Transcranial Doppler sound detection of cerebral microembolism during transapical aortic valve implantation.

OBJECTIVE: Transapical aortic valve implantation (TAVI) is a new method that might reduce the surgical risk of conventional surgical aortic valve replacement in very high-risk patients. Increased downstream microembolization is expected in transapical aortic valve implantation. However, whether it usually occurs, how often, and its clinical relevance are not known. We report the results of ultrasound microembolic signal detection in the middle cerebral artery during the procedure. METHODS: Fifty patients (mean age: 80 ± 5 years; mean EuroSCORE: 36 ± 13 %) underwent transapical aortic valve implantation. Intraoperative transcranial Doppler (TCD) sound examination of both middle cerebral arteries (MCA) was used to identify high-intensity transient signals (HITS) and microembolic signals (MES) during seven phases of the procedure. Pre- and postoperative computed tomography of the brain and clinical neurological examinations were performed preoperatively and daily during the first postoperative week. RESULTS: During the procedure, HITS [right MCA: 435 ± 922 (range 9-5765); left MCA: 471 ± 996 (range 24-6432)] and MES [right MCA: 78 ± 172 (range 1-955); left MCA: 62 ± 190 (range 2-1553)] were detected in all patients. Most of the MES were recorded during valvuloplasty [right MCA: 3 ± 5.6 (range 0-31); left MCA: 2 ± 4.9 (range 0-30)] and positioning of the prosthetic valve in the aortic position [right MCA: 6 ± 5 (range 0-22); left MCA: 2 ± 6.9 (range 0-38)]. Postoperatively, there were no clinical signs of new cerebral embolism. CONCLUSIONS: Cerebral microemboli were detected by intraoperative transcranial Doppler sound examinations in all patients during transapical aortic valve implantation. Most of the signals were detected during balloon valvuloplasty and delivery of the prosthetic valve.

Revascularization of the occluded right coronary artery during left ventricular assist device implantation.

A 62-year-old man with end-stage ischemic cardiomyopathy and left ventricular function of 20% was evaluated for heart transplantation. Cardiac catheterization revealed proximal occlusion of the dominant right coronary artery (RCA) with collateral blood flow and significant stenosis in the distal part, but no significant re-occlusions of the stented left coronary artery and no significant stenosis of the left circumflex artery. When the patient became catecholamine dependent, Novacor left ventricular assist device (LVAD) implantation, as a bridge to transplantation, was considered and the patient operated upon. To avoid ischemic right heart failure after LVAD implantation, a concomitant re-vascularization of the distal RCA was performed. The post-operative course was uneventful. Five weeks later, a control angiogram showed the patent bypass graft. The distal stenosis of the RCA was treated successfully with dilation and stent implantation. The patient is presently in stable condition on LVAD and awaits transplantation as an outpatient.

Is contrast-related vasodilatation after intra-coronary iodixanol and iopromide in vivo endothelium-dependent?

AIMS: Goals of the study were the assessment of the correlation between flow-dependent and contrast-related vasodilatation, comparison of iodixanol to iopromide and evaluation of the impact of plaque on vasodilatation in coronary arteries. METHODS AND RESULTS: A controlled randomized paired cross-over comparison between iodixanol (320mgI.ml(-1)) and iopromide (300mgI.ml(-1)) was performed in 10 consecutive patients. Vessel area (Visions Five-64 F/X intra-vascular ultrasound-catheter, Endosonics and blood flow velocity measurements (0.014inches Doppler guide wire, Cardiometrics were recorded simultaneously at an identical position, at baseline, after i.c. bolus injection of 10ml physiologic saline (flow-dependent vasodilatation), and after application of contrast agent 1 and contrast agent 2 as randomized. The action of iodixanol and iopromide on the vascular wall did not differ and was equal to local flow-dependent vasodilatation induced by a saline bolus (correlation 0.95-- 0.98). The increase in local luminal area after injection of saline, iodixanol and iopromide in morphologically normal vessels (approximately 2.5mm(2)) was absent in atherosclerotic segments. Both contrast agents and saline demonstrated a nearly identical flow increase. CONCLUSION: If iodixanol or iopromide are used as contrast agents, contrast-related vessel area increase in vivo seems to be endothelium-dependent.

