Effect of intravenous contrast for left ventricular opacification and border definition on sensitivity and specificity of dobutamine stress echocardiography compared with coronary angiography in technically difficult patients.

BACKGROUND: The study evaluates whether Optison used during dobutamine stress echocardiography (DSE) will improve endocardial border definition and whether this will translate to an improvement in sensitivity and specificity of the test in patients with poor echocardiographic windows. DSE is extremely valuable in the workup of patients with coronary artery disease. The test is limited in patients with suboptimal endocardial border visualization. Frequent studies have demonstrated improved endocardial border visualization with intravenous contrast agents at rest. METHODS AND RESULTS: We studied 229 patients: 112 had good rest echocardiography with no contrast and 117 had poor rest echocardiography with Optison injection during DSE. Percentage of endocardial border visualization, wall thickening, sensitivity, and specificity were compared in both groups, as was interobserver variability. Both groups were matched with respect to age, percentage of previous myocardial infarctions, resting wall motion abnormality, percentage of coronary stenosis, and number of diseased coronary arteries. Optison significantly improved endocardial border visualization, especially at peak stress. The ability to measure wall thickening was significantly higher in the contrast DSE group with suboptimal images versus the noncontrast group with optimal images (89% ability to measure wall thickening vs 71%, P =.01). This resulted in a comparable sensitivity (79% vs 71%, P = not significant [NS]), specificity (76% vs 82%, P = NS), and diagnostic accuracy (80% vs 76%, P = NS). Agreement on test interpretation was higher among 3 observers in contrast DSE versus noncontrast DSE groups (79% vs 69%, P =.01). CONCLUSIONS: In patients with poor echocardiographic windows, the use of Optison during DSE improves endocardial border visualization, which translates to a comparable sensitivity and specificity to noncontrast DSE tests in patients with good echocardiographic windows.

Abnormal endothelial function in young African-American females: discordance with blood flow.

In this pilot study, we sought to compare the vasodilatory and hemodynamic properties of the peripheral vasculature in the forearms of young, healthy African-American females to similarly matched white females. We used high-resolution ultrasound of the brachial artery to evaluate 11 African-American females and 8 white females. When normalized to nitrate-induced dilation, endothelium-dependent dilation was reduced in young African American females compared to white females (0.6 in African American females compared to 1.0 in white females). These results indicate the need for a larger study to examine this phenomenon.

For left ventricular opacification and endocardial border definition: is it really important which contrast agent we use, or is it the imaging modality we choose?

AIMS: The purpose of this study was to prospectively compare the effect of three imaging modalities (fundamental, harmonics, and power harmonics) on left ventricular opacification and endocardial border definition with two different echo agents, Optison and Albunex. METHODS: A total of 84 patients who had suboptimal transthoracic images were studied with echo contrast agents Albunex (n=41) and Optison (n=43). Each contrast agent was examined with three different imaging modalities, fundamental, harmonics and power harmonics, respectively. Left ventricular opacification was obtained by videodensitometric analysis. Percentage of endocardial border visualization was determined by indexing circumference of visualized endocardium to total circumference. Variables were compared with respect to three imaging modalities between two different echo agents. RESULTS: Higher videointensities and higher percentages of endocardial visualization were achieved with Optison compared to Albunex with fundamental and harmonics. However, there was no significant difference between Optison and Albunex with respect to LV opacification and border visualization by power harmonics. CONCLUSION: These results indicate that left ventricular opacification and endocardial border visualization is significantly improved by using power harmonic imaging as compared to harmonics or fundamental imaging following both echo contrast agents. Furthermore, although Optison is clearly superior to Albunex in opacifying left ventricle, power harmonic imaging compensates for the less robust agent.

Mitral valve replacement: randomized trial of St. Jude and Medtronic Hall prostheses.

