Multiplane transesophageal echocardiography and stroke

Transesophageal echocardiography (TEE) is considered a basic tool in the diagnostic and follow-up evaluation of stroke patients, since vp to 40% of cerebral ischemic events are presumed to have a cardiac origin. TEE offers a superior resolution of the posterior cardiac structures, such as left atrium and appendage and atrial septum, as well as of the aorta. By means of TEE, evidence has accumulated that some cardiovascular abnormalities (left-sided thrombi, tumors and vegetative lesions, complicated plaques of the aortic arch) are associated with ischemic stroke. Nevertheless, some issues remain unresolved. Will exclusion of atrial thrombus by multiplane TEE preclude embolism after cardioversion of atrial fibrillation? If anticoagulation before and after cardioversion is needed to provide adequate protection against embolism, will TEE be indicated in all patients? Moreover, can the detection of spontaneous echo contrast or enlarged and hypokinetic left atrial appendage in atrial fibrillation modify the therapeutic strategy? Is atrial septal aneurysm (ASA) a real embolic source, particularly when a right-to-left shunt is not associated? Considering the high prevalence of patent foramen ovale (PFO) in normal subjects, how can we identify patients at higher risk of embolism? Furthermore, methodologic points have to be taken into account when we analyze data from the literature. First, most studies are retrospective; a sole prospective study demonstrated that atherosclerotic plaques >4 mm thick in the aortic arch are significant predictors of recurrent brain infarction and other cardiovascular events in patients greater than or equal to 60 years of age. Second, the association between the aforementioned cardiac abnormalities (mainly ASA and PFO) and cardiogenic embolism is biased by the patient-enrollment criteria used in those studies so that their pathogenetic role has not yet been established. prospective studies with the enrollment of appropriate control groups will be necessary to define what can be considered a marker of embolic risk; the diagnosis "cardiogenic embolism" will not be a definitive diagnosis in most cases. (C) 1998 by Excerpta Medica, Inc

Critical pathways in the emergency department improve treatment modalities for patients with ST-elevation myocardial infarction in a European hospital

The use of protocols for patients with ST-elevation myocardial infarction (MI) is growing, but no definite conclusion regarding the value of critical pathways in Europe has been drawn

Neutropenic enterocolitis in acute leukemia: diagnostic and therapeutic dilemma

The main purpose of this report is to focus on the importance of an accurate etiologic diagnosis of gastrointestinal complications during chemotherapy for acute myeloid leukemia, taking into account that a syndrome characterized by bowel wall thickening associated with diarrhea and abdominal pain may have etiologies different from neutropenic enterocolitis (NE) and in such a case necessitate a different treatment approach. We describe a case of a 46-year-old woman affected by acute myeloid leukemia presenting the onset of a syndrome with clinical features of NE. Supportive therapy for NE was instituted, but during treatment the patient presented a life-threatening gastrointestinal bleeding and was submitted in emergency to hemicolectomy. Following surgery, the patient recovered completely and she is currently alive in complete remission after receiving allogeneic bone marrow transplantation. Histological examination of the surgical specimens showed that the acute abdominal syndrome was related to massive infiltration of the bowel by leukemia cells. A correct baseline evaluation and a prompt diagnosis of the complication may help in making the therapeutic decision, which in our case led necessarily to a surgical procedure, because the bleeding was due to post-chemotherapy necrosis of the leukemic infiltrating tissue. A close collaboration between the hematologist and the surgeon may provide guidelines for behavior in such cases, giving these patients the possibility of survival and the opportunity to carry on the treatment planned for the primary disease

Identification of professional scuba divers with patent foramen ovale at risk for decompression illness

Functional and anatomic characteristics of patent foramen ovale (PFO) were investigated in 66 professional scuba divers (41 with and 25 without decompression illness) using transthoracic and transesophageal echocardiography. PFO with right-to-left shunting at rest is associated with decompression illness, particularly the neurologic type. A wider patency diameter together with a higher membrane mobility are associated with the risk of developing the disease in divers with PFO. © 2004 by Excerpta Medica, Inc

Left ventricular remodelling index (LVRI) in various pathophysiological conditions: a real‐time three‐dimensional echocardiographic study

BACKGROUND: Various studies have reported a close correlation between real‐time three‐dimensional echocardiography (RT3DE) and cine magnetic resonance imaging studies for the assessment of cardiac volumes and mass. OBJECTIVE: The aim of our study was to evaluate changes in left ventricular volumes and mass in subjects with different pathophysiological conditions. A ratio between left ventricular mass and end‐diastolic volume (LVRI), detected by RT3DE, was used to describe various patterns of left ventricular remodelling. METHODS: RT3DE was performed to calculate left ventricular end‐diastolic (LVEDV) and end‐systolic volume (LVESV), ejection fraction (LVEF) and mass in 220 selected subjects. Of these, 152 were healthy volunteers, 19 top‐level rowers, 23 patients with dilated cardiomyopathy and 26 patients with hypertrophic cardiomyopathy. Off‐line analysis was performed by two independent operators by tracing manual endocardial and epicardial borders of the left ventricle through eight cutting planes. Inter‐ and intra‐observer variability were calculated. RESULTS: Despite the increase in LV volume and mass in the rowers, LVRI remained unchanged compared with control subjects (p = 0.455), while significantly lower values were found patients with dilated cardiomyopathy (p<0.001) and significantly higher values in patients with hypertrophic cardiomyopathy (p<0.001). There was inter‐ and intra‐observer variability. CONCLUSION: The LVRI may serve as a simple and useful indicator of left ventricular adaptation to physiological and pathological conditions