteries, and an emboligenic mechanism was excluded. Only a significant rise of blood pressure in TGA and significant valvular insufficiency of the internal jugular vein were established. New research should clarify whether these simultaneous functional circulatory changes have relevance for metabolic stress in the cornu ammonis of the hippocampus.

Prediction of a good response to cardiac resynchronization therapy in patients with severe dilated cardyomyopathy: could conventional echocardiography be the answer after all?

OBJECTIVES: The aim of this study was to assess the performance of echocardiographic parameters to predict response to cardiac resynchronization therapy (CRT). BACKGROUND: CRT reduces morbidity and mortality due to the proper selection of candidates for CRT. METHODS: The 12-month trial was performed on 70 optimally medicated patients with standard inclusion criteria: NYHA class III or IV heart failure, left ventricular ejection fraction (LVEF) ≤ 35%, and QRS ≥ 120 ms. All parameters were evaluated by conventional and tissue Doppler-based methods. Indicator of positive CRT response was more than 20% in improvement of LVEF. RESULTS: LVEF increased >20% in 42 patients. Out of 43 tested baseline echocardiographic parameters, 12 showed statistical difference between responders and nonresponders. Out of these 12 parameters, six (LVSV, LVSI, LVFS, RVd, VPMR, and PISA) had modest to moderately good ability to predict LVEF response with sensitivity ranging from 62.2% to 82.4%, and specificity ranging from 56.5% to 81.2%. For those parameters, the area under the receiver-operating characteristic curve for positive response to CRT was ≤0.76. Multivariate regression analysis resulted in selection of LVSI and LVFS as possible predictive independent parameters for a good response. The cutoff value for LVSI was 38.7 mL/m(2) (P = 0.045) and for LVFS was 13% (P = 0.032). CONCLUSIONS: Contribution of LVSI and LVFS is to be confirmed in larger trials. Simplicity of their assessment by conventional echocardiography could be an argument for adding them to the inclusion criteria for CRT in severe heart failure patients.

[Pacemaker optimization guided by echocardiography in cardiac resynchronization therapy]. / Ehokardiografski bodjena optimizacija rada pejsmejkera kod resinhronizacione terapije slabosti srca.

INTRODUCTION: Cardiac resynchronization therapy (CRT) or biventricular pacing is a contemporary treatment in the management of advanced heart failure. Echocardiography plays an evolving and important role in patient selection for CRT, follow-up of acute and chronic CRT effects and optimization of device settings after biventricular pacemaker implantation. In this paper we illustrate usefulness of echocardiography for successful AV and VV timing optimization in patients with CRT. A review of up-to-date literature concerning rationale for AV and VV delay optimization, echocardiographic protocols and current recommendations for AV and VV optimization after CRT are also presented. OUTLINE OF CASES: The first case is of successful AV delay optimization guided by echocardiography in a patient with dilated cardiomyopathy treated with CRT is presented. Pulsed blood flow Doppler was used to detect mitral inflow while programming different duration of AV delay. The AV delay with optimal transmittal flow was established. The optimal mitral flow was the one with clearly defined E and A waves and maximal velocity time integral (VTI) of the mitral flow. Improvement in clinical status and reverse left ventricle remodelling with improvement of ejection fraction was registered in our patient after a month. The second case presents a patient with heart failure caused by dilated cardiomyopathy; six months after CRT implantation the patient was still NYHA class III and with a significantly depressed left ventricular ejection fraction. Optimization of VV interval guided by echocardiography was undertaken measuring VTI of the left ventricular outflow tract (LVOT) during programming of different VV intervals. The optimal VV interval was determined using a maximal LVOT VTI. A month after VV optimization our patient showed improvement in LV ejection fraction. CONCLUSION: Optimal management of patients treated with CRT integrate both clinical and echocardiographic follow-up with, if needed, echocardiographically guided optimization of AV and VV delays, which offers the possibility of additional clinical improvement in such patients.

[New echocardiographic tehniques in optimal patient selection for cardiac resynchronization therapy in the treatment of chronic heart failure].

