Role of echocardiography/Doppler in cardiogenic shock: silent mitral regurgitation.

Two cases of cardiogenic shock and pulmonary edema due to acute, severe, silent mitral regurgitation are discussed. The mechanism for the mitral regurgitation was papillary muscle rupture in the setting of acute myocardial infarction. Echocardiography established the presence, severity, and cause of the mitral regurgitation and the associated hyperdynamic left ventricular function in the setting of cardiogenic shock. Transesophageal echocardiography is excellent for assessing the mitral valve in critically ill patients in whom transthoracic echocardiography may be inadequate or misleading. This allowed for emergency mitral valve replacement without prolonged attempts at medical stabilization.

Transesophageal echocardiography to improve positioning of radiofrequency ablation catheters in left-sided Wolff-Parkinson-White syndrome.

Two patients with the Wolff-Parkinson-White syndrome who underwent successful radiofrequency catheter ablation of their left-sided bypass tracts are described. Transesophageal echocardiography, a relatively new echocardiographic technique, was utilized in both patients and provided excellent visualization of intracardiac anatomy as well as the catheter tip. Transesophageal echocardiography was also synergistic with fluoroscopy and the intracardiac electrogram in providing more precise catheter placement. In addition, the use of transesophageal echocardiography may reduce fluoroscopic exposure and shorten the procedure time.

Pulmonary artery obstruction due to giant cell arteritis.

Giant cell arteritis is often referred to in the context of polymyalgia rheumatica with temporal artery involvement. There are, however, more malignant forms of presentation of this necrotizing arteritis involving either the great vessels of the aorta or, occasionally, the pulmonary arteries. Our case relates to giant cell arteritis presenting as pulmonary artery obstruction in a patient without polymyalgia rheumatica or extensive aortic or proximal great vessel involvement.

Analysis of historical variables, risk factors and the resting electrocardiogram as an aid in the clinical diagnosis of recurrent chest pain.

A prospective study on 184 consecutive patients presenting with the chief complaint of recurrent chest pain (RP) for diagnostic coronary arteriography (CA) was conducted utilizing a simple questionnaire of historical, physical and electrocardiographic variables. A linear logistic regression analysis yielded a final data set of 13 variables. Concurrently, staff cardiologists who obtained the questionnaire data through direct questioning rendered a clinical diagnosis of either angina (coronary artery disease [CAD]) or noncardiac chest pain. Utilization of the regression analysis increased diagnostic accuracy from 69 to 86% (p less than 0.0003); sensitivity from 83 to 88% (NS) and specificity from 49 to 84% (p less than 0.0001). The best predictive variables for the presence or absence of obstructive CAD documented by CA were in order of decreasing value: age, electrocardiogram, pain aggravated by sex, sex (gender), pain aggravated by movement, diabetes mellitus, pain described as prickling, pain described as burning, pain relieved by rest, pain with radiation to both arms, associated nausea, associated dyspnea, and a history of a lipid disorder. Four variables were predictive of normal coronary anatomy (NCA), pain aggravated by movement, prickling, nausea, and dyspnea. Although this set of predictor variables may not apply equally well to all populations of cardiac patients, the availability and relative simplicity of the program allow for adding or deleting variables and thus provide for considerable potential in the diagnostic assessment of RP. An inexpensive pocket computer can utilize the coefficients generated by the logistic regression program to calculate the probability of CAD as the cause of RP.

Reoperation for correction of anomalous origin of the left coronary artery from the pulmonary artery with return of left ventricular function.

An adult patient is presented in whom anomalous origin of the left coronary artery from the pulmonary artery was diagnosed in infancy. Initial treatment included a palliative poudrage procedure. Resulting widespread, dense adhesions were encountered during reoperation in adulthood and precluded direct reimplantation of the left coronary artery into the aorta. Instead, a tunnel within the pulmonary artery was constructed from the aorta to the left coronary ostium using a baffle of woven Dacron. Preoperative and postoperative studies showed improvement in ejection fraction and resolution of diaphragmatic hypokinesis.

On the relationship between Q waves in leads II and VF and inferior-posterior wall motion abnormalities.

Twelve electrocardiographic criteria, based on various combinations of Q wave morphology in leads II and aVF, were tested in 235 cases for their diagnostic value in detecting inferoposterior wall motion abnormality (presumably reflecting infarction in the area) as demonstrated on left ventriculogram. The most reliable indicator of inferoposterior wall motion abnormality was found to to a QR complex with a Q wave width greater than or equal to .03 or greater than or equal to .04 sec associated with a Q/R ratio greater than .25. Using as criterion a QR complex with a Q wave width greater than or equal to .04 sec and a Q/R ratio greater than .25, the sensitivity was 41.9% in the cases with akinetic-dyskinetic wall motion and 3.7% in the cases with hypokinesis with an associated specificity of 100%. By lowering the Q wave duration to greater than or equal to .03 sec, the sensitivity increased to 51.6% and 9.3%, respectively, while retaining a very high specificity (96%). The exclusion of cases with a Q and R of less than 5 mm markedly lowered the sensitivity with a negligible increase in specificity. QS complexes in leads II or aVF were not found to be reliable indicators of inferoposterior wall motion abnormality.

Nonvolumetric assessment of ventricular function by two-dimensional echocardiography in patients with coronary artery disease.