Lung water, hemodynamics and dyspnea before and after valvuloplasty in mitral stenosis.

UNLABELLED: The investigation was to elucidate the role of the reduction of extravascular pulmonary fluid in the immediate symptomatic improvement and its impact on hemodynamics in patients with mitral stenosis treated by percutaneous transluminal valvuloplasty. METHODS: In a prospective study of 12 patients with severe mitral stenosis extravascular pulmonary fluid volume was determined by a combined dye and thermodilution technique (COLD Z-021(TM) Version 5.x, Pulsion((R))) before and after valvuloplasty. Cardiac output, left atrial pressures, atrial V-waves, diastolic transmitral gradients and their respiratory changes were measured. Dyspnea was assessed by validated questionnaires. RESULTS: Symptomatic improvement correlated (r=0. 808) with a decrease of extravascular lung water, but not with either an increase or a decrease of cardiac output or left atrial filling pressures. The decrease of the lung water index may be predicted from the lung water index before valvuloplasty, the final left atrial mean pressure and the cardiac index prior to intervention. The change of the mean difference between inspiratory and expiratory mitral gradient demonstrated a significant inverse correlation with the change of mean left atrial filling pressures (r=-0.778) and with extravascular lung water after valvuloplasty (r=-0.871). CONCLUSION: There is a complex relationship between left atrial filling pressures, extravascular lung water, respiratory changes of gradients, and dyspnea that need further investigation.

Reproducibility of serial intravascular ultrasound measurements in patients with angiographically silent coronary artery disease after heart transplantation.

BACKGROUND: Intracoronary ultrasound (ICUS) imaging is the most sensitive method for the early detection and serial evaluation of vasculopathy of transplants. Both lack of agreement between observers and lack of agreement between serial, independent pullback procedures (repeatability), which can result in a variable intraluminal catheter position may limit the reproducibility of ICUS measurements. OBJECTIVE: To evaluate the reproducibility of serial measurements of standard linear and area cross-sectional coronary dimensions in patients with non-obstructive transplant vasculopathy. METHODS: We performed ICUS imaging of patients without angiographic evidence of obstructive epicardial coronary artery disease after heart transplantation. A 30 MHz phased-array transducer was used. Two independent pullbacks of the left anterior descending coronary artery were performed and recorded on CD-ROM for off-line quantitative analysis of the most severely diseased site. Agreement of observers and repeatability of serial measurements were calculated by the use of linear regression analysis and Bland-Altman plots. RESULTS: Regarding agreement of observers, correlation coefficients for intra-observer agreement ranged from r = 0.98 to r = 0.99; those for interobserver agreement ranged from r = 0.87 to r = 0.98. Serial measurements of the identical coronary artery cross-section within independent catheter pullback procedures were possible for 104 of 112 target lesions (92.90/%). Correlation coefficients ranged from r = 0.91 to r = 0.97 (for lumen diameter r = 0.91, for lumen area r = 0.93, for vessel diameter r = 0.91, for vessel area r = 0.97, for thickness of plaque r = 0.96 and for area of plaque 0.94). The mean difference of measurements was around zero for all parameters with SD from 0.13 to 0.4 mm for linear parameters and from 1.53 to 1.82 mm2 for area parameters. CONCLUSION: Serial intravascular ultrasound measurements are highly reproducible without any evidence of systematic error and a SD of differences of measurements beyond the maximal spatial resolution of currently available intravascular ultrasound catheters.

[Influence of image quality on the diagnostic accuracy of dobutamine stress magnetic resonance imaging in comparison with dobutamine stress echocardiography for the noninvasive detection of myocardial ischemia]. / Einfluss der Bildqualität auf die Genauigkeit der nichtinvasiven Ischämiediagnostik mit der Dobutamin-Stressmagnetresonanztomographie im Vergleich zur Dobutamin-Stressechokardiographie.

