[Echocardiographic assessment of myocardial function during His bundle and right ventricular pacing]. / Echokardiographische Beurteilung der myokardialen Funktion unter His-Bündel- und rechtsventrikulärer Schrittmacherstimulation.

INTRODUCTION: In patients with pacemaker (PM) therapy, His bundle stimulation (HBS) may lead to a more synchronous activation of the left ventricle (LV) than conventional right ventricular stimulation (RVS). In this study, we investigated to which extent this effect can be objectified by means of contemporary echocardiographic functional imaging. METHODS: In all, 15 RVS patients (6 women, mean age 76.6 ± 4.1 years) and 15 HBS patients (6 women, mean age 74.6 ± 3.7 years) underwent echocardiography with and without cardiac pacing. Besides LV end-diastolic volume (EDV), ejection fraction (EF), and global strain (GLS), we measured global and regional myocardial work and LV efficiency based on noninvasive pressure-strain loops. RESULTS: In all HBS patients, optimization of PM settings resulted in immediate changes in myocardial function parameters. With pacing, RVS patients showed a higher decrease in EF and GLS than HBS patients. Global LV work and LV work efficiency decreased significantly only in RVS patients. CONCLUSION: Changes in regional and global myocardial function can by proven and quantified by functional echocardiography. In patients under PM therapy, HBS shows functional advantages in comparison to conventional RVS.

[Patient with heparin-induced thrombocytopenia type II and implanted left ventricular assist device]. / Patient mit heparininduzierter Thrombozytopenie Typ II und implantiertem linksventrikulärem Assistdevice.

The administration of heparin can lead to life-threatening heparin-induced thrombocytopenia (HIT) type II, which is caused by antibodies against heparin-platelet factor 4-complexes. The multimorbid patient presented here suffered from HIT II. Preoperative and postoperative prevention of thrombosis was successfully conducted with argatroban and the management of anticoagulation is presented. During therapy with argatroban, discrepancies in the partial thromboplastin time (PTT) and the international normalized ratio (INR) appeared sporadically. The clinical causes for these differences remain unclear.

First experience with an oral combination therapy using bosentan and sildenafil for pulmonary arterial hypertension.

BACKGROUND: New oral substances such as beraprost, bosentan and sildenafil have proven effective in different forms of pulmonary arterial hypertension (PAH), both alone and in combination with standard treatment such as intravenous and inhaled prostacyclins. However, there are few reports so far on the effect of a combination of exclusively oral substances. In this paper, we present our initial findings of treatment using a combination of these oral substances in a heterogeneous group of patients with different forms of PAH. MATERIALS AND METHODS: Eleven patients with a median age of 12.9 years (5.5-54.7 years) with both idiopathic PAH and forms associated with congenital cardiac defects (PAH-CHD) with a mean pulmonary arterial pressure > 25 mmHg were enrolled in an observational, open-label, prospective, single-centre study. Either combination treatment with bosentan and sildenafil was started initially, or an existing bosentan treatment was complemented with sildenafil given as an add-on therapy. Mean doses given were 2.3 +/- 0.6 mg kg(-1) for bosentan and 2.1 +/- 0.9 mg kg(-1) for sildenafil. Clinical status, exercise capacity, and haemodynamics were assessed at baseline and at the end of the observation period after a mean follow-up time of 1.1 years (0.5-2.5 years). RESULTS: No major side effects regarding liver function and blood pressure regulation were noted. One patient died of sudden death elsewhere. Most patients were in New York Heart Association (NYHA) functional class III. Clinical improvement was about one NYHA class (mean 2.8 +/- 0.4-1.6 +/- 0.8, P = 0.001), which was associated with an increase of transcutaneous oxygen saturation (89.9 +/- 9.9-92.3 +/- 7.1%; P = 0.037), maximum oxygen uptake (18.1 +/- 6.8-22.8 +/- 10.4 mL kg(-1) x min; P = 0.043), and 6-minute walking distance (351 +/- 58-451 +/- 119 m; P = 0.039). Mean pulmonary arterial pressure measured invasively decreased (62 +/- 12-46 +/- 18 mmHg; P = 0.041). CONCLUSIONS: In our patient group, a combination of oral bosentan and sildenafil proved to be safe and effective. Clearly, randomized, double-blind, placebo-controlled studies are warranted to define the role and type of combination therapies in PAH.