Cardiac resynchronization therapy (CRT) has important role in the contemporary treatment of heart failure, systolic dysfunction and mechanical disynchrony. Classical indications for CRT are severe heart failure (NYHA class IlI or IV), a broad QRS (more than 120 ms) and left ejection fraction less than 35% despite optimal medical therapy. Several have studies demonstrated the important role of echocardiography in patient selection for CRT, follow up and estimation of CRT effects, as well as the optimization of biventricular pacemaker. Basically, there are three types of cardiac asynchrony: interventricular asynchrony, between the right and left ventricle, intraventricular asynchrony, between the myocardial segments within the left ventricle and atrioventricular asynchrony, between the atria and ventricles. Although many echocardiographic techniques are used in patient selection for CRT, no ideal approach has yet been found.There are several techniques and parameters used in the assessment of myocardial asynchrony: two dimensional (2D) echocardiography, one dimensional echocardiography (M-mode), Doppler echocardiography, different modalities of tissue Doppler including Colour Coded Tissue Doppler Imaging--TDI, measurements of local tissue deformation indices (strain and strain rate), speckle tracking, 3D echocardiography, semiquantitative assessment of myocardial border, vector velocity imaging. Each of these techniques has advantages and limitations. A special accent in this revue is on the consensus report from the American Society of Echocardiography Dyssynchrony Writing group. According to this consensus report colour coded tissue Doppler is the most appropriate technique for myocardial asynchrony estimation and patients selection for CRT. The same group recommended that definitive decision for CFT implantation should not be based only on echocardiographic analysis, but rather on the whole clinical aspect of the patient.

[Spectrum of echocardiographic findings in patients with systemic sarcoidosis].

INTRODUCTION: Sarcoidosis is a granulomatous disease that may involve multiple organ systems. Cardiac sarcoidosis may be a primary or a secondary process. Clinical manifestations of cardiac sarcoidosis include impulse conduction disorders, various arrhythmias, symptoms and signs of heart failure and even sudden death. The aim of the present paper was to assess the possibilities for echocardiographic detection of pathological changes in the hearts of patients with diagnosed systemic sarcoidosis. MATERIAL AND METHODS: The study group consisted of 31 patients with histological evidence of sarcoidosis obtained by biopsy of target organ (most frequently the lungs). There were 26 females and 5 males, aged from 38 to 74 years, mean age 53.67 +/- 9.48 years. The duration of sarcoidosis varied from 1 to 33 years, mean duration 6.56 years. All patients underwent Color Doppler echocardiographic examination with standard echocardiographic views. RESULTS: Increased left ventricular end-diastolic diameter was registered in 6/31 patients (19%), while end-systolic dimension was increased in 2 patients (6%). However, left ventricular dimensions were more increased in the group of patients with sarcoidosis lasting 4 years or longer. Majority of patients with sarcoidosis (27/31 or 86%) had normal values of left ventricular systolic function. The diastolic function of the left ventricle was impaired in 19/31 patients (61%). Only one female patient had hypertrophied apical segments of interventricular septum (15-17 mm) and lateral left ventricular wall (14 mm), while basal segments of inferior, posterior and lateral left ventricular walls were thin and dyskinetic, but coronary angiography revealed normal findings. Laminar fibrosis within interventricular septal myocardium was identified in 14/31 sarcoidosis patients (45%), while granulations in ventricular septal myocardium were present in 10/31 patients (32%). Right ventricular systolic pressure over 30 mmHg was established in 5/31 patients (16%). Slight pericardial effusion was found in 4/31 patients (12%). CONCLUSION: Echocardiography is a very useful method for obtaining important information on morphological and functional changes in myocardium of patients with sarcoidosis. However, neither of previously mentioned echocardiographic signs is specific for cardiac sarcoidosis. The diagnosis of cardiac sarcoidosis cannot be made solely on the basis of echocardiographic findings. Other diagnostic procedures, from clinical findings to endomyocardial biopsy, must be employed as well.