Left coronary artery ostial stenosis from Takayasu's arteritis diagnosed using transthoracic color flow and pulsed Doppler echocardiography.

Coronary artery stenosis is seen in 10-45% of patients with Takayasu's arteritis (TA) and coronary ostia are most frequently involved. It may cause angina pectoris and sudden death during the early course of the disease. We describe a 14-year-old girl who first presented with exertional angina and syncope and was diagnosed as having left coronary artery ostial stenosis from TA by using transthoracic echocardiography. This is the first report showing the important role of color flow and pulsed Doppler echocardiography to detect coronary artery stenosis caused by TA.

[Evaluation of echocardiographic left ventricular wall motion analysis supported by internet picture viewing system].

BACKGROUND: Assessment of deterioration of regional wall motion by echocardiography is not only subjective but also features difficulties with interobserver agreement. Progress in digital communication technology has made it possible to send video images from a distant location via the Internet. OBJECTIVES: The possibility of evaluating left ventricular wall motion using video images sent via the Internet to distant institutions was evaluated. METHODS: Twenty-two subjects were randomly selected. Four sets of video images (parasternal long-axis view, parasternal short-axis view, apical four-chamber view, and apical two-chamber view) were taken for one cardiac cycle. The images were sent via the Internet to two institutions (observer C in facility A and observers D and E in facility B) for evaluation. Great care was taken to prevent disclosure of patient information to these observers. Parasternal long-axis images were divided into four segments, and the parasternal short-axis view, apical four-chamber view, and apical two-chamber view were divided into six segments. One of the following assessments, normokinesis, hypokinesis, akinesis, or dyskinesis, was assigned to each segment. The interobserver rates of agreement in judgments between observers C and D, observers C and E, and intraobserver agreement rate (for observer D) were calculated. RESULTS: The rate of interobserver agreement was 85.7% (394/460 segments; Kappa = 0.65) between observers C and D, 76.7% (353/460 segments; Kappa = 0.39) between observers D and E, and 76.3% (351/460 segments; Kappa = 0.36)between observers C and E, and intraobserver agreement was 94.3% (434/460; Kappa = 0.86). Segments of difference judgments between observers C and D were normokinesis-hypokinesis; 62.1%, hypokinesis-akinesis; 33.3%, akinesis-dyskinesis; 3.0%, and normokinesis-akinesis; 1.5%. CONCLUSIONS: Wall motion can be evaluated at remote institutions via the Internet.

Aortic valve repair for aortic regurgitation: intermediate-term results in patients with tricuspid morphology.

BACKGROUND AND AIM OF THE STUDY: Surgical results after aortic valve repair in patients with aortic regurgitation (AR) of tricuspid valve morphology and with no evidence of aortic root disease have not yet been clarified. METHODS: Between January 1994 and June 2001, aortic valve repair was performed in 40 patients (eight females, 32 males; mean age 61.0 +/- 10.5 years) of this type. Surgical results and follow up data were summarized after aortic valve repair (for AR) in these patients. RESULTS: One patient died in hospital (mortality 2.5%). The mean cardiopulmonary bypass time was 143.5 +/- 47.4 min, and mean aortic cross-clamp time 99.8 +/- 34.3 min. At follow up, the mean AR grade was 1.5 +/- 0.8 and mean NYHA class 1.0 +/- 0; both parameters showed significant improvement compared to preoperative status (p < 0.0001). Survival was 94.9% at one year and 82.6% at five years. The five-year reoperation-free rate was 87%. CONCLUSION: Aortic valve repair for AR in patients with tricuspid valve morphology is a safe procedure that provides good intermediate-term results.

[Coronary sinus ostial atresia with thrombus: a case report].

An 82-year-old woman presented with mitral regurgitation and atrial fibrillation. She was hospitalized for further examination of cardiac thrombus detected by transthoracic echocardiography. No definitive diagnosis could be made based on computed tomography and magnetic resonance imaging. Intravenous contrast echocardiography suggested a coronary sinus thrombus. Coronary angiography showed coronary sinus ostial atresia. Multislice computed tomography confirmed the presence of thrombus in the enlarged coronary sinus with coronary sinus ostial atresia and persistent left superior vena cava. Persistent left superior vena cava is present in 3% of patients with congenital heart disease. Persistent left superior vena cava is detected by chance during cardiac catheterization for other conditions in patients without cardiac malformations. The present case was detected at an advanced age, and in the absence of prior symptoms.

Effects of exercise training on left ventricular function evaluated by the Tei index in patients with myocardial infarction.

BACKGROUND: This study investigated the influence of exercise training on left ventricular (LV) function in patients with acute myocardial infarction (AMI) using a new index of cardiac function, the Tei index. METHODS AND RESULTS: The study enrolled 53 consecutive patients (36 males, 17 females; mean age: 65+/-10 years) with AMI. Exercise training was performed for 6 months; peak VO2 and the Tei index were measured at the start of the cardiac rehabilitation program and 1, 3, and 6 months later. The peak VO2 improved from 14.3+/-3.3 to 18.5+/-5.2 ml.min -1.kg-1 after 6 months (p<0.01). Although there were no significant changes in LV ejection fraction over the 6 months, the Tei index improved from 0.50+/-0.18 to 0.41+/-0.19 (p<0.05). When the DeltaTei index was compared among the 3 groups classified by the Tei index at baseline, the values improved in the groups with high/slightly high values compared with the normal group. CONCLUSION: Both cardiac function, as evaluated by the Tei index, and exercise capacity improved after exercise training in patients with AMI. The greater improvement was seen in the population with the higher value (lower cardiac function) according to this index.

