Stress echocardiography

In the studies reported in this thesis, stress echocardiography (either with exercise or with pharmacological agents) and myocardial perfusion scintigraphy have been performed in different groups of patients and in different clinical conditions. Some practical aspects on the protocols of echocardiographic tests are briefly reportedThis thesis presents the initial experience on stress echocardiography done at the Department of Cardiology, University Hospital of Rotterdam. The main purposes of this research were: 1) to assess the safety and feasibility of stress echocardiography; 2) to evaluate the sensitivity and specificity of stress echocardiography for the detection of coronary artery disease; 3) to compare the results of stress echocardiography with those obtained at myocardial perfusion scintigraphy; 4) to compare the results of different pharmacological stress agents in the same group of patients. 3

La storia delle università nell'Italia repubblicana

In the last decade the history of universities in Italy has been marked by a substantial increase in the number of studies addressed to the Republican period. However, we haven’t yet a history of universities in Emilia Romagna as a Region, particularly focused on the post-war period from 1945 to 1968. Emilia Romagna, with its 4 Universities (Bologna, Ferrara, Modena and Reggio, Parma), is an interesting case-study through which to highlight local features and recurring national aspects

Transthoracic three-dimensional echocardiography in adult patients with congenital heart disease

Objectives: This study sought to assess both the feasibility and potential role of transthoracic three-dimensional echocardiography for the evaluation of adult patients with congenital heart disease. Background: The unrestricted views with depth perception provided by three-dimensional echocardiography with dynamic volume-rendered display may enhance visualization of cardiac structures and detection of abnormalities in patients with congenital heart defects. Methods: We studied 33 patients with various heart defects (mitral valve anomalies in 9, aortic valve anomalies in 5, subaortic membrane in 5, ventricular septal defect in 4, transposition of the great arteries in 3, tetralogy of Fallot in 2, other defects in 5). Cross-sectional images of the specific region of interest were acquired from either the parasternal or apical window with the rotational technique (2° interval with electrocardiographic and respiratory gating) and postprocessed for resampling in cubic format. From these three-dimensional data sets a multitude of cut planes were selected, presented in volume-rendered dynamic display and analyzed by two observers for comparison with standard two-dimensional images to assess their additional information. Results: Three-dimensional reconstruction was possible in all patients. Structures of interest were evaluated from unusual viewpoints, providing both cardiologists and surgeons with immediate feedback. When compared with standard two-dimensional images, additional information was provided for 12 patients (36%). The mitral valve, aortoseptal continuity and interatrial septum were the structures for which three-dimensional echocardiography was most useful. Conclusions: Transthoracic three-dimensional echocardiography is feasible and facilitates spatial recognition of the intracardiac anatomy in a significant proportion of patients and enhances diagnostic confidence of complex congenital heart disease

Functional evaluation of ultra-octogenarian patients undergoing Cardiac Rehabilitation: correlation between Six minute Walking Test and Rivermead Mobility Index

Background. There is an increasing need for admission of octogenarians to cardiac rehabilitation programs. The aim of this study was to evaluate if the Rivermead Mobility Index (RMI) (scale of mobility) is related to the functional capacity assessed by the 6 Minute Walking Test (6MWT). Methods. We selected 108 consecutive patients ≥ 80 years (M = 53, mean age 82.5 ± 2.7 years, after cardiac surgery n = 72, heart failure n = 36) enrolled to our cardiac rehabilitation unit. All patients were evaluated with the RMI and underwent 6MWT both at admission (RMI1 and 6MWT1) and after a period of daily physical training (RMI2 and 6MWT2). The RMI2/RMI1 and 6MWT2/6MWT1 ratios were calculated as indexes of functional improvement (IM). Results. The average in hospital stay was 20 ± 11 days with an average of 11.9 training sessions per patient. The average distance walked at 6MWT1 and 6MWT2 was 193 ± 116 and 278 ± 122 m, respectively (p <0.001). The average score of RMI1 and RMI2 was 8.5 ± 3.4 and 13.1 ± 2.9, respectively (p <0.001). The values of 6MWT1 and RMI1 results were significantly correlated (r = 0.56, p <0.001). The RMI IM was significantly correlated to 6MWT IM (r = 0.309, p = 0.002). At multivariate analysis, RMI IM was found to be predictive of 6MWT IM even after correction for age, gender, length of hospitalization and number of sessions of training. Conclusions. In octogenarians, cardiac rehabilitation results in a significant improvement of both RMI and 6MWT. RMI IM is independently correlated to 6MWT IM. Therefore, RMI could be a useful tool for evaluating the improvement of functional capacity even in patients who cannot undergo 6MWT

Exercise echocardiography and single photon emission computed tomography in patients with left anterior descending coronary artery stenosis

