Calsamiglia, Giuseppe

Cannizzaro, Giorgio

Capomolia, Soccorso

Fomi, Giovanni

Franchini, Mariella

Pozzoli, Massimo

Rossi, Davide

Tavazzi, Luigi

Traversi, Egidio

Elsevier - Publisher Connector 

JACC February 1996 ABSTRACTS-Poster 2 l lA 
tory, eleofmphysiclog~ fea~ren were consistant with NV cunduction. In both 
cases maximal preexcllation was seen only after a sudden prolongation of 
the H~H2 Inte,'val, i,'¢llcating a switch of AV nodal conduction from fast to 
slow pathway. Late atdal extrastimull dudng wide-QRS tachycardla never 
advanced the subsequent ventricular beat. In one case, His bundle activa- 
tion oocurred always retrog~dely during preexcited tachycard'~, with sudden 
changea in cycle length due to retrograde dual AV nodal physiology, sug- 
gastive Of a macro-reentrant circuit. In the other case, the His bundle was 
exclusively activated in antegrede dirPP.tf~n, indicating that the NV fiber was 
only used es a bystander. A distinct Mat~aim poCendal was recorded in beth 
eases at the vontdcular htce~on of the fibers In the the mid. to posteroasptal 
region of the AVannulus. RF current delivery to these sites abolished Mabaim 
tiber conduction without altedng AV nodal physiology. In the case with the 
NV fFoer as a bystander, AV nodal reentrant achycerdia was still Inducibla 
with a narrow QRS complex. It was subsequently abolished by slow loath- 
way ablation. Co~luslons: Nodevantricular accas~ory pathways r e ~  
a rare subset of Mahaim fibers. They am related to slow AV nodal pathway 
conduction, but must not necessarily be part of the reentrant circuit. Ablation 
of the NV Mahaim fiber can be salectively performed without ablation of the 
slow AV nodal pathway, 
- '~"~ Dnes Radiofrequency Ablation Induce a 
Prethrombutie State? 
Leigh A. Hutchinson, Alice J. Cohen, Edith Menshavez-Tan, Nell Abts, 
Jonathan S. Steinberg. St. Luke's-Rooseve# Hospital Center and Columbia 
Universi~, New York, NY~ St Michael's Medical Confer, Newark, NJ 
Although thromboembellsm is an uncommon complication Of radiofrequency 
ablation (RFA), it has been suggested that RFA results In activation Of the 
coagulation (COAG) system possibly increasing this dsk. We hypothesized 
that it is the catheter insertion and prolonged catheter placement rather than 
RFA that causes COAG system activation. In order to explore this issue, 
2 groups were studied: Grp I (n = 17) dudng RFA and Grp 2 (n = 14) 
dudng routine EPS, Groups were similar in clinical charectedstics and recent 
iovasive procedures. Specimens were drawn for COAG studies following the 
insertion of venous sheaths ('1"1) and 1 hr post RFA or EPS (3"2). Prothrombin 
to thrombin co,wersion was measured using thrombin antithrombln complex 
(TAT) and prothrombin activation peptide (F1.2). 
Results: 
TAT (mc~) F1.2 (nmoLq) 
T1 T2 T1 1"2 
Grpl 24 .5~21.2  58.2:1:49.6 1.9±1.2 3.0±1.9 
Grail 43.0 :E 58.0 82A~90.8 2.5 :E 2.3 2.6± 1A 
Levels were elevated throughout both the RFA andthe EPS procedures 
relative to normal values of TAT (1.0--4.1 /zg/I and F1.2 (0.44-1.1 nmo~). 
These elevations in COAG parameters were not dltferont (p = ns) between 
Grp I and Grp II at T1 and T2. In a subset of RFA and EPS pts (n = 15), 
specimens sampled just pdor to catheter insertion confirmed time dependent 
increases in TAT (p = 0.06) and F1.2 (p < 0,0001 )from inser~on to completion 
of procedures. 
Con~usion: Dudug RFA, activation of the COAG cascade, as assessed 
by sensitive assays, is a consequence of catheter insertion and placement 
rather than RF delivery. Moreover, COAG activation is of a similar magnitude 
far RFA and diagnostic EPS. Thus COAG activation is an unlikely mechanism 
for potentiating dsk of thrombuembelism specifically for RFA procedures. 
~ Lack of  Acute Echocardiographic Change With 
