echo-Doppler Examination Research Articles

Kinetic evaluation of an I.V. bolus of MR contrast media

Currently, it is assumed that the pharmacokinetic properties of the first minutes of an I.V. MR contrast media bolus are similar to those of an I.V. iodinated contrast media bolus used in CT. Correct timing of an MRA examination is crucial for obtaining sufficient arterial contrast. This study sought to evaluate the temporal change of arterial signal intensity within 150 s after I.V. bolus injection of Gd-DTPA. Thirty consecutive patients (14 women/16 men; mean age: 51 ± 11 years) were prospectively examined with a 1.0 Tesla clinical scanner. A single axial slice was acquired in 1.25 sec with manufacturer provided gradient echo sequence through the aorta at the level of the renal arteries. Investigation was started simultaneously to the application of contrast media (0.1 mmol/kg bodyweight Gd-DTPA at three different rates 2 mL/sec, 3 mL/sec and 4 mL/sec) and repeated for 2.5 min. An additional echo Doppler examination excluded patients with any cardiac disorders. Maximum signal (1300% increase compared to the basic value) in the aorta was achieved 20 ± 6 sec after start of bolus injection. Then a plateau phase was maintained for the remaining investigation time (2.5 min). No significant difference was shown for different injection rates. After a bolus injection of Gd-DTPA the arterial contrast remains on a high level for at least 2 min. However, correct timing of the bolus arrival is still crucial to discriminate arteries and veins. An injection rate between 2 mL/sec and 4 mL/sec has no influence on early contrast media dynamics.

Skeletal muscle mass independently predicts peak oxygen consumption and ventilatory response during exercise in noncachectic patients with chronic heart failure

OBJECTIVESWe sought to assess whether skeletal muscle mass might be a predictor of peak oxygen consumption (Vo2) and relation of the ventilation to carbon dioxide production (VE/VCo2) slope in patients with chronic heart failure (CHF) independent of clinical conditions, neurohormonal activation and resting hemodynamics.BACKGROUNDA variety of abnormalities characterize skeletal muscle and contribute to exercise intolerance in patients with CHF. Skeletal muscle mass is a determinant of peak Vo2both in healthy patients and in patients with CHF, but there are no reports on the independent predictive value of this parameter, which can be measured with great accuracy by whole-body dual energy X-ray absorptiometry (DEXA). The influence of skeletal muscle mass on VE/VCo2slope is not known either.METHODSWe prospectively evaluated 120 consecutive noncachectic patients with CHF. Every patient underwent a cardiopulmonary exercise test, an echo-Doppler examination and an evaluation of neurohormonal activation and body composition as assessed by DEXA.RESULTSAt the univariate analysis, New York Heart Association (NYHA) class (p < 0.0001), age (p < 0.0001), male gender (p < 0.0001) and plasma renin (p < 0.0001) significantly related with peak Vo2. There was a significant correlation between lean mass and absolute peak Vo2(r = 0.70, p < 0.0001) and VE/VCo2slope (r = −0.27; p < 0.01). At the multivariate analysis, lean mass predicted peak Vo2and VE/VCo2slope independently of NYHA functional class, age, gender, neurohormonal activation and resting hemodynamics.CONCLUSIONSSkeletal muscle mass is an independent predictor of peak Vo2and VE/VCo2slope in stable noncachectic patients with CHF. Future studies will determine whether an increase in skeletal muscle mass in the individual patient might result in an improvement in parameters of exercise capacity.

Adaptive common carotid arteries remodeling after unilateral internal carotid artery occlusion in adult patients

This study was undertaken in human adults to examine modifications in common carotid internal diameter (ID), intima-media thickness (IMT), cross-sectional area (CSA) and wall shear stress (WSS) occurring both on the ipsilateral side of an internal carotid artery (ICA) occlusion and on the non-occluded contralateral side. Seventeen patients with unilateral ICA occlusion had repeated echo-Doppler examinations during 1 year and were compared to 12 volunteers with control non-occluded common carotid arteries (CCA). The cause of ICA occlusion was atherosclerosis in nine patients, dissection in five, and undetermined in three. The results showed a significant reduction in ID on the occluded side (5.15 +/- 0.30 mm) compared with the non-occluded side (5.96 +/- 0.20 mm, P < 0.05) and with control arteries (5.55 +/- 0.10, P < 0.05). A significant reduction in blood flow was observed on the occluded side (404 +/- 58 ml/min) compared with the non-occluded side (703 +/- 51 ml/min, P < 0.0001) and with controls (567 +/- 27 ml/min, P < 0.0001). Wall cross-sectional area was found to be positively correlated to blood flow (r = 0.35, P < 0.01), without any significant difference in mean CSA between both sides. Interestingly, wall shear stress values were identical on both sides whatever the cause of ICA occlusion, and did not differ from those in controls. Our results suggest that in humans, the internal diameter of the common carotid artery decreases in response to chronic decrease in blood flow, in order to maintain a constant wall shear stress even in pathological arteries.