[Quality assurance in echocardiography. Three-level system in formation and qualifying and concept of an external quality review]. / Qualitätsleitlinien Echokardiographie Stufenkonzept Ausbildung, Qualifizierung und Externe Qualitätssicherung.

Measures of quality assurance in echocardiography can be categorized according to standard principles into measures of reviewing structure, processing, and results. This document contains 1) the description of a three level system for education and qualifying in echocardiographic examinations (quality of structure) and 2) the draft of an external quality assurance process for reviewing the results of one echocardiographic investigator or of one laboratory of echocardiography (quality of results). The document also contains a draft description of a nationwide independent institution for certification, which is needed for both projects.A level 1 investigator should be able to perform and interpret a basic investigation. A basic investigation allows to exclude most of all cardiac diseases that can be diagnosed by echocardiography, and pathological findings should be filtered out. A level 2 investigator is able to perform an extended examination, and a comprehensive echocardiographic diagnosis can be established after her or his examination. Additional specific training and experience is necessary to be certified for TEE and stress echo examinations. A level 3 echocardiographer has done research work in echocardiography and should have performed certified teaching courses in echocardiography. The external quality assurance process should provide the possibility to certify the results and reports of a single investigator or of an echo laboratory, according to standard principles of reviewing the records. The process of certification is exclusively performed on a voluntary basis. The nationwide institution of certification should be part of the academy of education in cardiology of the German Society of Cardiology.

[A standardized documentation structure for data documentation in echocardiography. Work Team on Standards and LV Function of the Work Group on Cardiovascular Ultrasound of the German Society of Cardiology, Heart and Circulation Research]. / Eine standardisierte Dokumentations-struktur zur Befunddokumentation in der Echokardiographie. Für den Arbeitskreis Standardisierung und LV-Funktion der Arbeitsgruppe Kardiovaskulärer Ultraschall der Deutschen Gesellschaft für Kardiologie--Herz- und Kreislaufforschung.

Presently, there are no well-defined standards for documentation of echocardiographic studies. Nevertheless, standards are essential to provide comparability of data and to realize electronic communication, both essential for quality management in echocardiography. Therefore, the working group "Standards and LV function" of the German Society of Cardiology developed a consensus for documentation of echocardiographic studies. In the present paper this consensus is presented and illustrated by typical clinical examples. Additionally, a prototype of a user-oriented software based on this data set is presented. The complete data set for transesophageal and transthoracic echocardiography and the software prototype can be downloaded at http:@echo.ma.uni-heidelberg.de.

A simplified, practical echocardiographic approach for 3-dimensional surfacing and quantitation of the left ventricle: clinical application in patients with abnormally shaped hearts.

The goal of this study was to validate the quantitative accuracy of a system for 3-dimensional (3D) echocardiographic reconstruction of the left ventricle to assess its volume and function in human beings by using 3 apical views as a simplified technique to promote practical clinical application. End-diastolic and end-systolic volumes (EDV, ESV) and ejection fraction (EF) were obtained by 3D echocardiography in 50 patients with dilated or geometrically distorted left ventricles and compared with values from magnetic resonance imaging (20 consecutive patients), angiography (22 consecutive patients), and radionuclide imaging (8 consecutive patients). Three-dimensional results were also compared with 2-dimensional (2D) echocardiographic estimates. Three-dimensional left ventricular reconstruction provided values that correlated and agreed well with pooled data from the other techniques for EDV (y = 0.93x + 9.1, r = 0.95, standard error of the estimate [SEE] = 15.2 mL, mean difference = -0.5 +/- 15.4 mL), ESV (y = 0.94x + 4.3, r = 0. 96, SEE = 11.4 mL, mean difference = 0.4 +/- 11.5 mL), and EF (y = 0. 90x + 4.1, r = 0.92, SEE = 6.2%, mean difference = -0.9 +/- 6.4%) (all mean differences not significant versus 0), with greater errors by 2D echocardiography. Intraobserver and interobserver variabilities of 3D echocardiography were less than 6% for EDV, ESV, and EF. The overall time for image acquisition and 3D reconstruction was 5 to 8 minutes. Although this 3D method uses only a small number of apical views, it accurately calculates EDV, ESV, and EF in patients with dilated and asymmetric left ventricles and is more accurate than 2D echocardiography. The flexible surface fit used to combine the 3 views provides a convenient visual output as well as quantitation. This simple and rapid 3D method has the potential to facilitate routine clinical applications that assess left ventricular function and changes that occur with remodeling.