The analysis of wall motion abnormalities with dobutamine stress echocardiography is an established method for the detection of myocardial ischemia. With ultrafast magnetic resonance tomography, the application of identical stress protocols as used for echocardiography is possible. In 208 consecutive patients (147 M, 61 F) with suspected coronary artery disease, dobutamine stress echocardiography partially using harmonic imaging and dobutamine stress magnetic resonance tomography (DSMR) were performed prior to cardiac catheterization. DSMR images were acquired during short breath holds in 3 short axis-, a 4-, and a 2-chamber view using a turbo gradient echo technique. Patients were examined at rest and during a standard dobutamine-atropine scheme until submaximal heart rate was reached. Regional wall motion was assessed in a 16 segment model. Significant coronary heart disease was defined as angiographic >/=50% diameter stenosis. With DSMR, significantly more patients yielded very good (69%) or good (13%) image quality in comparison with dobutamine stress echocardiography (20% and 31%, p<0. 05). Moderate image quality occurred in 16% with MR and 41% with dobutamine stress echocardiography (p<0.05), 2% and 8% were non-diagnostic. With each technique 18 patients could not be examined (DSE: emphysema: 10, adipositas: 8, DSMR: claustrophobia: 11, adipositas: 6, contraindication: 1). Four patients did not reach target heart rate. In 107 patients, significant coronary artery disease was found. With DSMR sensitivity was 88.7% (dobutamine stress echocardiography: 74.3%; p<0.05) and specificity 85.7% (dobutamine stress echocardiography: 69.8%; p <0.05). This difference was most pronounced in the group with moderate echocardiographic image quality. High dose DSMR is superior to dobutamine stress echocardiography and can replace this technique especially in patients with moderate echocardiographic image quality.

Noninvasive diagnosis of ischemia-induced wall motion abnormalities with the use of high-dose dobutamine stress MRI: comparison with dobutamine stress echocardiography.

BACKGROUND: The analysis of wall motion abnormalities with dobutamine stress echocardiography (DSE) is an established method for the detection of myocardial ischemia. With ultrafast magnetic resonance tomography, identical stress protocols as used for echocardiography can be applied. METHODS AND RESULTS: In 208 consecutive patients (147 men, 61 women) with suspected coronary artery disease, DSE with harmonic imaging and dobutamine stress magnetic resonance (DSMR) (1.5 T) were performed before cardiac catheterization. DSMR images were acquired during short breath-holds in 3 short-axis views and a 4- and a 2-chamber view (gradient echo technique). Patients were examined at rest and during a standard dobutamine-atropine scheme until submaximal heart rate was reached. Regional wall motion was assessed in a 16-segment model. Significant coronary heart disease was defined as >/=50% diameter stenosis. Eighteen patients could not be examined by DSMR (claustrophobia 11 and adipositas 6) and 18 patients by DSE (poor image quality). Four patients did not reach target heart rate. In 107 patients, coronary artery disease was found. With DSMR, sensitivity was increased from 74.3% to 86.2% and specificity from 69.8% to 85.7% (both P<0.05) compared with DSE. Analysis for women yielded similar results. CONCLUSIONS: High-dose dobutamine magnetic resonance tomography can be performed with a standard dobutamine/atropine stress protocol. Detection of wall motion abnormalities by DSMR yields a significantly higher diagnostic accuracy in comparison to DSE.

Test procedure for artificial mitral valves.

The flow curve of a valve-tester has a great influence on the performance of a valve. Usually the flow curve of the aorta is used. However, the mitral valve flow curve differs greatly from the flow curve of the aortic valve. It varies with the pulse rate and is further changed in patients with certain heart diseases. To investigate the different mitral flow conditions, ultrasonic flow curves from patients with a mechanical artificial mitral valve were analyzed. The curves show that a mitral valve prosthesis has not only to work under physiological flow conditions, but also in pathologically deviant flows. According to these results three different characteristic flow curves were selected and used to test several valves with a computer controlled valve-tester. The mean diastolic pressure difference and the whole closing behavior were influenced by the flow curve; and the differences in energy losses were particularly great. This indicates, that the flow curve must be adjusted appropriately.

