Heart adaptations to long-term aerobic training in paraplegic subjects: an echocardiographic study.

STUDY DESIGN: Case-control. OBJECTIVES: To execute an echocardiographic comparison between trained and untrained spinal cord injury (SCI) subjects, and to evaluate whether long-term heart adjustments to endurance training are comparable to those observed in able-bodied (ABL) subjects. SETTING: Italy. METHODS: We enrolled: (1) 17 male SCI patients (lesion level T1-L3, 34±8 years, body mass index (BMI) 23.0±2.8 kg m(-2)), 10 of whom were aerobically trained for >5 years (SCI(T)); (2) 18 age-, sex- and BMI-matched ABL subjects (35±6 years, BMI 23.6±2.8 kg m(-2)), 10 of whom were aerobically trained for >5 years (ABL(T)). Training frequency and volume were recorded by a dedicated questionnaire. All subjects underwent a trans-thoracic echocardiography; SCI subjects also performed an exhaustive incremental exercise test. Comparisons were made between ABL and SCI groups, between trained and untrained subjects within each group (analysis of variance). RESULTS: Effects of SCI-Compared with ABL subjects, SCI patients showed lower end-diastolic volume (76±21 vs. 113±23 ml, P<0.05) and ejection fraction (61±7% vs. 65±5%, P<0.05). Effects of training-Compared with untrained status, the intra-ventricular septum thickness (SCI, +18%; ABL, +4%), the posterior wall thickness (SCI, +17%; ABL, +2%) and the total normalized heart mass (SCI, +48%; ABL, +5%) were higher in both SCI(T) and in ABL(T). VO2peak was higher in the SCI(T) subgroup compared with the SCI(U) group. CONCLUSIONS: Heart seems to positively adapt to long-term endurance training in SCI patients. Regular exercise may therefore increase heart size, septum and posterior wall thickness, which likely contributes to improved VO2peak. These morphological and functional changes may reduce cardiovascular risk in SCI individuals.

[Cardiac failure in ischemic cardiopathy]. / L'insufficienza cardiaca nella cardiopatia ischemica.

Heart failure is a major cause of morbidity and mortality and represents an important recognized health problem. Heart (or cardiac) failure is the pathophysiological state in which a myocardial dysfunction is frequently but non always responsible for the inability of the heart to pump blood at a rate commensurate with tissues metabolic requirements. Ischemic heart disease is the commonest cause of heart failure frequently associated with left ventricular systolic dysfunction, although some patients, particularly the elderly, have diastolic dysfunction. Coronary heart disease is responsible for left ventricular systolic dysfunction (and cardiac failure) in the acute and chronic stage. Myocardial dysfunction is usually a consequence of myocardial infarction that may lead to ventricular remodeling with compensatory dilation and hypertrophy and subsequent systolic and diastolic dysfunction resulting in heart failure. Many patients with heart failure and/or left ventricular dysfunction are unknown. The echocardiographic screening of patients with known or suspected left ventricular dysfunction remains an important topic for future clinical epidemiological research and allows for improvement of therapeutic management of patients with cardiac dysfunction.

Adjunctive thrombus aspiration and mechanical protection from distal embolization in primary percutaneous intervention for acute myocardial infarction.

Primary percutaneous intervention for acute occlusion of a native coronary artery may be complicated by distal embolization of plaque or thrombotic debris, with infarct extension. We tested the clinical application of a new therapeutic strategy combining maximal antiplatelet therapy, with glycoprotein IIb/IIIa inhibition, and adjunctive mechanical protection from distal embolization and direct aspiration of thrombus with a new balloon and catheter system (PercuSurgetrade mark). Successful aspiration of thrombus could be obtained in 7 out of 8 attempted procedures, with inability to negotiate the angulated take-off of the circumflex coronary artery in one patient. The current mechanical characteristics of the device, primarily developed for use in larger saphenous vein grafts, and certain caveats and limitations are discussed. New dedicated systems should be available in the near future for the native coronary circulation. Excellent immediate angiographic results were obtained in all treated patients, without evidence of loss of distal branches and no intraprocedural complications.

A rare case: surviving acute left main coronary artery occlusion in Kawasaki's disease.

We present a case of cardiogenic shock due to acute thrombotic occlusion of the left main coronary artery in Kawasaki's aneurysmal coronary artery disease. The patient was treated with PTCA as a bridge to CABG. Because of a persistent low-output syndrome, orthotopic heart transplantation was successfully performed three days later. The patient is alive and well one year after the event.