Prevalence of heart failure in Asturias (a region in the North of Spain)

C disagreement exists on data published on the prevalence of heart failure.1–6 However, studies on both the prevalence and natural history of heart failure generally tend to be retrospective and to have been performed in patients referred to specialized centers (most of whom are in advanced stages of heart failure). Therefore, these patients are not representative of congestive heart failure in the community.6–8 Because of the lack of diagnostic criteria and data on the prevalence of heart failure, we conducted a field study in 1996 to establish its prevalence of this in our community. For these reasons we followed the Framingham clinical criteria of heart failure3 (Table 1). We also included 2 dimensional echo-Doppler examinations to stratify heart failure into systolic or diastolic failure.9–11 • • • In September 1995, the census of Asturias in Northen Spain, with a population of 1,098,725, contained 515,487 persons aged . 40 years. Assuming an epsilon of 6 1, a confidence interval of 95%, and a prevalence of heart failure .1% (1% to 5%), we selected a random sample of 380 subjects, a number statistically representative of this population. The total sample size for the study included 6% more subjects than what was originally estimated to adjust for the possible effect of dropouts; we decided not to replace those who failed to attend appointments. These subjects were stratified according to age and sex. Of the 400 randomized persons, 9 were excluded because of census errors. The remaining 391 persons (100%) underwent medical examination, 367 (93%) underwent electrocardiography, 356 (91%) chest xray examinations; 2 dimensional echo-Doppler studies estimated left ventricular ejection fraction in 351 patients (89%). Two dimensional echo-Doppler studies were recorded with a Hewlett-Packard (Andover, Massachusetts) ultrasound unit (model 1500) and 2.5MHz transducer. Those presenting with a left ventricular ejection fraction .50% (by the Teichholz method) were considered to have normal systolic function.9,12,13 Diastolic function10,11,14 was assessed by left ventricular filling patterns: mitral valve E (m/s)/mitral valve A (m/s) (E/A) ratio, deceleration time, and isovolumetric relaxation time (Table 2). For systolic and diastolic assessment, a mean of 3 measurements was obtained in each patient with sinus rhythm, and a mean of 5 measurements was obtained in those with atrial fibrillation. The echo study results were used for further stratification of heart failure (systolic and diastolic dysfunction). Stratification of the population according to age and sex, presence of heart failure, and echo data results are shown in Table 3. Table 3 shows the stratification according to the age of the population and of the sample aged .40 years. The mean age of the sample was 59.5 6 12.5 years. In terms of gender our sample contained 183 men From the Division of Cardiology, Hospital Central de Asturias, Oviedo University, Asturias, Spain. This work was supported by a Merck, Sharp & Dohme Grant. Dr. Cortina’s address is: Division of Cardiology, Hospital Central de Asturias, C/Julian Claveria s/n, 33006 Oviedo, Asturias, Spain. E mail: ROSARIOCORTINA@teleline.es. Manuscript received October 12, 2000; revised manuscript received and accepted January 17, 2001. TABLE 1 Criteria for Heart Failure

Congenital Kinking of the Internal Carotid Artery in Twin Brothers

We report magnetic resonance (MR) angiographic evidence of congenital kinking of the internal carotid artery in 4-year-old twin brothers. The first twin presented with a left pulsating laterocervical mass ≈2 cm in diameter. On examination, the mass had a palpable thrill and a systolic murmur. An echo-Doppler examination …

Validation of the ejection fraction-velocity ratio: a new simplified “function-corrected” index for assessing aortic stenosis severity