Safety of intracoronary ultrasound imaging in patients with acute myocardial infarction.

In 103 patients with acute myocardial infarction, intracoronary ultrasound imaging (ICUS) was performed before and after percutaneous transluminal coronary angioplasty (PTCA) with a pre-PTCA success rate of 79 of 103 patients (76.7%), post-PTCA rate of 88 of 103 patients (85.4%), and a reversible subacute occlusion rate after initial ICUS of 3.9%. Time consumption was 7 +/- 1 minute for pre-PTCA ICUS and 3 +/- 1 minute for post-PTCA ICUS.

Intravascular ultrasound assessment of direct percutaneous transluminal coronary angioplasty in patients with acute myocardial infarction.

BACKGROUND: Acute myocardial infarction is caused by sudden thrombotic occlusion of the coronary artery due to a previous rupture of atherosclerotic plaque. OBJECTIVE: To use intracoronary ultrasound measurements to evaluate lumen and plaque changes in patients with acute myocardial infarction. METHODS: Patients (n = 103) with acute myocardial infarction who had been scheduled to undergo primary percutaneous transluminal coronary angioplasty (PTCA) were selected. Both before and after successful coronary angioplasty, intracoronary 30 MHz ultrasound studies were performed using a 3.5F monorail catheter. The ultrasound catheter was successfully advanced into the occluded vessel segment without major complications prior to PTCA in 79 of 103 (76.7%) patients and after PTCA in 88 of 103 (85.3%) patients. RESULTS: The plaques were eccentric in 66 patients (83.5%). The plaque morphology was purely low echogenic in 14 (17.7%), highly echogenic in six (7.6%) and mixed in 59 (74.7%) patients. Partial (59 of 79, 74.7%) or ring-like calcification (3 of 79, 3.8%) was observed in 62 patients (78.5%). Plaque fissuring or dissection was detected prior to PTCA in 25 patients (31.7%). Coronary angioplasty successfully enlarged the inner luminal area from 2.1 +/- 0.7 to 7.4 +/- 1.9 mm2 (P < 0.01), whereas the plaque-thrombus area decreased significantly (13.8 +/- 1.7 mm2 before and 9.0 +/- 1.9 mm2 after PTCA; P < 0.01). The total vessel area remained virtually constant (15.9 +/- 1.9 mm2 before and 16.4 +/- 2.5 mm2 after PTCA, NS). PTCA-induced plaque rupture or dissection was observed in only 13 (16.5%) patients. CONCLUSION: Intracoronary ultrasound imaging can be performed safely and successfully prior and subsequent to PTCA in selected patients with acute myocardial infarction. Early reperfusion via PTCA seems to be attributable to a significant reduction in the amount of low-echogenic plaque and thrombus material, whereas factors like balloon-induced dissection and stretching of vessels play only a minor role.

Intravascular ultrasound imaging in patients with acute myocardial infarction.

Myocardial infarction is the result of acute thrombotic occlusion of a coronary artery secondary to rupture of an atherosclerotic plaque. Intracoronary ultrasonic examinations (ICUS) were performed in patients with acute myocardial infarction in order to describe intraluminal ultrasonic findings at the site of an acute coronary occlusion. Coronary angiography and ICUS studies were performed consecutively within 6 h after the onset of chest pain in 50 patients with acute myocardial infarction (AMI) prior to percutaneous coronary angioplasty (PTCA). Following angiographic documentation of a proximal occlusion, a 3.5 mechanical ultrasound catheter (30 MHz) was advanced successfully through the lesion in 42 of 50 patients (84%). In 37 of the 42 patients (88.1%), ICUS differentiated between pulsatile, low echogenic, intraluminal material suggesting thrombus, and mural more highly echogenic atherosclerotic plaque. A negative imprint of the ICUS catheter was documented within the low echogenic material in 25 of 42 (60%) patients with AMI. Low echogenic intraluminal material was found in 31 of 42 (73.4%) segments proximal to the highly echogenic plaque and in 28 of 42 (66.7%) segments distal to it, indicating pre- and post-stenotic thrombus in AMI. The plaque appeared eccentric in 32 of 42 patients (76.2%) with AMI. Cross-sectional area stenosis due to highly echogenic plaque averaged 48 +/- 14%. Calcification of plaque was evident in 35 of 42 patients (83.3%) and the surface of the plaque was rough in 30 of 42 (42.4%). Fissures were found in 10 (23.8%) and a dissection was detected in four (9.5%) cases.