Radlefrequency Catheter Ablation: A Prospective 
Study of  158 Patients 
Jeffrey M. Orood, John S. Goftdiener, Ralph J. Verdino, Cynthia M. Tmcy. 
Georgetown University Hospital, Washinglon, DC 
Radiofrequency catheter ablation (RFA) treats a vaflety Of arrhythmias. This 
involves catheter manipulations traversing cardiac valves, tmnsseptal punc- 
lure, and endocardial energy delivery. Potential complications include va;vu- 
lar damage, creation of intracardiac shunts, and cardiac pedoretion. To quan- 
lily acute effects of RFA on cardiac anatomy and function, we prospectively 
compared echocardiograms (2.dimensional and Doppler) obtained prior to 
and within one week post ablation on 158 adults (mean age = 44 4-16 years, 
82 men, 76 women). Patients underwent 187 procedures for 202 arrhythmla 
subst~tss (119 accessory pathways (AP's), 53 AV node modifications, 15 
AV node ablations, 4 ventricular tachycardias, 5 atrial fluttam, and 6 ectopic 
atrial tachycardias). All but one AP were ablated on the atrial side of the 
annulus; 85 transseptals were performed. Any reported echocardiographic 
changes wore reviewed by a single investigator in a blinded fashion. Echo 
changes were seen in six patients. These included: 3 pedcerdial effusions 
(1 of which was clinically evident as tampanade; 2 required no treatment); 
1 normalization of septal motion after AP ablation; 1 new septal wall motion 
abnormality not associated with a change in Overall function; and 1 decrease 
in ejection fraction without dinicel correlation, seen on a technicaJly limited 
study. There were no acute intrecardiac shunts or valvular changes. In this 
adult population, we conclude: 1) acute changes post ablation were rare; 
2) bansssptal puncture did not create intracardlac shunts: 3) acute valvular 
lesions were not created; and 4) relevant peficerdial effusions were rare and 
clinically evidanL 
Echo Ass~menl  of Right Ventdcular and 
Aortic Root Function 
Tuesday, March 26, 1996, 9:00 a.m.--11:00 a.m. 
Orange County Convention Center, Hall E 
Presentation Hour: 9:00 a.m.-10:00 a.m. 
~ Echocurdiogmphy for Right Ventricular Volume 
Determination: A Comparative Study With 
Magnetic Resonance Imaging 
Nicole Aebischer, Rate Meuli, Xavier Jeanrenaud, Lukas Kappcmberger. 
Centre Hospitalier Universitaire Vaudois, Lausanne, Switzedand 
Various geometrical models hOve been used for right ventdcular volume 
(RVV) determination using echucardiogrepby (echo). However the RV anatomy 
defies simple geomeffical assumption. Models taking into consideratk~ the 
crescentic aspect Of the RV on cress-section might be more appropriate for 
RW determination. 
The purpose of this study was to compare previously proposed geomet- 
dcal models desolbing the RV as a pyramid (Pyr), an ellipeoid (EUip) or a 
tapadng figure (TaD) with 2 new medals (Cm 1, Cm2) based onthe crsscentic 
aspect of the RV cross-section. Echo derived RV volumes were compared to 
magnetic resonance imaging (MRI) derived volumes. Ten subjects, 8 normal 
volunteers and 2 patients with dilated RV were studied. Standard echo views 
were obtained from the parastemal shnd axis and the apical 4 chamber. 
MRI RW was obtained from short axis plan using the Sirnpson's role. Sta- 
tistical analysis was performed by regression analysis and the Blarid-Aitman 
method. 
Cml C~ ~.  B~ T~ 
Coe~d~3on 0.~ 0.~ 0.~ 0.~ 0.~ 
Meand~emnce'(~ 10~ 10A ~.6 ~.8 ~ 
I~¢one l .  0.~ 0.91 0.13 0~ ~ 
*mean ¢lgference betwesn MRI RVV ar',d RW derived from other echo melho~. 
Conclusion: models for RVV determination based on RV anatomical iaed- 
madcs gave higher coefficient of coweh~on and higher intraclass comela~on 
than the geometric models when compared to MRI. Although a small un- 
derastimation persists, those models should be recommended for clinical 
setting. 
~ O n  Une Assessment of  Right Ventricular 