Left atrial chamber and appendage function after internal atrial defibrillation: a prospective and serial transesophageal echocardiographic study.

OBJECTIVES: The purpose of this prospective study was to assess left atrial chamber and appendage function after internal atrial defibrillation of atrial fibrillation and to evaluate the time course of recovery. BACKGROUND: External cardioversion of atrial fibrillation may result in left atrial appendage dysfunction ("stunning") and may promote thrombus formation. In contrast to external cardioversion, internal atrial defibrillation utilizes lower energies; however, it is unknown whether the use of lower energies may avoid stunning of the left atrial appendage. METHODS: Transesophageal and transthoracic echocardiography were performed in 20 patients 24 h before and 1 and 7 days after internal atrial defibrillation to assess both left atrial chamber and appendage function. Transthoracic echocardiography was again performed 28 days after internal atrial defibrillation to assess left atrial function. The incidence and degree of spontaneous echo contrast accumulation (range 1+ to 4+) was noted, and peak emptying velocities of the left atrial appendage were measured before and after internal atrial defibrillation. To determine left atrial mechanical function, peak A wave velocities were obtained from transmitral flow velocity profiles. RESULTS: Sinus rhythm was restored in all patients. The mean +/- SD peak A wave velocities increased gradually after cardioversion, from 0.47 +/- 0.16 m/s at 24 h to 0.61 +/- 0.13 m/s after 7 days (p < 0.05) and 0.63 +/- 0.13 m/s after 4 weeks. Peak emptying velocities of the left atrial appendage were 0.37 +/- 0.16 m/s before internal atrial defibrillation, decreased significantly after internal atrial defibrillation to 0.23 +/- 0.1 m/s at 24 h (p < 0.01) and then recovered to 0.49 +/- 0.23 m/s (p < 0.01) after 7 days. The corresponding values for the degree of spontaneous echo contrast were 1.2 +/- 1.2 before internal atrial defibrillation versus 2.0 +/- 1.0 (p < 0.01) and 1.1 +/- 1.3 (p < 0.01) 1 and 7 days after cardioversion, respectively. One patient developed a new thrombus in the left atrial appendage, and another had a thromboembolic event after internal atrial defibrillation. CONCLUSIONS: Internal atrial defibrillation causes depressed left atrial chamber and appendage function and may result in the subacute accumulation of spontaneous echo contrast and development of new thrombi after cardioversion. These findings have important clinical implications for anticoagulation therapy before and after low energy internal atrial defibrillation in patients with atrial fibrillation.

Aortic dissection: a comparative study of diagnosis with spiral CT, multiplanar transesophageal echocardiography, and MR imaging.