Left ventricular ejection fraction (EF) was prospectively predicted by nonvolumetric parameters obtained by M-mode and two-dimensional (2DE) echocardiography in 55 patients with angiographically proven coronary artery disease. In particular, the mitral E-point to septum separation (EPSS) could predict the angiographic ejection fraction (EF) according to the formula %EF = 74 - 2 (EPSS) with a correlation of 0.81 and a standard error of the estimate (SEE) of 12%. An EPSS of greater than 10 mm predicted ventricular dysfunction with a sensitivity of 0.81 and a specificity of 0.93. A Wall Motion Score (WMS), obtained by summing segmental wall motion assessed as normal = 4, hypokinetic = 3, akinetic = 2, dyskinetic = 1, for each of seven segments and dividing by seven (the number of segments evaluated), also correlated with the angiographic EF (r = .76). An abnormal WMS was found to be less than 3.3 and together with an EPSS greater than 10 mm, these parameters had a sensitivity of 0.90, a specificity of 0.92, and predictive value of 0.90 for ventricular dysfunction, as evidenced by an EF of less than 0.51. We conclude that the EPSS has a great a predictive value for the EF as the more vigorous quantitative volumetric echocardiographic estimates. Together with the WMS, these parameters are of considerable clinical value in detecting ventricular dysfunction.

M-mode and two-dimensional echocardiographic correlation with findings at catheterization and surgery in patients with mitral stenosis.

Thirty-two consecutive patients referred to our institution for evaluation of rheumatic mitral stenosis were studied with M-mode echocardiography (M-mode E), two dimensional echocardiography (2DE), and cardiac catheterization. Twenty-three of these patients underwent mitral valve surgery, 11 requiring mitral valve replacement, and 12 requiring open mitral commissurotomy. Clinical and noninvasive parameters were assessed in order to predict catheterization-determined mitral valve areas as calculated by the Gorlin formula, and to predict the choice of operation in patients selected for surgery. For the prediction of valvular area, 2DE planimetry correlated highly (r = 0.89, p less than 0.01) with Gorlin formula results. The presence or absence of pericardial effusion, the anterior-posterior valve leaflet separation (M-mode E), and the left atrium-aortic index (2DE) correlated poorly with the degree of mitral stenosis as determined by the Gorlin formula. The most useful predictors of type of mitral surgery were age over 50 years, 2DE valve classification, the presence or absence of calcium at fluoroscopy, and degree of anterior leaflet-septal separation (M-mode E).

Myocardial infarction in a young woman with isolated coronary arteritis.

A 26-year-old black woman presented with a febrile illness and subsequently sustained an inferior myocardial infarction with chest pain. CPK-MB elevation and ECG changes. Left ventriculography revealed inferior wall hypokinesis, and coronary angiography demonstrated multiple aneurysms of the coronary arteries. Findings on visceral angiography of multiple organs was normal. Various etiologies were considered; however, her clinical course was felt to be most consistent with periarteritis nodosa and steroid therapy was instituted.

Myocardial infarction before age 36: risk factor and arteriographic analysis.

One-hundred consecutive patients who were 35 years of age of younger underwent coronary arteriography after clinical myocardial infarction. Ninety-two percent were men. Four distinct subgroups were identified: Ninety-four patients (78 percent) had significant coronary artery disease (greater than 50 percent diameter narrowing of at least one major coronary artery), 20 (17 percent) had normal coronary arteries, 5 (4 percent) had major coronary arterial anomalies and 1 patient had coronary arteritis. Of the patients with obstructive coronary disease, risk factors were smoking in 89 percent, positive family history of coronary artery disease in 48 percent, hypertension in 21 percent and a history of lipid abnormality in 20 percent. Risk factors were distinctly less frequent in the groups without coronary atherosclerosis. In the group with coronary artery disease, the prevalence rate of one, two and three vessel disease was 32, 26 and 42 percent, respectively. Coronary arterial anomalies included anomalous origin of the left coronary artery from the pulmonary artery (three patients) and single right and single left coronary artery (one patient each). It is concluded that myocardial infarction before age 36 is a disease of men who smoke and who often have a family history of premature coronary artery disease. Twenty-two percent of patients will have normal coronary arteries, coronary arterial anomalies or coronary vasculitis. Coronary arteriography should be considered for patients who sustain a myocardial infarction before age 36 for purposes of diagnosis, management and prognosis.

Two-dimensional echocardiography in predicting left ventricular wall motion abnormalities and left ventricular function.

In an attempt to formulate a reliable noninvasive method of detecting segmental wall motion disturbances, we examined 25 patients with coronary artery disease by two-dimensional echocardiography (2-DE), standard 12-lead electrocardiography (ECG), and biplane left ventriculography. The 2-DE technic predicted qualitative wall motion abnormalities as defined by ventriculography with a sensitivity of 88% and a specificity of 86%. The ECG (Q waves) predicted segmental wall motion disturbances with only 50% and 51% sensitivity and specificity, respectively. Extrapolating the advantages of 2-DE to the assessment of global myocardial function, left ventricular wall motion index (LVWMI) and E-point septal separation (EPSS) by 2-DE were correlated with left ventriculographic ejection fractions; r values were high (.73 and -.76, respectively) in both instances. Thus, 2-DE provides a reliable noninvasive technic by which both regional and global myocardial wall motion disturbances can be assessed. Unlike previous noninvasive methods, the 2-DE results compared very favorably with those of biplane left ventriculography.