BACKGROUND: This study was designed to better define the merits of the bileaflet and tilting-disc valves. METHODS: We prospectively randomized 156 patients (mean age, 59 years) to receive either the St. Jude (n = 80) or the Medtronic Hall (n = 76) mitral valve prosthesis between September 1986 and December 1997. The two groups were not significantly different with respect to preoperative New York Heart Association class, left ventricular ejection fraction, incidence of mitral stenosis or insufficiency, extent of coronary artery disease, completeness of revascularization, or cross-clamp or bypass time. RESULTS: The operative mortality (11.2% versus 13.1%, St. Jude versus Medtronic Hall, respectively) and late mortality (27% versus 22%, St. Jude versus Medtronic Hall, respectively) were not significantly different. Follow-up was complete in all hospital survivors with a mean of 60.7 months (range, 1 to 133 months). The analysis of 10-year actuarial survival and freedom from valve-related events demonstrated no significant differences between the cohorts. Freedom from reoperation was higher in the St. Jude group (p < 0.01). Comparisons of patient functional status and echocardiographic hemodynamic parameters obtained at the time of follow-up demonstrated no significant differences between the two prostheses. CONCLUSIONS: This study suggests that there is no difference between the St. Jude and Medtronic Hall prostheses with respect to late clinical performance or hemodynamic results and therefore does not support the preferential selection of either prosthesis.

Prognostic significance of late-peaking left ventricular velocity contour in patients with aortic stenosis undergoing valve replacement.

BACKGROUND: The presence of an abnormal late-peaking left ventricular velocity contour, detected by Doppler echocardiography, has been reported in patients with hypertrophic cardiomyopathy, left ventricular hypertrophy, and aortic stenosis. METHODS AND RESULTS: To evaluate the clinical and prognostic significance of this characteristic Doppler finding, we studied a group of patients (n = 57) with isolated AS undergoing aortic valve replacement. Patients were divided into two groups according to the presence (n = 28) or absence (n = 29) of a hypertrophic late-peaking left ventricular velocity pattern. There were no differences between the groups with respect to age, sex, and presence of coronary artery disease. Peak preoperative aortic valve gradients were similar in both groups (70 vs. 67 mm Hg; p = not significant). The postoperative course of patients with abnormal late-peaking ventricular velocity contour was complicated by a higher incidence of arrhythmias (80% vs. 38%; p = 0.0002). Hypotension and the use of inotropic support were significantly more common in the group with abnormal late-peaking ventricular velocity contour (79% vs. 24%; p = 0.0001 and 76% vs. 26%; p = 0.0001, respectively). Hemodynamically, patients with a late-peaking velocity pattern exhibited a higher pulmonary diastolic pressure (16+/-3 vs 12+/-2 mm Hg; p = 0.0003), wedge pressure (12+/-4 vs 10+/-2; p < 0.05), and systemic vascular resistance (2126+/-459 vs 1553+/-199; p = 0.0001) and lower cardiac index (2.4+/-0.3 vs 2.9+/-0.4; p = 0.0001). CONCLUSIONS: An abnormal late-peaking ventricular velocity contour pattern appears to be a high risk marker for postoperative complications in patients undergoing aortic valve replacement. Routine Doppler evaluation in patients undergoing valve replacement for AS may therefore identify these patients.

Effect of treatment of isolated systolic hypertension on left ventricular mass.

CONTEXT: Left ventricular (LV) hypertrophy is a common problem among elderly patients with isolated systolic hypertension (ISH), but the effect of treatment of ISH on LV mass is not known. OBJECTIVE: To assess the ability of antihypertensive drug treatment to reduce LV mass in ISH. DESIGN: Echocardiographic Substudy of the Systolic Hypertension in the Elderly Program (SHEP). PATIENTS: A total of 104 participants at the St Louis SHEP site who had interpretable baseline echocardiograms, 94 of whom had 3-year follow-up echocardiograms. INTERVENTION: The SHEP participants were randomized to placebo or active treatment with chlorthalidone (12.5-25 mg/d), with atenolol (25-50 mg/d) added if necessary to maintain goal blood pressure. MAIN OUTCOME MEASURE: Change in LV mass assessed by echocardiography. RESULTS: Minimum follow-up was 3 years. In the active treatment group, 91% and 80% of subjects were receiving treatment with chlorthalidone alone by the end of years 1 and 3, respectively. The LV mass index was 93 g/m2 in the active treatment group and 100 g/m2 in the placebo group (P<.001). The LV mass index declined by 13% (95% confidence interval, - 3% to - 23%) in the active treatment group compared with a 6% increase (95% confidence interval, - 3% to + 16%) in the placebo group over 3 years (P=.01). CONCLUSION: Treatment of ISH with a diuretic-based regimen reduces LV mass.

Pharmacologic stress-induced regional myocardial blood flow heterogeneity and left ventricular wall thickening abnormality: comparison of intravenous adenosine with dipyridamole in a model of critical coronary stenosis.