A new echocardiographic method for the evaluation of aortic stenosis (AS) severity has recently been introduced: the fractional shortening-velocity ratio (FSVR = fractional shortening/4 Vmax2). An important advantage of the method is the possibility of avoiding the difficulties related to the measurement of left ventricular outflow tract in calcific AS for assessing the continuity equation. FSVR, however, also shows some significant limitations especially in patients with regional wall motion abnormalities and conduction defects. To overcome this problem, we developed a new index: the ejection fraction-velocity ratio (EFVR = ejection fraction/4 Vmax2), where percent ejection fraction and Vmax have been obtained with an apical echocardiographic approach. In 343 consecutive patients with AS, aortic valve area was measured by cardiac catheterization (Gorlin), whereas FSVR and EFVR were calculated by echo-Doppler examination performed within 24 hours. Mean valve area was 0.70 ± 0.30 cm2, mean EFVR was 0.78 ± 0.41, and mean FSVR was 0.45 ± 0.26. The linear correlation area-EFVR was highly significant (r = 0.88). Correlation valve area-FSVR was also significant (r = 0.82). EFVR allowed identification of patients with severe AS (area ≤0.8 cm2) with good sensitivity (88%) and specificity (85%), whereas FSVR demonstrated sensitivity of 88% and specificity of 73%. Thus, the EFVR, a very simple and not time-consuming index, is strongly related to aortic valve area in patients with AS. It allows identification of patients with severe AS with good sensitivity and specificity (better than FSVR). The EFVR, taking into consideration both ejection fraction and transvalvular pressure gradient, may be very useful in the evaluation of patients with AS and left ventricular dysfunction.

Physiological or pseudophysiological ECG changes in endurance-trained athletes.

"Sudden cardiac death" in seemingly healthy, active, and asymptomatic people has always been a tragic fact and is now occurring more frequently. Thus, the preventive detection of "subjects at risk" becomes a priority. A traditional resting electrocardiogram can sometimes give useful indications. Fifty-two competitive triathletes were compared with 22 control persons with similar anthropometric parameters. All subjects underwent the same noninvasive cardiac exploration with electrocardiography, bidimensional echo-Doppler examination, and maximal spiroergometric exercise tests, on a stationary bicycle as well as on a treadmill. In the triathletes we noted manifest signs of eccentric as well as concentric left ventricular hypertrophy with arguments for a supernormal diastolic left ventricular function, with important hemodynamic adjustments and with consequences on the resting electrocardiogram. We described "ten commandments" in evaluating the resting electrocardiogram of healthy competitive athletes. We suspect that the occurrence of ventricular premature beats at peak load of a maximal exercise could be the first expression of a pathological cardiac adaptation to sports activities. The resting electrocardiogram can show interesting details in detecting the "subjects at risk" for problems such as possible lethal arrhythmias and "sudden cardiac death." The analysis of the four subgroups of triathletes compels us to feel dubious about the "athletic heart syndrome" as a physiological entity. In several cases the "athletic heart" is possibly a transitional situation to a pathological hypertrophic and dilated cardiomyopathy.

Advanced mitral annular calcification is associated with severe coronary calcification on fast dual spiral computed tomography.

Mitral annular calcification (MAC) may be a form of atherosclerosis and can lead to serious clinical consequences. The possible linkage between the presence and extent of MAC and coronary calcium score on CT is unknown. The goal of the present study was to investigate whether an association between MAC and coronary calcification (CC) exists in hypertensive patients with increased cardiovascular risk. Five hundred twenty-two patients (284 men and 238 women, age range 52-80 years, mean 65+/-6 years), who were recruited to the INSIGHT study in the authors' region, underwent fast spiral CT of the heart as well as an echo Doppler examination. MAC was defined as advanced when the thickness of the calcium deposit was 5 mm or more; it was defined as trivial otherwise. The advanced MAC group comprised 62 patients, the trivial MAC group 215 patients, and the control group (without MAC) 245 patients. The prevalence of nonsevere CC was similar among the study groups, whereas the prevalence of severe CC (total calcium score >300) and the prevalence of proven coronary artery disease were associated with the presence and extent of MAC: respectively, 12% and 15% in control patients, 18% and 20% in patients with trivial MAC, and 29% and 29% in patients with advanced MAC. Multivariate analysis identified advanced MAC as an independent variable associated with severe CC and proved coronary artery disease. The results of this study demonstrated an association of advanced MAC and severe CC on spiral CT and proved coronary artery disease on the clinical level. Thus, advanced but not trivial MAC makes the noninvasive diagnosis of coronary atherosclerosis more likely and presumably could be considered as a new indication for further coronary evaluation in high-risk patients.

Cardiac function at rest in hypothyroidism evaluated by equilibrium radionuclide angiography.