Left ventricular opacification by intravenous contrast echocardiography.

BACKGROUND: The present study was undertaken in order to evaluate the efficacy of the intravenous administration of Albunex in obtaining left ventricular opacification and the relationship between left ventricular opacification and pulmonary pressures and cardiac function. METHODS: Fifty-two adult patients, mostly affected by ischemic heart disease, were enrolled in the study. In 37 of these patients, a complete right heart hemodynamic study was performed after Swan-Ganz catheterization. Albunex was administered in three randomized doses (0.10, 0.15 and 0.20 ml/kg) to all the patients. Left ventricular opacification was assessed both visually and using videodensitometric analysis. RESULTS: Left ventricular opacification was obtained in 93% of all the injections and an intermediate or strong opacification was obtained in 68%, while absent opacification was observed in 6% of the injections, irrespective of the contrast dose. An incremental opacification efficacy trend was observed from the lower to the higher dose, with an intermediate or strong opacification in 58 and in 77% of 0.10 and 0.20 ml/kg injections, respectively. Irrespective of the contrast dose, an enhancement of the endocardial borders was observed in 61% of the wall segments suboptimally visualized in basal conditions. The endocardial borders enhancement was obtained in 39 and in 79% of segments using the 0.10 and the 0.20 ml/kg doses, respectively. No statistically significant differences were observed between the videodensitometric parameters obtained using the three contrast doses. Finally, a significant relationship was observed between left ventricular opacification parameters and pulmonary pressures and left ventricular functional parameters, irrespective of the contrast doses considered. CONCLUSIONS: The results we obtained demonstrate the good overall efficacy of Albunex administered intravenously in order to obtain left ventricular opacification in a clinical population of cardiac patients. Moreover, they suggest that the dosage to be used clinically should preferably be at least 0.20 ml/kg, although no significant influence of contrast dosage on videodensitometric parameters has been observed. Finally, irrespective of the contrast dosage, the magnitude of left ventricular opacification appears to be influenced by the hemodynamic status of the patient.

RITED (Registro Italiano Test Eco-Dobutamina): side effects and complications of echo-dobutamine stress test in 3041 examinations.

AIM: The aim of the study was to report the incidence and clinical meaning of side-effects caused by echo-dobutamine testing in a large population and to evaluate any possible correlation between dobutamine dose and side-effects. METHODS: The study population consisted of 3041 patients enrolled from January 1994 to August 1995 at 63 centers participating in the Italian Register of Echo-Dobutamine Testing (Registro Italiano Test Eco-Dobutamina, RITED). The four major indications were myocardial infarction older than one month (40.4%), recent myocardial infarction (22.7%), coronary artery disease without a history of myocardial infarction (10.8%) and suspected coronary artery disease (19.3%). Dobutamine was administered in a peripheral vein at 5, 10, 20, 30, 40 micrograms/kg/minute + atropine 1 mg in four divided doses of 0.25 mg/minute. RESULTS: Severe complications were asystole, which went as high as 6" in one patient, and ventricular fibrillation in two patients. The clinical side-effects were headache (2.5%), hypotension (2.2%), nausea (1.7%), bradycardia (1.4%), palpitations (0.5%), tremors (0.3%), dyspnea (0.2%), paresthesia (0.2%) and hypertension (0.2%). Atrial arrhythmia was recorded in 10.6% of patients, while ventricular arrhythmia was recorded in 26.5%. The percentage of supraventricular and ventricular repetitive arrhythmia did not increase with dosage. The cumulative incidence of supraventricular and ventricular repetitive arrhythmia, considered as an interruption criteria, was 6.6% and 5.9%, respectively. CONCLUSIONS: Echo-dobutamine stress test seems to be a very safe and reliable test for unmasking myocardial ischemia or viability in known or suspected coronary artery disease. It has been shown to be widely applicable in clinical practice for outpatients as well, as long as a protected environment is available.

Lack of Correlation Between Activation of Hemostatic Mechanism and Inflammation in Unstable Angina Pectoris.