Variations in reported sensitivity of myocardial perfusion scans or wall motion abnormalities during pharmacologic stress with intravenous adenosine and dipyridamole may be caused by differences in myocardial oxygen demand or myocardial blood flow redistribution induced by each agent. To investigate the physiologic correlates of functional abnormalities during pharmacologic stress testing, regional myocardial blood flow (radiolabeled microsphere technique) and left ventricular segmental wall thickening (quantitative two-dimensional echocardiography) were measured in 9 dogs with an open chest model of critical stenosis of the left circumflex coronary artery. Data were obtained at baseline and peak drug infusion for intravenous adenosine (0.42 mg/kg over a 3-minute period) and for intravenous dipyridamole (0.56 mg/kg over a 4-minute period). Adenosine and dipyridamole induced regional flow abnormality in 7 (77%) of 9 dogs. Myocardial segments with decreased endocardial/epicardial flow ratio were similar for both agents (2.9 +/- 1.8 vs 2.7 +/- 1.3, p = [NS]). Segments with myocardial flow heterogeneity (ratio of endocardial flow to control left anterior descending/left circumflex endocardial flow) were similar for both agents (2.7 +/- 0.9 vs 2.3 +/- 1.0, p = NS). Adenosine-induced wall thickening abnormality (77% vs 55% with dipyridamole) correlated with regional flow abnormality. Significantly lower mean arterial pressure (53 +/- 1.7 mm Hg vs 64 +/- 1.9 mm Hg, p < 0.01) and more prolonged drug effect (18 +/- 6.4 min vs 3 +/- 1.4 min, p < 0.001) were seen for dipyridamole compared with adenosine. Adenosine induces regional flow abnormality similar to dipyridamole but with less hemodynamic perturbation, and adenosine-induced wall thickening abnormality more closely parallels regional flow abnormality.

Differential characterization of blood flow, velocity, and vascular resistance between proximal and distal normal epicardial human coronary arteries: analysis by intracoronary Doppler spectral flow velocity.

To characterize coronary blood flow velocity parameters and to determine the relation among velocity, volumetric flow, and vascular resistance in awake human beings, we performed paired proximal and distal velocity measurements in 28 angiographically normal coronary arteries. Mean velocity, peak velocity, diastolic-to-systolic velocity ratio, and diameter and cross-sectional area of proximal and distal arteries were determined and coronary flow and vascular resistance computed. Mean velocity and coronary vasodilator reserve were similar for all three native arteries and were preserved from proximal to distal segments. Volumetric flow decreased from proximal to distal segments. The demonstrated inverse and curvilinear (polynomial) relation between volumetric flow and vascular resistance agrees with theoretical and animal models of coronary physiologic characteristics and suggests a nadir of coronary vascular resistance below which coronary flow no longer increases.

Quantitation of aortic regurgitation by Doppler echocardiography: a practical approach.

Aortic regurgitation is most frequently assessed noninvasively by Doppler echocardiography by use of continuous wave and Doppler color flow mapping. To compare both Doppler methods, 161 patients who had undergone cardiac catheterization and complete echocardiographic studies were studied. The continuous wave parameters analyzed included the slope of the diastolic deceleration and the pressure half-time of the regurgitant jet. From color flow Doppler, conventional parameters such as JH and its ratio to LVOH, JASA and its ratio to LVOA, and the regurgitant JA and its ratio to the LVA were obtained. The JH/LVOH was the color flow parameter that best correlated with angiography (r = 0.91). A ratio of < or = 25% was used to predict mild aortic regurgitation with 96% accuracy. A ratio of > or = 40% was also used to predict severe aortic regurgitation (3 to 4+) with 96% accuracy. Absolute JH at the origin of the regurgitant jet was the second best color flow parameter that correlated with angiography (r = 0.89). When continuous wave-derived slope was used, a significant overlap among different degrees of aortic regurgitation was observed. Predictive accuracy for mild aortic regurgitation was 70% by using a slope < 2 m/sec2 and 86% for severe aortic regurgitation when using a slope > 3 m/sec2. In conclusion, color flow Doppler appears to be superior to continuous wave Doppler in the assessment of aortic regurgitation. The JH/LVOH appears to be the best color parameter for quantifying aortic regurgitation. The measurement of the absolute JH at its origin appears to be the simplest and most practical method for assessing the degree of aortic regurgitation.

Analysis of coronary blood flow velocity dynamics in angiographically normal and stenosed arteries before and after endolumen enlargement by angioplasty.