To compare the diagnostic value of exercise echocardiography and perfusion single photon emission computed tomography (SPECT) in the detection of the presence and the severity of coronary artery disease, we studied 21 patients with isolated stenosis of different degree of the left anterior descending artery. Both echocardiography and SPECT were performed in conjunction with the same symptom-limited bicycle exercise test. Positivity of the test was based on the presence of exercise-induced wall motion abnormalities and transient perfusion defects, respectively. For both tests, an 'ischemic' score was derived, as index of extent and severity of myocardial ischemia. Coronary arteriography was evaluated by caliper. The agreement between exercise echocardiography and SPECT for the presence of coronary artery disease was 90%; the discordance was due to two patients with positive echocardiography and negative SPECT. A good correlation between ischemic wall motion and perfusion score indices was found (r=0.78, p<0.0001. Moreover, the percent diameter stenosis was well correlated with both ischemic indices (r= 0.75, p<0.0001; r=67, p<0.001, respectively). In patients with a positive test, the mean value of ischemic wall motion score index was higher in patients with a diameter stenosis ≥ 70% than in patients with a diameter stenosis <70% (0.59 ± 0.19 vs 0.29 ± 0.12, p < 0.01); a similar trend was found for ischemic perfusion score index (0.51 ± 0.35 vs 0.27± 0.12, ns). The results of this study indicate that in patients with single vessel disease of left anterior descending artery exercise echocardiography and SPECT give the same information on the presence, the extent and the severity of myocardial ischemia

Improved cardiac risk stratification in major vascular surgery with dobutamine-atropine stress echocardiography

Objectives: This study sought to optimize preoperative cardiac risk stratification in a large group of consecutive candidates for vascular surgery by combining clinical risk assessment and semiquantitative dobutamine-atropine stress echocardiography. Background: Dobutamine-atropine stress echocardiography has been used for the prediction of perioperative cardiac risk in a small group of patients scheduled for elective major vascular surgery on the basis of the presence or absence of stress-induced regional left ventricular wall motion abnormalities. Methods: Clinical risk assessment and dobutamine-atropine stress echocardiography were performed in 302 consecutive patients presenting for major vascular surgery. The extent and severity of stress wall motion abnormalities and the heart rate at which they occurred, in addition to the presence of wall motion abnormalities at rest, were assessed. Results: The absence of clinical risk factors (angina, diabetes, Q waves on the electrocardiogram, symptomatic ventricular tachyarrhythmias, age >70 years) identified a low risk group of 100 patients with a 1% cardiac event rate (unstable angina). Dobutamine-atropine stress echocardiographic findings were positive in 72 patients. Twenty-seven patients had a perioperative cardiac event (cardiac death in 5, nonfatal infarction in 12, unstable angina pectoris in 10); all 27 patients had positive stress test results (positive predictive value 38%, negative predictive value 100%). The semiquantitative asse

Hemodynamic changes, plasma catecholamine responses, and echocardiographically detected contractile reserve during two different dobutamine-infusion protocols

We studied hemodynamic changes, catecholamine responses, and the occurrence of improved wall thickening by echocardiography during two different dobutamine-infusion protocols. Forty-three patients were studied by using a stepwise incremental dobutamine dose-infusion protocol (10-40 μg/kg/min, 3-min intervals); a subgroup of 11 patients also underwent a continuous dobutamine-infusion protocol (10 μg/kg/min for 12 min) in random order. No patient used β-blockers. At 3-min intervals, blood pressure, heart rate, and plasma concentrations of dobutamine, epinephrine, and norepinephrine were measured. The echocardiographic improvement of wall thickening was analyzed only in paired protocols by visual assessment in left ventricular regions with normal wall motion at rest. The mean heart rate increased in the continuous and stepwise protocols from 73 to 99 and 74 to 132 beats/min. There was no significant change in blood pressure response between the two protocols. The mean plasma dobutamine concentrations during the continuous and stepwise protocols at 0, 3, 6, 9, and 12 min were 0/0; 31/38; 80/203; 106/448; and 120/692 ng/ml, respectively. In each patient, a response curve was constructed for the plasma dobutamine concentration versus heart rate. The heart rate increment and dobutamine concentration at which wall thickening was detected were similar with both protocols (14 ± 5 vs. 12 ± 7 beats/min) and (8) ± 40 vs. 92 ± 48 ng/ml; mean ± SD). Wall thickening was noted in two of 11 patients b

Prominent crista terminalis mimicking a right atrial mass: case report

The crista terminalis is a normal anatomical structure within the right atrium that is not normally visualised in the standard views obtained while performing a transthoracic echocardiogram. In this case report, transthoracic echocardiography suggested the presence of a right atrial mass in a patient with end stage renal disease. However, subsequent transesophageal echocardiography revealed that the right atrial mass was actually a thick muscular bridge in the right atrium consistent with a prominent crista terminalis. An understanding of the anatomy and the echocardiographic appearance of a prominent crista terminalis will minimize the misdiagnosis of this structure avoiding unnecessary expensive additional tests