In the acute phase of unstable angina, activation of the hemostatic mechanism is demonstrated by an increase in the plasma levels of markers of thrombin generation (prothrombin fragment 1+2) and thrombin activity (fibrinopeptide A). Increased concentrations of plasma C-reactive protein, an acute-phase reactant, have also been reported in patients with unstable angina. However, whether there is a correlation between the activation of the hemostatic mechanism and the acute-phase reaction of inflammation remains unclear. We measured the plasma levels of prothrombin fragment 1+2, fibrinopeptide A, and C-reactive protein in 91 patients consecutively hospitalized with recent-onset rest angina (Class IIIB Braunwald's classification), finding that they were above the normal limits in 48 (53%), 45 (49%), and 30 (33%) patients, respectively. There was no correlation between prothrombin fragment 1+2 and fibrinopeptide A (P = 0.34), prothrombin fragment 1+2 and C-reactive protein (P = 0.10), or fibrinopeptide A and C-reactive protein (P = 0.75). Plasma levels of prothrombin fragment 1+2 and fibrinopeptide A were both above normal levels in 32% of patients; 19% had both prothrombin fragment 1+2 and C-reactive protein, and 18% both fibrinopeptide A and C-reactive protein levels above the upper normal limits. All three markers were abnormally high in 11% of patients. According to the kappa cofficient test, the agreement between the elevation of the plasma concentrations of the markers was "random." In approximately half of the patients with acute unstable angina, there was an increase in the markers of the activation of the hemostatic mechanism and, in a smaller proportion, an increase in plasma C-reactive protein levels. The activation of the coagulation cascade and the acute-phase reaction of inflammation were infrequently associated in individual patients.

C-reactive protein elevation and early outcome in patients with unstable angina pectoris.

C-reactive protein, a reactant of the acute phase of inflammation, has been shown to be increased in patients with unstable angina. Moreover, it has recently been found that increased C-reactive protein is associated with a poor outcome during hospitalization in selected patients with severe unstable angina. The aim of this study was to investigate the prognostic value of C-reactive protein elevation in a large population with unstable angina. We measured serum levels of this marker in 140 patients hospitalized with unstable angina (class IIIB of the Braunwald classification, mean time from last anginal episode 5 +/- 5 hours). Thirty-nine of them (28%) had increased serum levels on hospital admission and 33 (24%) experienced an adverse outcome (myocardial infarction or refractory angina) during hospitalization. Kaplan-Meier analysis showed that the probability of developing cardiac events during hospitalization was not different between patients with and without abnormal C-reactive protein levels. Furthermore, the incidence of ischemia at Holter monitoring during the first 72 hours after hospitalization was not different between patients with and without abnormal C-reactive protein. In a representative population of patients with unstable angina, a sizable proportion had increased serum C-reactive protein levels; however, abnormal concentrations of C-reactive protein do not predict an adverse outcome in the early phase after the acute episode.

Persistent thrombin generation during heparin therapy in patients with acute coronary syndromes.

Intravenous heparin, a fundamental therapy in the treatment of patients with acute coronary syndromes, acts by inhibiting thrombin and activated factors X, IX, XI, and XII. It has also been demonstrated that heparin reduces plasma fibrinopeptide A, a marker of thrombin activity, but it is unknown whether it decreases prothrombin fragment 1+2, an indirect marker of thrombin generation. We measured the plasma levels of prothrombin fragment 1+2, fibrinopeptide A, and antithrombin III in 64 consecutive patients with unstable angina or myocardial infarction receiving intravenous heparin. Blood samples were obtained at baseline (before any treatment) and then at 90 minutes and 24 and 48 hours after the administration of an intravenous bolus of heparin (5000 IU) followed by a continuous infusion of 1000 IU per hour to maintain activated partial thromboplastin time at more than double its baseline levels. In comparison with baseline, there was a significant decrease in fibrinopeptide A at 90 minutes and at 24 and 48 hours (baseline, 2.3 nmol/L; 90 minutes, 1.15 nmol/L; 24 hours, 1.4 nmol/L; 48 hours, 1.2 nmol/L; P < .0001) but no change in prothrombin fragment 1+2 levels (baseline, 1.27 nmol/L; 90 minutes, 1.3 nmol/L; 24 hours, 1.33 nmol/L; 48 hours, 1.29 nmol/L; P = NS). Antithrombin III activity decreased at 24 and 48 hours (baseline, 108%; 24 hours, 97%; 48 hours, 95%; P < .0001). Hence, in patients with acute coronary syndromes, intravenous heparin at a dose reaching an activated partial thromboplastin time that adequately suppresses thrombin activity does not suppress increased thrombin generation.

Activation of the hemostatic mechanism after pharmacological cardioversion of acute nonvalvular atrial fibrillation.