Perioperative changes in dynamic aortic root morphology after Yacoub's root remodeling and concomitant aortic annuloplasty.

We have performed aortic root remodeling concomitant with aortic annuloplasty (subvalvular circular annuloplasty: it tightens the aortic annulus, using Gore-Tex strip (N.L. Gore and Associates, Arizona, USA)) in patients with AAE and AR. We examined morphologic changes in the aortic root during cardiac cycles, using pre- and post-operative echocardiography. Twelve patients were underwent the procedure. Their grade of AR was 3.2+/-1.0. Five adults with normal aortic roots were studied as controls. The systolic and diastolic radius of each cusp was measured at the annulus, the Valsalva and the STjunction level. The ratio of diastolic radius to systolic radius in the control, pre-operative data and post-operative data was obtained. In the controls, the rate of diameter change during the cardiac cycle was largest at the annulus level (Right coronary cusp (RCC), Left coronary cusp (RCC), Noncoronary cusp (NCC); 1.00+/-0.2, 1.12+/-0.1, 1.23+/-0.2), second largest at Valsalva level (RCC, LCC, NCC; 0.96+/-0.6, 1.07+/-0.2, 0.97+/-0.2), and smallest at the ST junction (RCC, LCC, NCC; 0.95+/-0.4, 1.03+/-0.2, 0.93+/-0.2). Pre-operative data showed that it was largest at the Valsalva level. Post-operative data showed that the rate of change at each level was not significantly different from the control data. All patients were in NYHA class I and the grade of AR was 0.4+/-0.7 at the latest follow-up. Subvalvular circular annuloplasty did not interfere with annulus motion during the cardiac cycle. Aortic root remodeling and concomitant aortic annuloplasty restored near normal cyclic aortic root motion and morphology on the short-term.

Morphological analysis of aortic root in eccentric aortic regurgitation using anyplane two-dimensional images produced by transesophageal three-dimensional echocardiography.

BACKGROUND AND AIM OF THE STUDY: Evaluation of leaflet dysfunction in aortic valve repair is important. In eccentric aortic regurgitation (AR), it is unclear whether leaflet dysfunction other than prolapse exists. The study aim was to validate the hypothesis that eccentric AR correlates with leaflet dysfunction. METHODS: Both anyplane 2-D images produced by a 3-D reconstruction system and surgical views for 21 patients with eccentric AR (11 with aortic valve prolapse, group A; 10 without prolapse, group B) were analyzed prospectively. Vertical height from annulus to coaptation point (termed AC), and distance from coaptation point to sinotubular junction (CS) were measured at early diastole. RESULTS: For group A, AC and CS values were 1.3 +/- 2.2 mm and 25.9 +/- 3.4 mm respectively for leaflets of eccentric AR jet origin, and 3.8 +/- 0.4 mm and 22.7 +/- 2.1 mm for other leaflets. For group B, AC and CS values were 4.7 +/- 0.9 mm and 39.8 +/- 7.0 mm for leaflets of eccentric AR jet origin, and 7.8 +/- 0.9 mm and 31.9 +/- 5.7 mm for other leaflets. The AC for leaflets of eccentric AR jet origin was smaller than AC for other leaflets (p < 0.01) between both groups. There was no difference between CS for leaflets of eccentric AR jet origin and other leaflets in group A, but CS for leaflets of eccentric AR jet origin was larger than for other leaflets in group B (p <0.01). AC and CS values for leaflets of eccentric AR jet origin in group B were larger than those for group A. Leaflets of eccentric AR jet origin were always shifted toward the direction of the base in the anyplane images, and elongated in the surgical view. CONCLUSION: Anyplane 2-D images obtained by 3-D echocardiography showed that aortic leaflets of eccentric AR jet origin shifted towards the direction of the base with or without prolapse, and were accompanied by dysfunction. Color flow Doppler determination of the eccentricity of AR jet origin was useful in predicting aortic valve dysfunction.

Noninvasive Measurement of Left Coronary Blood Flow Reserve by Transthoracic Doppler Echocardiography: Comparison with Doppler Guidewire Ultrasonography.

The development of new ultrasound instrumentation has made epicardial coronary artery blood flow imaging easier with the use of transthoracic coronary Doppler echocardiography (TCDE). This study was performed to investigate the accuracy of coronary blood flow reserve (CFR) measurement by TCDE. In 15 patients with ischemic heart disease in the absence of valvular disease or atrial fibrillation, coronary flow at rest and flow with hyperemia induced by intravenous dipyridamole infusion were recorded by TCDE and Doppler guidewire ultrasonography. The CFR was determined as the ratio of the maximum hyperemic diastolic time-averaged peak velocity to the velocity at rest in the proximal or distal left anterior descending coronary artery. It was found that the CFR of the left anterior descending coronary artery measured by TCDE was comparable in accuracy with CFR measured by invasive methods (r = 0.87, P < 0.0001, n = 15).