Doppler evaluation of patients with constrictive pericarditis: Use of tricuspid regurgitation velocity curves to determine enhanced ventricular interaction

AbstractObjectives. This study sought to examine the value of analyzing Doppler echocardiographically derived tricuspid regurgitation signals during respiration in relation to the diagnosis of constrictive pericarditis.Background. A physiologic hallmark of constrictive pericarditis is enhanced ventricular interdependence, which produces reciprocal changes in right and left ventricular filling and ejection dynamics during the respiratory cycle. It was hypothesized that these changes could be detected noninvasively by analyzing Doppler echocardiographically derived tricuspid regurgitation signals and that this information could assist in noninvasively diagnosing constrictive pericarditis.Methods. Simultaneous Doppler echocardiography and catheterization studies of the right and left sides of the heart with high fidelity pressure manometers were performed in 5 patients with surgically confirmed constrictive pericarditis and 12 patients (control subjects) with heart failure due to other causes.Results. Changes observed in tricuspid regurgitation Doppler echocardiographic variables from onset to peak inspiration in patients with constrictive pericarditis were significantly different from those in control subjects. Mean (±SD) percent change in maximal tricuspid regurgitation velocity was 13% ± 6% and −8% ± 7% in the constrictive pericarditis and control groups, respectively (p < 0.0001); mean percent change in tricupsid regurgitation signal duration was 18% ± 2% and −2% ± 7%, respectively (p < 0.0001); mean percent change in tricuspid regurgitation time velocity integral was 27% ± 15% and −10% ± 12%, respectively (p < 0.0001).Conclusions. Respiratory changes in Doppler echocardiographically derived tricuspid regurgitation peak velocity and velocity duration are increased in patients with constrictive pericarditis and may be helpful in diagnosing this condition noninvasively

Assessment of myocardial perfusion by videodensitometry in the canine model

Assessment of the functional severity of coronary stenoses has become increasingly important as the intrinsic limitations of coronary angiography have been documented. Videodensitometric coronary flow reserve has been proposed as a means to assess the physiologic significance of a coronary stenosis in humans. This study compared videodensitometric assessment of coronary flow with microsphere quantitation in the closed chest canine model.In five dogs, flow rates were assessed at baseline, after vasodilation with adenosine, after vasoconstriction with vasopressin and during rapid cardiac pacing. The videodensitometric peak density, time to one-half peak density and washout time (time from peak to one-half peak density) were compared at each flow state with flow assessed by microsphere injection. Reproducibility of videodensitometric measurements from two different coronary injections during the same flow state was best with peak density (r = 0.94).Videodensitometric flow ratios (flow state under study to flow at rest) using peak density demonstrated a fair correlation with flow ratios by microsphere (r = 0.81). There was poor correlation between flow ratios when time to one-half peak or washout time was used.Videodensitometric flow measurements used in vivo to assess a wide range of drug-induced coronary flows may not accurately reflect coronary flow measured by microsphere

Outcome of Patients With Hypertrophic Cardiomyopathy and a Normal Electrocardiogram

ObjectivesThis study sought to clarify the frequency, clinical phenotype, and prognosis of those patients with hypertrophic cardiomyopathy (HCM) who present with a normal electrocardiogram (ECG).BackgroundHypertrophic cardiomyopathy is the most common cause of sudden death in young people. Screening advocates have recommended a 12-lead ECG for the early detection of HCM in athletes, yet the clinical outcomes of those presenting with a normal ECG remains to be fully delineated.MethodsBaseline characteristic and echocardiographic data were collected on all patients with HCM who initially presented to our institution with a diagnostic echocardiogram but a normal ECG. Follow-up was obtained and compared with the prognosis of HCM patients who presented with abnormal ECGs.ResultsWe compared 135 HCM patients with a normal ECG with 2,350 HCM patients with an abnormal ECG. The latter group was more likely to have worse symptoms, have higher gradients, and a greater degree of septal wall thickness than the patients with a normal ECG. Severe obstructive symptoms requiring surgical myectomy and implantation of an implantable cardioverter-defibrillator were more common in patients with abnormal ECGs. Cardiac survival was significantly better in the group with a normal ECG at presentation—none of these patients had a cardiac death at follow-up.ConclusionsAlmost 6% of patients presenting with demonstrable echocardiographic evidence of HCM had a normal ECG at the time of diagnosis. This subset of patients with normal ECG-HCM appears to exhibit a less severe phenotype with better cardiovascular outcomes

Intravascular ultrasound imaging: In vitro validation and pathologic correlation

AbstractIntravascuiar ultrasound imaging is a new method in which high resolution images of the arterial wall are obtained with use of a catheter placed within an artery. An in vitro Plexiglas well model was used to validate measurements of the luminal area, and an excellent correlation was obtained. One hundred thirty segments of fresh peripheral arteries underwent ultrasound imaging and the findings were compared with the corresponding histopathologic sections. luminal areas determined with ultrasound imaging correlated well with those calculated from microscopic slides (r = 0.98).Three patterns were identified on the ultrasound images: 1) distinct interface between media and adventitia, 2) indistinct interface between media and adventitia but different echo density layers, and 3) diffuse homogeneous appearance. The types of patterns depended on the relative composition of the and adventitia. Calcification of intimal plaque obscured underlying structures. Atherosclerotic plaque was readily visualized but could not always be differentiated from the underlying media

Dual-Chamber Pacing for Hypertrophic Cardiomyopathy: A Randomized, Double-Blind, Crossover Trial

AbstractObjectives. In a double-blind, randomized, crossover trial we sought to evaluate the effect of dual-chamber pacing in patients with severe symptoms of hypertrophic obstructive cardiomyopathy.Background. Recently, several cohort trials showed that implantation of a dual-chamber pacemaker in patients with severely symptomatic hypertrophic obstructive cardiomyopathy can relieve symptoms and decrease the severity of the left ventricular outflow tract gradient. However, the outcome of dual-chamber pacing has not been compared with that of standard therapy in a randomized, double-blind trial.Methods. Twenty-one patients with severely symptomatic hypertrophic obstructive cardiomyopathy were entered into this trial after baseline studies consisting of Minnesota quality-of-life assessment, two-dimensional and Doppler echocardiography and cardiopulmonary exercise tests. Nineteen patients completed the protocol and underwent double-blind randomization to either DDD pacing for 3 months followed by backup AAI pacing for 3 months, or the same study arms in reverse order.Results. Left ventricular outflow tract gradient decreased significantly to 55 ± 38 mm Hg after DDD pacing compared with the baseline gradient of 76 ± 61 mm Hg (p < 0.05) and the gradient of 83 ± 59 mm Hg after AAI pacing (p < 0.05). Quality-of-life score and exercise duration were significantly improved from the baseline state after the DDD arm but were not significantly different between the DDD arm and the backup AAI arm. Peak oxygen consumption did not significantly differ among the three periods. Overall, 63% of patients had symptomatic improvement during the DDD arm, but 42% also had symptomatic improvement during the AAI backup arm. In addition, 31% had no change and 5% had deterioration of symptoms during the DDD pacing arm.Conclusions. Dual-chamber pacing may relieve symptoms and decrease gradient in patients with hypertrophic obstructive cardiomyopathy. In some patients, however, symptoms do not change or even become worse with dual-chamber pacing. Subjective symptomatic improvement can also occur from implantation of the pacemaker without its hemodynamic benefit, suggesting the role of a placebo effect. Long-term follow-up of a large number of patients in randomized trials is necessary before dual-chamber pacing can be recommended for all patients with severely symptomatic hypertrophic obstructive cardiomyopathy.(J Am Coll Cardiol 1997;29:435–41