BACKGROUND: Given that the restoration of sinus rhythm after chronic atrial fibrillation is associated with embolic events, anticoagulation is prescribed before and after pharmacological and electrical cardioversion. However, the need for anticoagulation in patients with acute atrial fibrillation (lasting <48 hours) who undergo cardioversion is less clear. In addition, it is not known whether cardioversion to sinus rhythm determines a hypercoagulable state in these patients. METHODS AND RESULTS: In 21 patients with acute nonvalvular atrial fibrillation, plasma median concentrations of thrombin-antithrombin complex, a marker of thrombin generation, significantly increased from 2.8 ng/mL (interquartile range, 2.1 to 4.0 ng/mL) on hospital admission to 3.5 ng/mL (interquartile range, 2.9 to 6.0 ng/mL) after cardioversion to sinus rhythm obtained by means of infusion of antiarrhythmic drugs and decreased to 2.5 ng/mL (interquartile range, 2.0 to 3.5 ng/mL) at the 1-month follow-up visit (P=.04). Similarly, the levels of fibrinopeptide A, a marker of thrombin activity, increased from 1.1 nmol/L (interquartile range, 0.7 to 1.5 nmol/L) at baseline to 1.8 nmol/L (interquartile range, 1.1 to 3.0 nmol/L) after cardioversion and returned to 0.8 nmol/L (interquartile range, 0.6 to 1.1 nmol/L) at the 1-month follow-up visit (P=.02). CONCLUSIONS: A significant increase in plasma levels of the markers of thrombin generation and activity was observed in patients with acute atrial fibrillation early after pharmacological cardioversion to sinus rhythm. This is the first biochemical evidence that cardioversion of recent-onset atrial fibrillation determines a hypercoagulable state.

Pulmonary venous flow velocity patterns in 143 normal subjects aged 20 to 80 years old. An echo 2D colour Doppler cooperative study.

In order to find out the normal values and to evaluate the effects of age, heart rate, sex, and haemodynamic and standard echocardiographic parameters on pulmonary venous flow velocity obtained by the transthoracic approach. Doppler pulmonary venous flow parameters were measured in 143 healthy subjects aged from 20 to 80 years. Doppler pulmonary venous flow parameters which had the best correlation with age were: the peak velocity of the systolic wave (r = 0.39) and its integral (r = 0.5), the peak velocity of the diastolic wave (r = -0.6) and its integral (r = -0.44); the systolic (r = 0.68) and diastolic fractions (r = -0.68); the systolic/diastolic peak velocity ratio (r = 0.73) and the systolic/diastolic integral ratio (r = 0.7). The atrial reversal wave did not correlate with age; the atrial reversal wave was more difficult and probably less reliable to measure than the systolic and diastolic waves. The correlations of pulmonary venous flow parameters with mitral flow parameters were also examined. This study showed that, in healthy subjects, despite an increase in the early and atrial waves from the annulus to the tips of the mitral leaflets, there is a similar association between pulmonary venous flow and mitral flow measured at the annulus or at the tips of the mitral leaflets. The intra-observer reproducibility of all the pulmonary venous flow parameters considered were found to be excellent. Moderate inter-observer variability was observed for the systolic, diastolic and atrial reversal wave peak velocities and integrals; however, the systolic/diastolic ratio improved the precision of the measurements. Multivariate analysis showed that age is the principal determinant of the Doppler parameters of pulmonary venous flow: heart rate, sex, body surface area, the size of the left atrium in systole and the left ventricular ejection fraction all influence the Doppler parameters of pulmonary venous flow, even if only slightly.

Assessment of left internal mammary artery grafts using dipyridamole Doppler echocardiography.

Color Doppler echocardiography of the left mammary artery was combined with dipyridamole testing in order to assess the presence of significant (>70%) graft stenosis in 87 patients with a mammary artery graft to the left anterior descending coronary artery presenting with chest pain. Occluded grafts are detected by absent diastolic flow velocities at baseline, whereas the response of the diastolic flow velocity to dipyridamole distinguishes patients with critical versus noncritical stenosis of a patent graft.

Measurement of mitral valve area in mitral stenosis: four echocardiographic methods compared with direct measurement of anatomic orifices.

