A massive retroperitoneal hematoma during low-molecular-weight-heparin therapy

n/

Ventricular-Arterial coupling during dipyridamole stress

Background: The interaction of the heart with the systemic vasculature, termed ventricular-arterial coupling, is a central determinant of net cardiovascular performance in normal and pathological conditions. Ventricular and arterial elastance can be easily assessed by echocardiography, both at rest and during stress. Aim: To assess noninvasively left ventricular-arterial coupling in healthy and diseased subjects at rest and during dipyridamole (DIP) stress. Materials and methods: We enrolled 365 patients (63?16 years; 231 males) referred to stress echo lab: 131 "normals" (Nl); 86 patients with coronary artery disease, 68 with negative (CAD, SE -) and 18 with positive (CAD, SE+) stress echo; 148 with idiopathic dilated cardiomyopathy (DCM). In all, ventricular-arterial coupling was indexed by the ratio of ventricular force (Systolic Pressure/End-Systolic Volume index) to arterial elastance (EaI, ratio of end-systolic pressure by stroke volume). 2D echo (for ESV and stroke volume) and cuff sphygmomanometer (systolic pressure, multiplied x 0.90 to obtain end-systolic pressure) provided the raw measurements. Results: At rest, EaI was profoundly increased in DCM (6.3?4.4; p<.001 vs. all other groups: Nl=4?1.1; CAD, SE-=3.8?1; CAD SE+=4.2?1.3). DIP maximized ventricular-arterial coupling in normals. Residual vasodilatation and contractile reserve slightly increased cardiac efficiency in DCM and in CAD SE- pts. The CAD SE+ pts showed negative contractile reserve and the worse stress ventricular arterial coupling (see figure). Conclusions: Ventricular-arterial coupling was optimized by DIP in normals, and disrupted in CAD patients with stress induced ischemia. Effective arterial elastance is dramatically increased in DCM at rest and weakly responds to vasodilator stress

Genetic stress echocardiography: role of A2a receptors polymorphism in modulating coronary flow reserve response in non-ischemic dilated cardiomyopathy

Background: Vasodilator stress imaging is based on coronary A2a receptor stimulation via endogenous adenosine (with dipyridamole administration), exogenous adenosine, or selective A2a receptor stimulation (with binodenoson).The recognized inter-individual variability in response to adenosine might be in part determined by genetic polymorphism in A2a adenosine receptors. Aim: to assess whether A2a receptor (263 C>T and 1976 C>T) polymorphism affects the coronary flow reserve (CFR) response in patients with non-ischemic dilated cardiomyopathy (DCM). Methods: we evaluated 44 DCM patients 34 males; age 62?9 years) by transthoracic dipyridamole (0.84 mg/kg) stress echocardiography. All patients had an ejection fraction <40% (mean 21.1?16.3%) and angiographically normal coronary arteries with NYHA class <3. CFR was assessed on left anterior descending coronary artery using Doppler as the ration of maximal peak vasodilation (dipyridamole) to rest diastolic flow velocity. All patients underwent peripheral blood sampling and A2a receptor genotyping with PCR and enzyme restriction analysis. Results: CFR was 2.1?0.6 (range=1.5-4). There was no correlation between CFR and 263 C>T variant of A2a gene. However, patients with 1976 TT genotype had significantly lower values from 1976 CC patients (p<0.05). The 7 patients omozygous for 1976 TT had an OR=8.8 (95% CI, 1-81, p=0.04) for abnormal CFR. Conclusion: In DCM patients 1976 C>T polymorphism of the adenosine A2A receptor gene may affect CFR response. In particular, the 1976-TT variant of A2a gene blunts the coronary vasodilatory response

Valve disease in cardiac amyloidosis: an echocardiographic score

Cardiac amyloidosis (CA) may affect all cardiac structures, including the valves. From 423 patients undergoing a diagnostic workup for CA we selected 2 samples of 20 patients with amyloid transthyretin (ATTR-) or light-chain (AL-) CA, and age- and sex-matched controls. We chose 31 echocardiographic items related to the mitral, aortic and tricuspid valves, giving a value of 1 to each abnormal item. Patients with ATTR-CA displayed more often a shortened/hidden and restricted posterior mitral valve leaflet (PMVL), thickened mitral chordae tendineae and aortic stenosis than those with AL-CA, and less frequent PMVL calcification than matched controls. Score values were 15.8 (13.6-17.4) in ATTR-CA, 11.0 (9.3-14.9) in AL-CA, 12.8 (11.1-14.4) in ATTR-CA controls, and 11.0 (9.1-13.0) in AL-CA controls (p = 0.004 for ATTR- vs. AL-CA, 0.009 for ATTR-CA vs. their controls, and 0.461 for AL-CA vs. controls). Area under the curve values to diagnose ATTR-CA were 0.782 in patients with ATTR-CA or matched controls, and 0.773 in patients with LV hypertrophy. Patients with ATTR-CA have a prominent impairment of mitral valve structure and function, and higher score values. The valve score may help identify patients with ATTR-CA among patients with CA or unexplained hypertrophy

Feasibility of real-time three-dimensional stress echocardiography: pharmacological and semi-supine exercise