Function In Patients W'dh Chronic  Congestive 
Heart Failure by Echocardiographic Automated 
Boundary Detection - -  Comparison With 
Tricnepid Annular Plane Systogc Excursion and 
Gated Blood Pool Veutdculography 
Giovanni Feral, Msss~mo Pozzoli, Giorgio Cannizzaro, 
Gioseppo Caisamigli¢ Egidio Tmversi, Marietta Franchini, Dingle Ro~_si, 
Socoorco Capamoti¢ Lu~ Tavazal. Sdvatore Mauge# Foundation 
- -  l RCC~ - -  Mor r tascano  (P V) 
In patients with chronic heart failure, right vontdcular dysfunction is an im- 
partent determinant of global cardiac performance and is related to exercise 
tolerance and prognoals. The accuracy of time-area curves generated by 
echocan~phio  automated boundaries detection (EABD) in evaluating 
right vantricuiar function still needs to be defined. Accordingly, we inves- 
tigated 22 sinus ft~jthm patients (mean age 51 =1:7 years) with chronic 
heart failure due to dilated cardiomyo~, using two dhlerent echocardio- 
graphic methode: the two-dimansionsl right ventdcular fractional area change 
(FAC) obtained by EABD and the systolic excursion of the tricuspid annular 
plane (TAPSE). Results were compared with dght vantdcular ejection fraction 
(RVEF) evaluated by gated blood pool veetdculngraphy, considered as the 
reference technique. After optimizing the gain control to detect the most con- 
tinuous EABD and the maximal cavity size, arid-diastolic, end-systolic areas 
and FAC were automatically displayed. Ten consecutive cycles were aver- 
aged. Combining M-mode and two-dimensional echoca~ogrephy, TAPSE 
was calculated as the distance between the inseflJOn of the tricuspid valve 
in the right ventricular free wall in diastole and the annular plane in systole. 
T 
U 
E 
S~ 
D 
A 
Y 
P 
O 
S 
T 
E 
R 
212A ABSTRACTS-Poster JACC February 1996 
Radionuclide images were acquired in t,~e LAD best septal projection, on a 
64 x 64 pixets matrix. The examinations were performed within one hour 
and the results were I:!indly reviewed in two laberatodes and compared by 
linear regression analysis. Results: mean EABD right ventricutsr FAC was 
31 ± 6%; mean TAPSE 18 -4- 4 mm and mean radionuciide RVEF 33 :~ 5. 
r SEE p value 
FAC vs. radionuctide RVEF 0.87 0.34 <0.0001 
TAPSE vs. radionudide RVEF 0.76 0.36 <0.0005 
Conclusions: In patients with chronic heart failure, fight venfficutar function 
can be accurately estimated by on-line FAC generated by EABD.This method 
is more accurate than TAPSE. Compared with the radionuctide technique, 
the absence of radiation exposure and the real time display are potential 
advantages of ultrasound in the noninvasive assessment of dght ventricular 
function. 
~ Assessment of  Right Ar ie l  Pressure by Hepatic 
Vein Doppler Echocardiography: A Simultaneous 
Catheterization/Doppler Echocardiogrephi¢ Study 
David G. Hurrall, John D. Symanski, Had R Chaliki, Kyle W. Kladch, Ross 
D. Pascoe, Rick A. Nishimura. Mayo Clinic, Rochester, MN 
The non-invaslve assessment of fight ventficular systolic pressure from 
Doppler and tricuspid regurgitant velocity requires an accurate assumption 
of right atrial pressure (RAP). The 2D echo appearance of the inferior vena 
cava(IVC) has been used but may not reliably predict significant elevation of 
RAP. Therefore, 21 patients were studied in the cardiac catheterization lab- 
oratory comparing simultaneous RAP (measured at mid-systole) to on-,ca 
simultaneous Doppler recordings of the hepatic vein systolic (S) and atrial ra- 
versst(AR) velocities. The simultaneous IVC dimension was measured from 
2D echo. There was a direct correlation of IVC dimension with RAP (r = 
0.64;P < 0.01), but the sensitivity and specilicity of the IVC >_ 20 mm for a 
RAP > 20 mmHg was 67°/0 and 80°/= respectively. There was a significant 
inverse correlation of the(S-AR) velocity difference and RAP (r = 0.74;P < 