Intravascular ultrasound imaging in patients with acute myocardial infarction: comparison with chronic stable angina pectoris.

BACKGROUND: Myocardial infarction is the result of acute thrombotic occlusion of a coronary artery, most likely secondary to rupture of an atherosclerotic plaque. Intracoronary ultrasonic (ICUS) examinations were performed in patients with acute myocardial infarction (AMI) in order to describe intraluminal ultrasonic findings at the site of acute coronary occlusion. METHODS: Coronary angiography and ICUS studies were performed consecutively within 6 h of the onset of chest pain in 30 patients with AMI prior to percutaneous transluminal coronary angioplasty (PTCA). The control group consisted of 30 patients with chronic stable angina pectoris (SAP). Following angiographic documentation of a proximal stenosis or occlusion, a 3.5 or 4.8 F mechanical ultrasound catheter (20 MHz) was advanced successfully through the lesion in 25 of 30 (83%) patients with AMI and in 15 of 30 (50%) patients with SAP (P < 0.01). RESULTS: Intracoronary ultrasound permitted differentiation between pulsatile, low-echogenic intraluminal material suggesting thrombus and mural highly echogenic atherosclerotic plaque in 22 of 25 (88%) patients with AMI. A negative imprint of the ICUS catheter was documented within the low-echogenic material in 17 of 25 (68%) patients with AMI. Low-echogenic intraluminal material was found in 18 of 25 (72%) segments proximal and in 12 of 25 (48%) segments distal to the highly echogenic plaque, indicating prestenotic and post-stenotic thrombus in AMI. The plaque appeared eccentric in 22 of 25 (88%) patients with AMI. In comparison, stenotic lesions in chronic SAP patients were less frequently eccentric (5/15, 33%, P < 0.01) and contained a higher proportion of pure highly echogenic material (12/15, 80%). Cross-sectional area stenosis due to highly echogenic plaque averaged 52 +/- 13% in AMI and 82 +/- 3% in SAP (P < 0.01). Calcification of plaque was evident in 21 of 25 patients with AMI (SAP 12/15, 80%, NS). The surface of the plaque was rough in 13 of 25 (52%) AMI patients (SAP 4/15, 27%, P < 0.05). Fissures were detected in only seven (28%) patients and dissection was observed in two (8%) cases. The low incidence might be a result of the limited resolution of the ICUS system. CONCLUSION: This study demonstrates that ICUS with 4.8 or 3.5 F catheters is feasible and safe in selected patients with AMI, and adds little to the overall duration of the angioplasty procedure. The identification and demarcation of atherosclerotic plaque provided by ICUS could prove valuable in guiding PTCA, in deciding on appropriate therapy, and in acute and long-term follow-up of AMI patients.

Remodeling of myocardium and arteries by chronic angiotensin converting enzyme inhibition in hypertensive patients.