<p>Abstract</p> <p>Background</p> <p>Real time three dimensional (RT3D) echocardiography is an accurate and reproducible method for assessing left ventricular shape and function.</p> <p>Aim</p> <p>assess the feasibility and reproducibility of RT3D stress echocardiography (SE) (exercise and pharmacological) in the evaluation of left ventricular function compared to 2D.</p> <p>Methods and results</p> <p>One hundred eleven patients with known or suspected coronary artery disease underwent 2D and RT3DSE. The agreement in WMSI, EDV, ESV measurements was made off-line.</p> <p>The feasibility of RT-3DSE was 67%. The inter-observer variability for WMSI by RT3D echo was higher during exercise and with suboptimal quality images (good: k = 0.88; bad: k = 0.69); and with high heart rate both for pharmacological (HR < 100 bpm, k = 0.83; HR ≥ 100 bpm, k = 0.49) and exercise SE (HR < 120 bpm, k = 0.88; HR ≥ 120 bpm, k = 0.78). The RT3D reproducibility was high for ESV volumes (0.3 ± 14 ml; CI 95%: -27 to 27 ml; p = n.s.).</p> <p>Conclusions</p> <p>RT3DSE is more vulnerable than 2D due to tachycardia, signal quality, patient decubitus and suboptimal resting image quality, making exercise RT3DSE less attractive than pharmacological stress.</p

Second-opinion stress tele-echocardiography for the Adonhers (Aged donor heart rescue by stress echo) project

<p>Abstract</p> <p>Background</p> <p>To resolve the current shortage of donor hearts, we established the Adonhers protocol. An upward shift of the donor age cut-off limit (from the present 55 to 65 years) is acceptable if a stress echo screening on the candidate donor heart is normal. This study aimed to verify feasibility of a "second opinion" of digitally transferred images of stress echo results to minimize technical variability in selection of aged donor hearts for heart transplant.</p> <p>Methods</p> <p>The informatics infrastructure was created for a core lab reading with a second opinion from the Pisa stress echo lab. To test the system, simulation standard stress echo cineloops were sent digitally from 5 peripheral labs to the central core lab.</p> <p>Starting January 2009, real marginal donor stress echos were sent via internet to the central core echo lab, Pisa, for a second opinion before heart transplant.</p> <p>Results</p> <p>In the simulation protocol, 30 dipyridamole stress echocardiograms were sent from the five peripheral echo labs to the central core lab in Pisa. Both the echo images and reports were correctly uploaded in the web system and sent to the core echo lab; the second opinion evaluation was obtained in all cases (100% feasibility). In the transplant protocol, eight donor cases were sent to the Pisa core lab for the second opinion protocol, and six of them were transplanted in marginal recipients.</p> <p>Conclusions</p> <p>Second-Opinion Stress Tele-Echocardiography can effectively be performed in a network aimed to safely expand the heart donor pool for heart transplant.</p

Arterial pressure changes monitoring with a new precordial noninvasive sensor

<p>Abstract</p> <p>Background</p> <p>Recently, a cutaneous force-frequency relation recording system based on first heart sound amplitude vibrations has been validated. A further application is the assessment of Second Heart Sound (S2) amplitude variations at increasing heart rates. The aim of this study was to assess the relationship between second heart sound amplitude variations at increasing heart rates and hemodynamic changes.</p> <p>Methods</p> <p>The transcutaneous force sensor was positioned in the precordial region in 146 consecutive patients referred for exercise (n = 99), dipyridamole (n = 41), or pacing stress (n = 6). The curve of S2 peak amplitude variation as a function of heart rate was computed as the increment with respect to the resting value.</p> <p>Results</p> <p>A consistent S2 signal was obtained in all patients. Baseline S2 was 7.2 ± 3.3 m<it>g</it>, increasing to 12.7 ± 7.7 m<it>g </it>at peak stress. S2 percentage increase was + 133 ± 104% in the 99 exercise, + 2 ± 22% in the 41 dipyridamole, and + 31 ± 27% in the 6 pacing patients (p < 0.05). Significant determinants of S2 amplitude were blood pressure, heart rate, and cardiac index with best correlation (R = .57) for mean pressure.</p> <p>Conclusion</p> <p>S2 recording quantitatively documents systemic pressure changes.</p

Economic analysis including long-term risks and costs of alternative diagnostic strategies to evaluate patients with chest pain

Background: Diagnosis costs for cardiovascular disease waste a large amount of healthcare resources. The aim of the study is to evaluate the clinical and economic outcomes of alternative diagnostic strategies in low risk chest pain patients. Methods: We evaluated direct and indirect downstream costs of 6 strategies: coronary angiography (CA) after positive troponin I or T (cTn-I or cTnT) (strategy 1); after positive exercise electrocardiography (ex-ECG) (strategy 2); after positive exercise echocardiography (ex-Echo) (strategy 3); after positive pharmacologic stress echocardiography (PhSE) (strategy 4); after positive myocardial exercise stress single-photon emission computed tomography with technetium Tc 99m sestamibi (ex-SPECT-Tc) (strategy 5) and direct CA (strategy 6). Results: The predictive accuracy in correctly identifying the patients was 83,1% for cTn-I, 87% for cTn-T, 85,1% for ex-ECG, 93,4% for ex-Echo, 98,5% for PhSE, 89,4% for ex-SPECT-Tc and 18,7% for CA. The cost per patient correctly identified results $2.051 for cTn-I,$2.086 for cTn-T, $1.890 for ex-ECG,$803 for ex-Echo, $533 for PhSE,$1.521 for ex-SPECT-Tc ($1.634 including cost of extra risk of cancer) and$29.673 for CA ($29.999 including cost of extra risk of cancer). The average relative cost-effectiveness of cardiac imaging compared with the PhSE equal to 1 (as a cost comparator), the relative cost of ex-Echo is 1.5×, of a ex-SPECT-Tc is 3.1×, of a ex-ECG is 3.5×, of cTnI is ×3.8, of cTnT is ×3.9 and of a CA is 56.3×. Conclusion: Stress echocardiography based strategies are cost-effective versus alternative imaging strategies and the risk and cost of radiation exposure is void