OBJECTIVES: This study sought to compare the mitral valve areas of patients with rheumatic mitral valve stenoses as determined by means of four echocardiographic and Doppler methods with those obtained by direct anatomic measurements. BACKGROUND: There has been no systemic comparison between Doppler-determined valve areas and the true anatomic orifice in a single cohort. METHODS: In 30 patients with mitral stenosis, the mitral valve areas determined by two-dimensional echocardiographic planimetry, pressure half-time, flow convergence region and flow area were compared with the values directly measured on the corresponding excised specimen by means of a custom-built sizer. RESULTS: The correlation coefficient was r = 0.95 (SE 0.06, p < 0.0001) for two-dimensional planimetry; r = 0.80 (SE 0.09, p < 0.0001) for pressure half-time; r = 0.87 (SE 0.09, p < 0.0001) for flow convergence region; and r = 0.54 (SD 0.1, p < 0.002) for flow area. Two-dimensional echocardiographic planimetry, pressure half-time, flow convergence region and flow area overestimated the actual anatomic orifice by > 0.3 cm2 in 2, 1, 6 and 0 patients, respectively, and underestimated it by > 0.3 cm2 in 0, 4, 1 and 8 patients, respectively. CONCLUSIONS: Mitral valve areas determined by two-dimensional planimetry, pressure half-time and proximal flow convergence region reliably correlated with size of the anatomic orifice. The flow area method provided a less reliable correlation.

Prolonged streptokinase infusion in patients with unstable angina: results of a randomized, placebo-controlled clinical trial.

BACKGROUND: The purpose of this study was to assess the efficacy both of prolonged (48 h) and of short-duration (1 h) administrations of streptokinase in patients with unstable angina. In unstable angina, thrombosis is a dynamic process that waxes and wanes for hours and even days. The majority of previous studies have investigated the efficacy of short-duration thrombolytic regimens. METHODS: One hundred patients with acute unstable angina were randomly allocated to receive placebo, 1,500,000 U streptokinase during 1 h or 250,000 U streptokinase during 1 h and then a prolonged infusion of 100,000 U for the next 48 h. All of the treatments included intravenous heparin administration for 72 h. RESULTS: No death occurred in the study population. One of 34 patients treated with placebo (2.9%), three of 33 treated with streptokinase during 1 h (9.0%) and three of 33 treated with streptokinase during 48 h (9.0%) had a myocardial infarction. Refractory angina occurred in nine, three and seven patients receiving placebo, streptokinase during 1 h and streptokinase during 48 h, respectively. Kaplan-Meier analysis showed that the total probability for a patient to be free of cumulative events did not differ among the three groups of patients (NS). Fourteen patients (41%) receiving placebo, 15 patients (45%) receiving streptokinase during 1 h and 14 patients (42%) receiving streptokinase during 48 h had ischaemic episodes detected by Holter monitoring during the first 72 h after hospital admission (NS). Two patients receiving streptokinase during 48 h required blood transfusion, and a greater incidence of minor bleeding (P < 0.05) and adverse events (P < 0.02) was observed in patients receiving prolonged streptokinase administration than in those receiving streptokinase during 1 h or placebo. CONCLUSIONS: In patients with acute unstable angina, the administration of two different regimens of streptokinase significantly reduces the probability neither of developing cardiac events during hospitalization nor of ischaemia detected by Holter monitoring in the early phase after hospital admission. Although the sample size of the study provided sufficient power to exclude only a large difference in effect size, it did allow us to detect a significantly higher incidence of bleeding in the group of patients treated with prolonged streptokinase infusion.

Value of transthoracic two-dimensional echocardiography in predicting viability in patients with healed Q-wave anterior wall myocardial infarction.

The role of transthoracic echocardiography as a predictor of recovery after revascularization has not yet been established. Two-dimensional echocardiography was performed in 15 patients with a healed anterior wall myocardial infarction and severe, isolated stenosis of the left anterior descending coronary artery before, and 3 to 6 months after angiographically confirmed successful revascularization. The asynergic segments were classified into 2 groups according to 2 different echocardiographic patterns: those showing a normal acoustic reflectance with normal end-diastolic thickness (pattern A segments) and those showing an increase in acoustic reflectance and reduced end-diastolic thickness (pattern B segments). We hypothesized that pattern A segments were more likely to recover (viable myocardium) and that pattern B segments were consistent with irreversibility. A total of 240 segments in the 15 patients were evaluated before and after revascularization. Sixty-seven segments were asynergic; of these, 52 were judged to have pattern A and 15 pattern B. Of the 52 pattern A segments, 27 were hypokinetic and 25 akinetic. All of the pattern B segments were akinetic (n = 9) or dyskinetic (n = 6). Pattern A was predictive of postoperative recovery in 39 of 52 segments (75%) (p < 0.0001); pattern B was predictive of irreversibly damaged tissue in 13 of 15 segments (87%) (p < 0.0001). Thus, in patients with healed anterior wall myocardial infarction, resting transthoracic echocardiography is a simple and reliable predictor of the behavior of asynergic segments after revascularization.

