Contrast echocardiography in acute myocardial ischemia. II. The effect of site of injection of contrast agent on the estimation of area at risk for necrosis after coronary occlusion

Myocardial contrast echocardiography has been shown to accurately assess the area at risk for necrosis after acute coronary occlusion in the experimental model. The area at risk as determined by this method, however, has been defined in different ways depending on the model used. Some investigators have injected the contrast agent proximal to the site of coronary occlusion (left main coronary artery or aorta) and defined the area at risk as the segment of myocardium not showing a contrast effect (negative risk area). Others have injected the contrast agent directly into the occluded vessel and have defined the area at risk as that showing contrast enhancement (positive risk area).To evaluate whether the areas at risk determined by these two techniques are identical, six open chest dogs were studied using both methods. The area at risk was slightly but significantly larger when the contrast agent was injected into the occluded vessel than when it was injected proximally into the left main coronary artery (4.98 ± 1.69 versus 3.97 ± 1.27 cm2, p < 0.01). It is concluded that the site of injection of the contrast agent significantly influences the determination of area at risk. Therefore, data obtained by the two techniques should not be used interchangeably, and in a given study the area at risk should be measured consistently using one technique

The fractional shortening-velocity ratio: Validation of a new echocardiographic doppler method for identifying patients with significant aortic stenosis

AbstractPrevious studies have shown that Doppler echographic methods based on the continuity equation can accurately determine aortic valve area in patients with clinically significant aortic stenosis; nonetheless, methods based on the continuity equation are time-consuming and may not be technically possible in all subsets of patients. Thee purpose of this study was to develop and prospectively evaluate a simpler new noninvasive method for determining aortic valve area. With this new method, aortic valve area is obtained by dividing the percent fractional anteroposterior shortening at the midventriclevel by 4V2, where V is the peak instantaneous Doppler-derived How velocity across the aortic valve.In the fast part of the study, the fractional shortening-velocity ratio was used to examine a group of 25 patients evaluated retrospectively. There was a highly significant linear relation between the fractional shortening-velocity ratio (FSVR) and the aortic valve area (AVA) determined by the Gorlin formula at cardiac catheterization: FSVR = 1.1(AVA) − 0.1 (r = 0.88; significance of slope p < 0.001). Furthermore, a fractional shortening-velocity ratio <1.1 reliably identified all patients with clinically significant aortic stenosis (aortic valve area <1 cm2), whereas a fractional shortening-velocity ratio <0.8 reliably identified all patients with critical aortic stenosis (aortic valve area <0.7 cm2).This new method was then validated by prospectively applying the fractignal shortening-velocity ratio to a group of 44 patients from two separate institutions. This prospective study showed that a fractional shortening-velocity ratio <l.l had a seRR-Jitivity of 90% to 96% and a positive predictive accuracy of 90% to 92% for identifying patients with significant aortic stenosis, whereas a fractional shortening-velocity ratio <0.8 had a sensitivity of 100% and a predictive accuracy of 74% to % for identifying patients with critical aortic stenosis.In summary, the fractional shortening-velocity ratio is a new Doppler echocardiographic method that reliably identifies patients with clinically significant aortic stenosis. The simplicity of this new noninvasive method readily lends itself to routine clinical use

The natural history of regional wall motion in the acutely infarcted canine ventricle

Two-dimensional echocardiography was employed to define the natural history of regional wall motion abnormalities in a canine model of acute experimental myocardial infarction. Serial short-axis two-dimensional echocardiograms were recorded in 11 closed chest dogs before coronary occlusion and 10, 30, 60, 180 and 360 minutes after permanent coronary ligation. Radiolabeled microsphere-derived blood flows were obtained in each study period and the histochemical (triphenyltetrazolium chloride) extent of infarction was determined at 6 hours. Previously published methods were used to quantitate field by field (every 16.7 ms) excursion of 36 evenly spaced endocardial targets. The circumferential extent of abnormal wall motion was followed sequentially using previously published definitions of abnormality: 1) systolic fractional radial change of less than 20%; 2) dyskinesia (systolic bulging) at the point in time (echocardiographic field) in which there is maximal dyskinesia; and 3) correlation with composite normal ray motion falling outside the 95 % confidence limits defined in the control period. On the basis of the triphenyltet razolium chloride staining pattern, the ventricle was divided into five zones: central infarct zone, zone with greater than 25% transmural infarction, total infarct zone, border zones and normal zone. Mean systolic fractional radial change was calculated for each zone and used as an index of the magnitude of abnormal wall motion.Regardless of the definition of abnormality employed, the circumferential extent of abnormal wall motion manifested at 10 minutes after occlusion did not significantly change, even up to 6 hours later. Similarly, 10 minutes after coronary occlusion the three infarct zones and border zones demonstrated significantly reduced systolic fractional radial change. This remained stable over the remainder of the 6 hour study period.It is concluded that once established at 10 minutes after coronary occlusion, the circumferential extent and magnitude of abnormal wall motion do not significantly change in the immediate postinfarct (6 hour) period