0.001). A (S-AR) velocity difference < 0 cm/s was 94% sensitive and 100%o 
specific for a RAP > 20 mm Hg. Conclusion: The hepatic vein (S-AR) ve- 
locity difference is a sensitive and specific Doppler ech0cardiographic index 
for assessment of RAP and a better predictor of elevated RAP than the IVC 
diameter. 
~ RsspiretOry Variation of  Superior Vena Cava 
Doppler in Patients With Severe Emphysema: 
Correlat ion With Intrapleurel and Intreabdominal 
Pressure. 
Smonpom Boonyaratavej, Lyle J. O[son, Kenneth C. Beck, Catherine 
M. Swee, Jae K. Oh, James B. Seward. Mayo Clinic, Rochester, MN 
In normal subjects, superior vena cave flow is augmented by inspiration, in pts 
with chronic obstructive lung disease, the magnitude Of change of SVC for- 
ward flow velocity with respiration (z~SVC) is reported to be increased. Since 
the patient with severe emphysema may also have abnormal diaphragmatic 
motion, we hypothesized that ~ SVC magnitude is related to transdiaphrag- 
matic pressure change rather than intrapleUral pressure change alone. Meth- 
ods: Echocardlography with SVC Doppler was performed in emphysema pts 
who had Intrapteural (Ppl) and intraabdominal (Pab) pressure measurement 
by balloon manometty. ASVC was correlated with changes in Ppl and Pab. 
Transdiaphragmatic pressure was defined as Pab - PpL Results: 12 pts (age 
65 ± 5 yr, 7 M, 5 F) with severe emphysema (% FEV~ 20:1: 8) were studied. 
Mean ± SD of SVC systolic forward flow velocity (inspiration vs expiration) 
was 65 ± 17 ve 24:1:10 cm/s. Diastolic forward flow velocity was 41:1:12 
vs 9 4-12 cm/s. The correlation between Ppl and systolic or diastolic &SVC 
did not show ste.:;stical significance. However, systolic ASVC was highly 
correlated with transdiaphregmatic pressure change: r = 0,88, p = 0.0002, 
R 2 = 0.77 (figure). 
80, 
7,o 
~;4o. 
,~ , Qe  
~30 • • 
~,  
, 4 6 , ,o n ,4 ,6 
"~m~:ph~tk  p:rt~mm ch~Be (¢mRZO) 
Conclusion: In pts with emphysema transdiaphragmatic pressure is an 
important determinant of systolic &SVC. Therefore, diaphragmatic function 
must be taken into account in the Interpretation of augmented systolic &SVC. 
~ Echocerdiographic Predictors of  Exercise 
Capacity In Primary Pulmonary Hypertension 
Alan L. Hindeditor, Park W. Willis IV, Shu U, Gary Koch, Unda Clayton and 
the North Amedcan Pdmary Pulmonary Hypertension Study Group. 
University of North Carolina, Chapel Hill, NC: Burroughs We//come 
Company, Research Triangle Park, NC 
Primary pulmonary hypertension (PPH) is associated with abnormalities in 
dght heart structure and function which contribute to the morbidity and mor- 
tality of this disease. To assess the relation of cardiac abnormalities to 
exercise capacity in patients with severe PPH, we compared findings on two- 
dimensional and Doppler echocardtograms to results of a six-minute walk in 
patients with Class lit or Class IV symptoms. 
The 81 study subjects averaged 39 4- 3 years of age; 73% were female. All 
were treated with conventional medical therapy, including oral vaseditstors if 
tolerated. The distance walked in six minutes was invereaty correlated with 
the following: it) right ventdcalar diastolic area indexed by height (r = -0.25, p 
< 0.04), a measure of fight vantricutar size; b) diastolic eccentricity index (r = 
-0.37, p < 0.001), a measure of septet deformity which reflects the abnormal 
interaction between left and right ventricles; c) tricuspid regurgitation jet area 
(r = -0.36, p < 0.001), an estimate of the severity of tricuspid regurgitation; 
and d) pericardlal effusion size (r = -0.49, p < 0.001). 
In summary, in patients with severe PPH, poor exercise capacity is associ- 
ated with right ventdcutar dilatation, an abnormal interaction between left and 
right ventricles, tricuspid regurgitation, and presence of a peficardlal effusion. 