AIM: To investigate changes in left ventricular hypertrophy and diastolic function in hypertensive patients treated with an angiotensin converting enzyme (ACE) inhibitor. METHODS: Structural and functional changes in the heart and iliac artery were studied by echocardiography and intraluminal ultrasound in 15 hypertensive patients following 6 months of treatment with the ACE inhibitor quinapril at 10-40 mg/day. RESULTS: Systolic/diastolic blood pressure was reduced from 156/100 mmHg to 128/82 mmHg within 2 months and remained stable during the next 4 months of the study. The left ventricular mass index was significantly reduced from 174 +/- 86 to 161 +/- 75 g/m2 (-7.4%, P < 0.05). The reduction in left ventricular hypertrophy was associated with a trend towards an improvement in diastolic function, but left ventricular systolic function did not change. There was a 3.9% increase in iliac lumen area and a significant decrease of 10.7% (P < 0.05) in the ratio between the intimal-medial and lumen area, which represents a decrease in wall thickness. A key result was a statistically significant decrease in pulse-wave velocity, from 13.7 +/- 2.6 to 12.1 +/- 2.0 m/s, and in the modulus of elasticity, from 20.5 +/- 7.2 to 15.8 +/- 5.6 x 10(4) N/m2 (P < 0.05). CONCLUSION: The present study demonstrates that 6 months of treatment with an ACE inhibitor induced a significant regression in left ventricular hypertrophy and a reduction in wall thickness. In addition, the results indicate that chronic ACE inhibition can decrease the stiffness of large elastic arteries independently of a reduction in blood pressure.

Quantitative assessment of peripheral and coronary artery lesions before and after balloon angioplasty: a comparison of intravascular ultrasound and angiography.

Intravascular ultrasound and conventional angiography were used to determine the degree of stenosis before and after angioplasty in 25 consecutive patients with peripheral arterial occlusive disease and 15 selected patients with coronary artery disease. Angiographic determinations of the luminal area and percent stenosis were made with the help of an automatic detection system, and the same parameters were evaluated planimetrically in the ultrasound studies. Following angioplasty of peripheral lesions, angiography demonstrated a significantly greater increase in mean luminal area (10.8 +/- 7.8 mm2 vs 5.8 +/- 4.0 mm2; P < 0.05) and a greater reduction in degree of stenosis (26% +/- 16% vs 14% +/- 11%; P < 0.05) than did the ultrasonic investigation. There was a significant but moderate correlation between values for the luminal area determined by angiography and ultrasound before angioplasty (r = 0.75; SEE = 4.8 mm2) and in normal proximal segments of coronary arteries (r = 0.79; SEE 4.1 mm2). Following angioplasty there was no significant correlation between angiographic findings and those determined by intravascular ultrasound in peripheral or coronary lesions. These results suggest that angiography and intravascular ultrasound are fundamentally different imaging and analysis techniques. Following angioplasty, conventional angiography rarely demonstrated dissection or intraluminal filling defects, while intravascular ultrasound detected plaque rupture and the presence of intraluminal atheroma in almost all cases. Quantitative determinations of luminal area and degree of stenosis rely on indirect measures with conventional angiography, while these parameters are determined directly by intravascular ultrasound.(ABSTRACT TRUNCATED AT 250 WORDS)

Quantitative echocardiographic analysis of global and regional left ventricular function: a problem revisited.

We recorded two-dimensional echocardiograms simultaneously with the respiration measurements of 20 normal subjects and 20 patients with anterior myocardial infarction. The apical long-axis and four-chamber views were quantitatively analyzed. Measurement variability of global ejection fraction and regional ejection fraction of 100 regions was calculated during inspiration and at end-expiration for two observers. To minimize variability, the endocardial contour was redefined and traced with an improved computer-assisted tracing system. Variability (absolute mean difference) between two beats at end-expiration was significantly less than during inspiration (p less than 0.05): for ejection fraction the variability at end-expiration was 3.4% and the variability during inspiration was 6.4% (mean, 54%; SD, 7%); for regional ejection fraction the variability at end-expiration was 11.8% and the variability during inspiration was 21.5% (mean, 56%; SD, 15%). Intraobserver and interobserver variability values of one beat at end-expiration for ejection fraction were 3.1% and 3.8%, respectively, and 9.5% and 12.8%, respectively, for regional ejection fraction. Variability in patients with myocardial infarction was comparable. This method of recording respiration and analyzing left ventricular function at end-expiration, with a new contour definition and tracing system, provides a measurement variability that is considerably less than that reported in previous echocardiographic studies and that is comparable to angiographic methods.