OBJECTIVES: This study was designed to assess whether the spectral waveform of coronary velocity on Doppler study is characteristically altered in the presence of significant stenosis with normalization of the spectral waveform after relief of endolumen obstruction. BACKGROUND: Although coronary flow reserve determinations have provided physiologic information complementary to the angiographic percent diameter narrowing, flow velocity measurements have been limited to proximal arteries with inconsistent results after angioplasty. A 12-MHz Doppler guide wire permits flow velocity determination in the proximal and distal coronary artery with fast Fourier spectral analysis. METHODS: With the Doppler guide wire, proximal arterial flow velocity and flow reserve measurements in 17 angiographically normal arteries were compared with measurements in 29 significantly stenosed arteries. Proximal and distal flow velocity measurements were also obtained before and after angioplasty of the 29 abnormal arteries. Velocity spectrum was digitized to compute peak diastolic velocity, peak systolic velocity, mean velocity, diastolic/systolic velocity ratio and first third and first half flow fraction. RESULTS: Compared with proximal stenosed arteries, proximal normal arteries had significantly higher peak diastolic velocity (64 +/- 26 cm/s vs. 41 +/- 26 cm/s) and higher coronary vasodilator reserve (2.3 +/- 0.8 vs. 1.6 +/- 0.7). Normal arteries had higher flows in the first third and first half of the coronary cycle (46 +/- 3% vs. 39 +/- 7% and 65 +/- 2% vs. 56 +/- 10%, respectively). Before angioplasty, coronary velocity variables were significantly lower distal than proximal to the stenosis. After angioplasty, there was a greater mean increase in distal velocities (200% vs. 90% for the proximal arteries) that resulted in near equalization of proximal and distal mean velocity and a significant reduction in proximal/distal mean velocity ratio (2.4 +/- 1.7 vs. 1.2 +/- 0.4). CONCLUSIONS: Before angioplasty, abnormal coronary flow velocity dynamics are more marked distal than proximal to the stenosis. Greater increase in coronary flow velocities in the distal circulation after relief of endolumen obstruction results in a significant reduction in the proximal/distal flow velocity ratio. Thus, normalization of Doppler-derived flow velocity variables with marked reduction of the proximal/distal flow velocity ratios parallels angiographic success and may prove useful as an additional end point measurement in interventional cases with questionable angiographic findings.

Color Doppler echocardiographic evaluation of patients with a flail mitral leaflet.

Chordal rupture with a subsequent flail mitral valve leaflet is now the most common cause of pure mitral regurgitation. To describe the Doppler color flow findings in flail mitral leaflet and the determinants of these findings, Doppler color flow mapping and conventional Doppler echocardiography were performed in 31 consecutive patients presenting with a flail mitral leaflet. In the 23 patients with a posterior flail leaflet, a distinctive highly eccentric and turbulent jet directed toward the posterior wall of the aorta was noted. In the eight patients with an anterior flail leaflet, a jet directed toward the posterolateral left atrial wall was noted. Maximal regurgitant jet area was significantly larger in patients with a flail anterior leaflet (13.1 +/- 3.0 cm2) than in those with a flail posterior leaflet (5.8 +/- 3.0 cm2, p = 0.0001). Maximal jet area to left atrial ratio was also significantly higher in those with a flail anterior leaflet (0.56 +/- 0.16) than in those with a flail posterior leaflet (0.27 +/- 0.17, p = 0.0006). When systolic left atrial velocities encoded as red were incorporated into the maximal jet area measurement, 7 of the 8 patients with an anterior flail leaflet had a jet area greater than 8 cm2, consistent with severe mitral regurgitation, compared with 13 of the 23 patients with a flail posterior leaflet. There was no correlation between jet area or jet area to left atrial ratio and any hemodynamic variable. Patients with acute mitral regurgitation exhibited a trend toward smaller jet areas, but this did not reach statistical significance. Regurgitant fraction calculated from pulsed Doppler recording of mitral and aortic flow was consistent with moderately severe or severe mitral regurgitation in all cases and averaged 70%. Thus, patients with a flail mitral valve leaflet have distinctive Doppler color flow findings. A highly eccentric and turbulent jet directed posteriorly to the aorta may contribute to a systematic underestimation of severe mitral regurgitation by conventional Doppler color flow criteria. The use of pulsed Doppler ultrasound to calculate regurgitant fraction in patients with a flail mitral valve leaflet may be helpful in reliably assessing the degree of mitral regurgitation.