These findings suggest hat abnormalities in right heart structure and function 
which can be measured by echocardiegraphy are important determinants of 
exercise capacity in PPH. 
~ Re¢onclliction of  Doppler  Predicted and Actual 
Pressure Gradients in Modif ied Slalock-Taussig 
Shunts 
Theresa A. Tacy, Kevin K. Whitehead, Edward G. Cape. Cardiac Dynamics 
Laboratory, Children's Hospftal of Pittsburgh, PA 
Accurate knowledge of the pressure gradient (PG) across a modified Blalock- 
Taussig shunt (BTS) is critical in surgical planning for staging to a cavopul- 
monary anastomosis. White it is common to estimate the aortopulmonary 
pressure gradient (PG) using the modified Bernoulli equation (MBE), the 
a~;curacy of this technique is limited due to viscous energy losses in the BTS 
which are unaccounted for in the MBE. Methods: We studied the relationship 
between PG predicted by MBE and aortopotmonary PG using a pulcafile 
flow model with Gore-Tex BTS connecting systemic and pulmonary circuits 
with variable compliance and resistance to generate 5 peak PG's, 20-100 
mmHg, and a range of mean PG from 5-88 mmHg. Effect of BTS length 
(L) and diameter (D) were investigated by varying L from 3 to 9 cm and D 
from 4 to 6 ram. The velocity (v) of the blood analog fluid within each BTS 
was measured by continuous wave Doppler for each condition, and the MBE 
was tested as a predictor of the PG across the BTS. An equation for poak 
PG was derived using established formulae for fluid contraction into a tube, 
PG = 1/2 n/2 [1.5 + fL/D], which incorporates a Reynolds number-dependent 
friction factor f. Results:The slope of the regression line (y ,, 0.80x, r = 0.97) 
reflected the tendency for underestimation of peak PG by MBE and was 
significantly different from unity (p ,= 0.01). The average error was 21% for 
all BTS and flow conditions (r = 0.97). The mean PG predicted by the MBE 
ntso significantly underestimated the mean tranducer PG, with an average 
underestimation of 24% (y = 0.74x, r = 0.98). Using the f equation, the mean 
error of peak PG decreased to 5%, and the slope of the regression line relat- 
ing Doppler predicted to PG (y = 1.04x;) was not significantly different from 
the line of unity (p > 0.05). Conclusions:The MBE should be applied tO BTS 
with caution because of its consistent underestimation of PQ. Application of 
fluid dynamlo theory may yield a truly accurate predictor of PG across BTS 
which is critical in surgical decision making. 
~ Dynamic Elsstl¢ Propert ies of Ascending Aorta In 
Coronary Artery Disease Evaluated by 
Dobutamine Stress E©hocerdiography 
George Athanassopoulos, Eteftherios Glazitzoglou, Demetrios Awamidas, 
Athanassios Maginas, Vassilios Voudris, Dennis V. Cokkinos. Cardiology 
Department, Onassis Cardiac Center, Athens, Greece 
Aortic distensibility is decreased in coronary artery disease (CAD) at rest. 
However its dynamic hanges during dobutamine infusion and the implica- 
tions for the relevant ventdculo.arterial coupling have not been clarified. 
Forty CAD patients (10 with 1, 12 with 2 and 18 with 3 vessel disease-VD, 
age 58 ~ 12) and 10 normals were studied during low dose dobutamine 


On line assessment of right ventricular function in patients with chronic congestive heart failure by echocardiographic automated boundary detection — Comparison with tricuspid annular plane systolic excursion and gated blood pool ventriculography 

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On line assessment of right ventricular function in patients with chronic congestive heart failure by echocardiographic automated boundary detection — Comparison with tricuspid annular plane systolic excursion and gated blood pool ventriculography

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