[The Duromedics mitral valve mechanical prosthesis: evaluation by means of transesophageal echocardiography]. / Protesi meccanica Duromedics in posizione mitralica: valutazione mediante ecocardiografia transesofagea.

We investigated via transesophageal echocardiography 29 patients with Duromedics mitral prosthesis to define the characteristics of normal and abnormal functioning valves as well as the advantages of this study compared to transthoracic echocardiography. The clinical and transthoracic examination identified three groups. The first group consisted of 8 patients with abnormal hemodynamic parameters (maximal velocity 245.5 +/- 38.4 cm/sec, maximal gradient 24.6 +/- 7.9 mmHg, medium gradient 9.8 +/- 0.8 mmHg, pressure half time 121.6 +/- 58.8 msec, valvular area 2.1 +/- 0.8 cm2). In 4 cases we detected a paravalvular regurgitant jet. The second group was formed of 12 symptomatic patients, with normal hemodynamic parameters (maximal velocity 169.1 +/- 20.1, maximal gradient 11.6 +/- 2.5, medium gradient 4.8 +/- 1.8, pressure half time 118 +/- 18 msec, valvular area 1.9 +/- 2.8 cm2). In 4 cases we detected a paravalvular regurgitant jet. The third group was formed by 9 asymptomatic patients with normal hemodynamic parameters: maximal velocity 160.6 +/- 26.6, maximal gradient 10.5 +/- 3.3, medium gradient 4 +/- 1, pressure half time 118 +/- 40, valvular area 2 +/- 0.5. We did not observe a regurgitant jet in any of these patients. Transesophageal echocardiography detected a paravalvular jet in all patients of the first group, with an area of 6.9 +/- 5.8 cm2; in the second group it demonstrated one or two valvular jets, with a maximal area of 5.1 +/- 3.2 cm2. Furthermore, it defined as valvular, the site of a jet previously described as paravalvular with the transthoracic examination.(ABSTRACT TRUNCATED AT 250 WORDS)

Two-dimensional echocardiographic analysis of the dynamic geometry of the left ventricle: the basis for an improved model of wall motion.

To establish an appropriate echocardiographic model for wall motion analysis we first determined the precise dynamic geometry of the left ventricle during systole, as visualized by two-dimensional echocardiography. With the epicardial apex and the aortic-ventricular and mitral-ventricular junctions as anatomic landmarks, we quantitatively analyzed apical long-axis views in 61 normal subjects, 41 patients with anterior myocardial infarction, and nine patients with posterior myocardial infarction. Thoracic impedance registration allowed exclusion of extracardiac motion from the measurements. In normal subjects the epicardial apex moved outwardly only 0.6 +/- 0.3 mm (mean +/- standard error). Examination of 15 hearts fixed in formalin revealed apical myocardial thickness of 1.5 +/- 0.2 mm. These data suggest that the observed inward motion of the endocardial apex (4.1 +/- 0.7 mm) resulted from obliteration of the apical cavity as a result of inward motion of the adjacent walls. Translation of the base was considerable in normal subjects (14.1 +/- 0.4 mm) and decreased in myocardial infarction (9.1 +/- 0.5 mm, p less than 0.0001). Unequal shortening of the adjacent walls in anterior and posterior myocardial infarction caused basal rotation in the opposite direction (-9.1 +/- 0.8 degrees and 9.7 +/- 1.4 degrees, respectively, p less than 0.0001 versus that of normal subjects, -3.4 +/- 0.7 degrees). Long-axis rotation was not clinically significant (less than 1 degree). We conclude that during ventricular contraction the apex serves as a stable point, whereas the base translates toward the apex because of shortening of the adjacent walls. We then propose a model for analyzing regional wall motion from two-dimensional echocardiograms on the basis of these observations.