Transthoracic 2D echo color Doppler assessment of internal mammary artery to left anterior descending coronary artery graft.

For noninvasive evaluation of anatomy and flow characteristics of internal mammary artery graft (IMA-graft), 2D echo-Color-Doppler (CDE) was performed in 60 patients (54 M, 6 F, mean age 54.1 +/- 6.9 y), who underwent coronary angiography 20.1 +/- 13 months after a coronary artery bypass graft (CABG). CDE was performed, using an echocardiographic unit equipped with a 5 MHz linear transducer. In all patients, measurements of IMA-graft diameter (mm), and peak systolic and diastolic flow velocity (cm/sec) were obtained at baseline and also in 16 patients after dipyridamole infusion (0.54 mg/Kg/min) and in 10 patients after sublingual nitroglycerin (NTG) (0.4 mg). Angiography showed the IMA-graft patency in 58/60 patients (96.8%). A typical biphasic flow was displayed by CDE in 49/58 patients (84.4%) with angiographic patency. Dipyridamole infusion increased both IMA-graft diameter and peak diastolic flow velocity (PDFV) from 2.28 +/- 0.51mm to 2.9 +/- 0.42mm and from 19.4 +/- 6.2 cm/sec to 93.9 +/- 29 cm/sec, respectively (p < 0.0001). No significant modifications of peak systolic flow velocity (PSFV) were observed. NTG increased PDFV from 29.11 +/- 8 cm/sec to 41.88 +/- 7.20 cm/sec (p < 0.005), while diameter and PSFV showed no statistically significant modifications. CDE is a useful diagnostic tool for noninvasive evaluation of IMA-graft patency both early after surgery and during long-term follow-up. CDE pharmacological stress improves the sensibility of the technique and it can provide indirect information about pathophysiology of recipient coronary vessel.

[Multiplane transesophageal echocardiography. The experience with 250 patients]. / Ecocardiografia transesofagea multiplana. Esperienza su 250 pazienti.

BACKGROUND AND OBJECTIVES: Multiplane transesophageal echocardiography provides countless tomographic planes through an angle of 180 degrees, thus overcoming the restriction encountered even with biplane transesophageal echocardiography. However, the incremental diagnostic value and clinical usefulness of this technique over biplane transesophageal echocardiography has not been extensively studied. STUDY POPULATION AND METHODS: In order to evaluate its advantages over biplane imaging, 250 patients (129 male, 121 females) aged 14-86 years, underwent multiplane transesophageal echocardiography. Indications for the study were the following: source of embolism in 83 patients, suspected prosthetic dysfunction in 58 patients, valvular disease in 46 patients, congenital heart disease in 30 patients, aortic disease in 17 patients, intra- or paracardiac masses in 11 patients, and other reasons in 5. All the patients underwent an initial comprehensive diagnostic assessment using only the transverse (0 degree) and longitudinal (90 degrees) plane as the biplane imaging technique. "Off-axis" tomographic sections through the full 0 degree to 180 degrees angle were subsequently obtained by means of the gradual electrical rotation of the transducer. The echocardiographic information obtained by rotating the transducer was then compared to that obtained by biplane imaging to determine whether the additional information provided by "off-axis" sections a) carried diagnostic data; b) were to be considered useful but not diagnostic; or c) irrelevant. RESULTS: Additional diagnostic information was obtained in 24 out of the 250 patients (9.6%), including the source of embolism in 9 patients, mitral insufficiency in 6 patients, bicuspid aorta in 2 patients, aortic endocarditis in 2 patients, mitral prosthetic dysfunction in 4 patients and complex congenital heart disease in 1 patient. Additional useful but non-diagnostic information was obtained in 162 patients (64.8%). These data mainly allowed a more comprehensive assessment of the cardiac abnormality, enhancing confidence in the transesophageal diagnosis. Finally, data considered to be irrelevant were found in 64 patients (25.6%). CONCLUSIONS: The present study indicates that the wide range of tomographic planes provided by multiplane transesophageal echocardiography allows a more comprehensive evaluation of cardiac diseases and makes an accurate diagnosis possible in a significant number of cases.