PURPOSE: To compare the usefulness of spiral computed tomography (CT), multiplanar transesophageal echocardiography (TEE), and magnetic resonance (MR) imaging in the diagnosis of thoracic aortic dissection and arch vessel involvement. MATERIALS AND METHODS: Forty-nine symptomatic patients with clinically suspected aortic dissection were examined with contrast material-enhanced spiral CT, multiplanar TEE, and 0.5-T MR imaging (T1-weighted, cardiac-gated, spin-echo sequences). Imaging results were confirmed at autopsy (five patients), intraoperative exploration (23 patients), angiography (nine patients), and follow-up (12 patients). RESULTS: Sensitivity in the detection of thoracic aortic dissection was 100% for all techniques. Specificity was 100%, 94%, and 94% for spiral CT, multiplanar TEE, and MR imaging, respectively. In the assessment of aortic arch vessel involvement, sensitivity was 93%, 60%, and 67%, respectively, and specificity was 97%, 85%, and 88%, respectively. CONCLUSION: Spinal CT and multiplanar TEE are as valuable as MR imaging in the detection of thoracic aortic dissection. In the assessment of the supraaortic branches, spiral CT is superior (P<.05).

Relation between symptoms and profiles of coronary artery blood flow velocities in patients with aortic valve stenosis: a study using transoesophageal Doppler echocardiography.

OBJECTIVE: To analyse profiles of coronary artery flow velocity at rest in patients with aortic stenosis and to determine whether changes of the coronary artery flow velocities are related to symptoms in patients with aortic stenosis. DESIGN: A prospective study investigating the significance of aortic valve area, pressure gradient across the aortic valve, systolic left ventricular wall stress index, ejection fraction, and left ventricular mass index in the coronary flow velocity profile of aortic stenosis; and comparing flow velocity profiles between symptomatic and asymptomatic patients with aortic stenosis using transoesophageal Doppler echocardiography to obtain coronary artery flow velocities of the left anterior descending coronary artery. SETTING: Tertiary referral cardiac centre. PATIENTS: Fifty eight patients with aortic stenosis and 15 controls with normal coronary arteries. RESULTS: Adequate recordings of the profile of coronary artery flow velocities were obtained in 46 patients (79%). Left ventricular wall stress was the only significant haemodynamic variable for determining peak systolic velocity (r = -0.83, F = 88.5, P < 0.001). The pressure gradient across the aortic valve was the only contributor for explaining peak diastolic velocity (r = 0.56, F = 20.9, P < 0.001). Controls and asymptomatic patients with aortic stenosis (n = 12) did not differ for peak systolic velocity [32.8 (SEM 9.7) v 27.0 (8.7) cm/s, NS] and peak diastolic velocity [58.3 (18.7) v 61.9 (13.5) cm/s, NS]. In contrast, patients with angina (n = 12) or syncope (n = 8) had lower peak systolic velocities and higher peak diastolic velocities than asymptomatic patients (P < 0.01). Peak systolic and diastolic velocities were -7.7 (22.5) cm/s and 81.7 (17.6) cm/s for patients with angina, and -19.5 (22.3) cm/s and 94.0 (20.9) cm/s for patients with syncope. Asymptomatic patients and patients with dyspnoea (n = 14) did not differ. CONCLUSIONS: Increased pressure gradient across the aortic valve and enhanced systolic wall stress result in characteristic changes of the profile of coronary flow velocities in patients with aortic stenosis. Decreased or reversed systolic flow velocities are compensated by enhanced diastolic flow velocities, particularly in patients with angina and syncope. This characteristic pattern of the profile of coronary artery flow velocities in patients with angina or syncope may be useful for differentiating those patients from asymptomatic patients.

[Recurrent arterial thromboembolism in hereditary hypoplasminogenaemia]. / Rezidivierende arterielle Thromboembolien bei hereditärer Hypoplasminogenämie.

HISTORY: A 26-year-old man sustained a wasp bite 5 years ago which caused arterial embolism to the right brachial artery. Now he again had a wasp bite with allergic reaction and an arterial embolus to the left brachial artery. 2 days later, after embolectomy and heparinisation, he had a cerebrovascular accident due to an embolus to the left internal carotid artery. 15 days later, despite oral anticoagulation (Quick value 10%), he had an embolism to the left femoral artery. INVESTIGATIONS: The source of the emboli was found by echocardiography to be a spherical floating thrombus on the aortic valve. The plasminogen level was only 45-61%. His mother and sister also had a low plasminogen level, i.e. he had congenital plasminogen deficiency. TREATMENT AND COURSE: At surgery, when the thrombus had been removed, a slit-like defect was found on one of the aortic leaflets and covered with a pericardial patch. At first heparin then phenprocoumon were administered, plus 250 mg ticlopidine twice daily. There have been no further complications. CONCLUSION: As the patient's fibrinolysis activity was normal, additional, probably allergic, factors must have been present to disturb the equilibrium between thrombogenesis and fibrinolysis thus causing thrombosis at a predisposed site.