A new echocardiographic model for quantifying three-dimensional endocardial surface area

A new technique for quantitatively mapping the three-dimensional left ventricular endocardial surface was developed, using measurements from standard cross-sectional echocardiographic images. To validate the accuracy of this echocardiographic mapping technique in an animal model, the endocardial areas of 15 excised canine ventricles were calculated using measurements made from echocardiographic studies of the hearts and compared with areas determined with latex casts of the same ventricles. Close correlation (r = 0.87, p < 0.001) between these two measures of endocardial area provided preliminary confirmation of the accuracy of the maps.To further characterize the mapping algorithm, it was translated into computer format and used to map the surfaces of idealized hemiellipsoids. Areas measured with this mapping technique closely approximated the actual areas of idealized surfaces with a wide spectrum of shapes; maps were particularly accurate for ellipsoids with shapes similar to those of undistorted human ventricles. Also, the accuracies of area calculations were relatively insensitive to deviation from the assumed positions of the echocardiographic short-axis planes. Finally, although the accuracy of the mapping technique improved as data from more transverse planes were added, the procedure proved reliable for estimating surface areas when data from only three planes were used. These studies confirm the accuracy of the echocardiographic mapping technique, and they suggest that the resulting planar plots might be useful as templates for localizing and quantifying the overall extent of abnormal wall motion

Translating Evidence-Based Policy to Practice: A Multilevel Partnership Using the Interactive Systems Framework

This is the published version, made available with the permission of the publisher.Despite increases in federal allocations, little is known about how to ensure successful implementation of evidence-based programs. This descriptive case study using the Interactive Systems Framework for Dissemination and Implementation illustrates the Prevention Support System (PSS) implemented for one federal evidence-based policy initiative. Exploring perspectives of intermediary organizations, the article describes the impetus for promoting evidence-based programming, multilevel systemic change, and the collaborations to develop strategic partnerships between national and state entities. Two early adopters, Kansas and Nebraska, illustrate the general capacity-building technical assistance activities conducted to build a multilevel PSS. The article concludes with outcomes, lessons learned, and recommendations for building stronger implementation capacity

Low pressure radiofrequency balloon angioplasty: Evaluation in porcine peripheral arteries

AbstractObjectives. The purpose of this study was to evaluate the efficacy of radiofrequency-powered thermal balloon angioplasty in an in vivo porcine model.Background. Various modes of thermal energy used adjunctively during balloon angioplasty have demonstrated the potential to enhance the results of acute lumen dilation.Methods. In normal pigs, 75 peripheral arteries were dilated with a newly designed, radiofrequency-powered, thermal angioplasty balloon. All inflations were performed at 2-atm pressure for 85 s. Dilations were performed either with (hot) or without (cold) the application of heat. Lumen dimensions and vessel morphology were assessed with intravascular ultrasonography. At the end of each study, dilated arterial segments were harvested for histologic examination.Results. Single cold balloon inflations resulted in a 12.7% increase in arterial cross-sectional area whereas single hot inflations resulted in a 22.9% increase (p < 0.03). Similarly, when multiple cold inflations were compared with multiple hot inflations, two, three and four sequential hot inflations resulted in a significantly greater increase in cross-sectional area than an equivalent number of cold inflations (p < 0.03).Histologic examination demonstrated a temperaturedependent effect on the depth of medial necrosis and extent of arterial wall thinning (p < 0.001) as well as evidence for uniform alteration of elastic tissue fibers at temperatures of ≥60 °C (p < 0.03).Conclusions. Low pressure radiofrequency thermal balloon angioplasty results in a greater increase in cross-sectional area in porcine peripheral arteries than does nonheated conventional balloon angioplasty. The pathologic basis for this enhanced dilation may be a temperature-dependent effect on medial necrosis, thinning of the arterial wall or alteration of vascular elastic fibers, alone or in combination