Influence of captopril on nitroglycerin-mediated vasodilation and development of nitrate tolerance in arterial and venous circulation.

We investigated whether captopril is able to potentiate vasodilation and prevent tolerance to a 48-hour infusion of nitroglycerin (NTG). Twenty-six patients were randomly assigned to a 7-day regimen of captopril (50 mg/day) or placebo. The hemodynamic response to a 0.8 mg sublingual NTG dose was assessed by measuring mean arterial pressure (MAP), mean pulmonary artery pressure (PAP), pulmonary capillary wedge pressure (PCWP), right atrial pressure (RAP), and cardiac output (CO), and calculating systemic (SVR) and pulmonary vascular resistances (PVR). The parameters were obtained serially at baseline and 1 to 10 minutes after the sublingual NTG application (day 1). Then intravenous NTG was started and maintained for 48 hours (1.5 micrograms/kg/min), and the hemodynamic study was repeated (day 3). There was no difference between the captopril and the placebo groups at day 1 (baseline values and response to sublingual NTG). After the 48-hour infusion, there was a complete loss of the NTG effects in the placebo group (day 1 vs day 3: PAP, 20 +/- 5 mm Hg vs 21 +/- 8 mm Hg; MAP, 86 +/- 11 mm Hg vs 90 +/- 9 mm Hg; SVR, 1295 +/- 330 mm Hg vs 1380 +/- 465 dyne.sec.cm-5) whereas there was still evidence of a persistent vasodilation in the captopril group (day 1 vs day 3: PAP, 19 +/- 4 mm Hg vs 13 +/- 4 mm Hg; MAP, 84 +/- 9 mm Hg vs 74 +/- 10 mm Hg; SVR, 1265 +/- 280 mm Hg vs 1140 +/- 425 dyne.sec.cm-5). The response to sublingual NTG on day 3 was markedly attenuated in the placebo group only. We conclude that captopril does not increase the vasodilatory response to nitroglycerin but is able to prevent developing nitrate tolerance in arterial and venous circulation.

Valvular aortic stenosis: risk of syncope.

BACKGROUND AND AIMS: Syncope is a serious complication of aortic stenosis. The aim of this study was to determine whether hemodynamic parameters are useful for estimating the risk of syncope in aortic stenosis. METHODS: In 43 patients with aortic stenosis, cardiac catheterization and echocardiography were performed to measure the pressure gradient across the aortic valve, the aortic valve area, left ventricular mass index, systolic left ventricular wall stress and peak systolic coronary artery flow velocities. Hemodynamic parameters were correlated with syncope and the accuracy of those parameters for determining the risk of syncope were assessed. RESULTS: Ten out of 43 patients experienced syncope. The highest correlation with syncope was found for systolic left ventricular wall stress (R = 0.74, p < 0.001). In descending order of correlation were peak systolic coronary artery flow velocity (R = 0.68, p = 0.002), the pressure gradient across the aortic valve (R = 0.62, p = 0.01) and the aortic valve area (R = 0.43, p = 0.03). Left ventricular mass index was not significantly correlated with syncope. Multivariate analysis revealed systolic left ventricular wall stress to be the only factor contributing to determining syncope (F-to-remove: 47.8). A discriminative value of > 225 dyn/cm-2 x 103 for left ventricular wall stress identified patients with a history of syncope with a specificity of 97% and a sensitivity of 90%. CONCLUSIONS: Syncope in aortic stenosis is closely correlated to increased left ventricular wall stress and attenuated, peak systolic coronary flow velocities. Cut off values may be used to identify patients with an increased risk of syncope.

Randomized comparison of aspirin and phenprocoumon for prevention of right-sided thromboembolic complications associated with transvenous defibrillation leads.

Death due to pulmonary embolism caused by thrombosis formation along a pacing wire has been reported in patients with antibradycardia pacemakers. The purpose of this prospective and randomized study was to evaluate the effects of prophylactically assigned aspirin (100 mg per day) or phenprocoumon (a coumarin derivative) on the incidence of right-sided thromboembolic complications associated with transvenous defibrillation leads. Multiplane transoesophageal echocardiography and pulmonary scintigraphy were performed in 62 consecutive patients immediately and 6 +/- 2 months after transvenous defibrillator implantation. Aspirin or phenprocoumon was administered to the patients in a randomized and parallel manner. By means of multiplane transoesophageal echocardiography and pulmonary scintigraphy no thromboembolic events were observed immediately after transvenous defibrillator implantation. After 6 +/- 2 months, however, multiplane transoesophageal echocardiography disclosed thrombi on the transvenous leads in 13 of 62 patients (21%) despite antithrombotic therapy. At the same time, pulmonary scintigraphy did not reveal any defects compatible with pulmonary embolism. Although thrombi occurred in only four patients treated with phenprocoumon, but in nine patients receiving aspirin, this difference was statistically insignificant. Other variables associated with the occurrence of thrombosis formation were not identified. One fatal intracranial haemorrhage occurred in the phenprocoumon group.(ABSTRACT TRUNCATED AT 250 WORDS)

Echocardiographic imaging of coronary sinus diverticula and middle cardiac veins in patients with preexcitation syndrome: impact on radiofrequency catheter ablation of posteroseptal accessory pathways.

To determine the value of echocardiography for identifying coronary sinus (CS) diverticula and middle cardiac veins (MCVs) in patients with posteroseptal accessory pathways (PAPs), transthoracic (TTE) and transesophageal echocardiography (TEE) were performed in 18 consecutive patients with PAP and in 15 control subjects with left lateral accessory pathway before CS angiography. The size, shape, and location of CS diverticula and MCV were described and compared to angiography. TEE and angiography were concordant for the identification of diverticula (n = 5) and agreed for depicting MCV in 22 of the 27 cases. TTE revealed 4 of 5 diverticula and identified 4 of 27 MCV (P < 0.001). Fourteen MCV but no diverticula were found in the control subject. There was no significant difference between transesophageal and angiographic measurements for the width (23.5 +/- 4.9 vs 26.8 +/- 6.6 mm) and height (13.5 +/- 3.8 vs 15.7 +/- 3.4 mm) of the diverticula, and the width (3.5 +/- 0.7 vs 3.7 +/- 0.6 mm) of MCV. TEE underestimated the length of the MCV (12.0 +/- 1.8 vs 27.2 +/- 6.0, P < 0.001). Delivery of radiofrequency energy within the neck of a diverticulum or within an MCV was successful in 5 of 5, and 6 of 13 cases in patients with PAPs, respectively. In conclusion, echocardiography was as reliable as angiography for detecting and describing CS diverticula and MCV in patients with preexcitation syndrome. Echocardiography is recommended prior to electrophysiological study because it may simplify radiofrequency catheter ablation.

Multiplane transesophageal echocardiographic evaluation of transvenous defibrillation leads.

Permanent transvenous cardioverter-defibrillator leads were investigated by multiplane transesophageal echocardiography (TEE) (1) to determine whether intracardiac lead segments can be visualized, (2) to verify the position of the coils, and (3) to detect possible thrombus formation. The diagnostic information obtained in 62 patients by TEE was compared to that of transthoracic echocardiography (TTE). Abnormal findings were only visualized by multiplane TEE. However, further controlled studies are needed to determine the clinical relevance of displaced caval (one patient) and ventricular coils (15 patients), ventricular (1 patient) or atrial (6 patients) loops, and of clinically uneventful thrombi (13 patients).