Previous studies have suggested that hypothyroidism affects both systolic and diastolic cardiac function. We have applied equilibrium radionuclide angiography to the study of heart function at rest in hypothyroidism. A prospective study, evaluating cardiac function at rest in primary hypothyroidism. Cardiac function was studied by means of equilibrium radionuclide angiography. Screening echo-Doppler examinations were performed on each patient. Twenty-six consecutive untreated hypothyroid patients without clinical or echocardiographic cardiac disease and 20 healthy matched controls. Between patients and controls, the time to peak emptying rate (161 +/- 6 msec vs. 144 +/- 6 msec, P < 0.05) and the time to peak filling rate (188 +/- 6 msec vs. 170 +/- 5 msec, P < 0.05), were the only discriminatory parameters. In hypothyroid patients, a trend towards a decrease in diastolic cardiac function, expressed as peak filling rate, was observed: 2.6 +/- 0.1 End Diastolic Volume (EDV)/s vs. 3.0 +/- 0.1 EDV/s, P = 0.06. Within the hypothyroid patient group, the time to peak emptying rate was more prolonged in patients with lower free thyroxine levels (R = -0.60, F = 13.5, P < 0.001). Peak filling rate was decreased in patients with lower free thyroxine levels (R = 0.51, F = 8.4, P < 0.01) whereas the time to peak filling rate was more prolonged (R = -0.62, F = 15, P < 0.001). In a large group of consecutive patients presenting with primary hypothyroidism, even in the absence of clinical cardiac disease and echocardiographic abnormalities, clear changes in myocardial performance at rest were observed. The most obvious effect of thyroid hormone deficiency on the heart was a lengthening of both systolic and early diastolic time characteristics. Diastolic rather than systolic cardiac function was influenced by hypothyroidism.

Limb immobilization and intimal hyperplasia--an echo-Doppler study in man.

The authors studied the circulatory alterations observed in the upper limbs of patients showing muscular atrophy due to flaccid paralysis of traumatic origin. Ten patients who had suffered avulsion of the nerve roots from C4 to D1 that occurred 9 to 216 months previously, presented a significant degree of muscular atrophy of the affected upper limb, despite physiotherapy. We performed echo-doppler examinations of the patients to measure the lumen of the subclavian, axillary, brachial, radial and ulnar arteries and also of the veins of both upper limbs. The measurements from both upper limbs in each patient were statistically compared. The data revealed a significant reduction of the width of the lumen of the arteries and veins and a reduced arterial blood flow in the affected limb in comparison with the normal one. The greater echogenicity and the abnormal Doppler waves of the affected vessels suggest that they presented an increased thickness and a hardened wall. The authors propose that this finding may be related to an intimal hyperplasia brought about by muscular atrophy or by the observed blood flow reduction.

"Peak Summation" Left Ventricular Filling Pattern in Patients with Chronic Heart Failure: Frequency and Complementary Value of Pulmonary Venous Flow in Its Hemodynamic Interpretation.

In patients with chronic heart failure (CHF) and a "peak summation" left ventricular pattern, no hemodynamic and prognostic information can be drawn from Doppler examination of mitral flow. In 263 consecutive patients with CHF who were undergoing simultaneous right heart catheterization and echo-Doppler examination, we prospectively determined (1) the frequency of the peak summation left ventricular filling pattern and (2) the incremental information contributed by pulmonary venous flow velocity patterns in providing noninvasive hemodynamic profile estimation. Isovolumic relaxation time of mitral flow, peak systolic (X), diastolic forward (Y), reverse (Z) flow velocity, and systolic fraction (X/X + Y) of pulmonary venous flow were measured. Forty-six of 263 (17%) patients had a peak summation left ventricular filling pattern. This subgroup showed more clinical deterioration (New York Heart Association functional class III-IV, 57% vs 49%; P < 0.01) and left atrial dysfunction (left atrial ejection fraction, 31% vs 39%; P < 0.001). However, 40% of these patients had a pulmonary wedge pressure of <18 mmHg and a cardiac index of >2.2 L/min/m(2). The systolic fraction of peak velocities of pulmonary venous flow showed a good correlation with pulmonary wedge pressure (r = -0.70, P < 0.05). The correlation was stronger in patients without mitral regurgitation (r = -0.81, P < 0.05). A systolic fraction of <40% was accurate (sensitivity, 100%; specificity, 95%) in identifying patients with a pulmonary wedge pressure of >18 mmHg. In patients without mitral regurgitation, this variable was also correlated with cardiac index (r = -0.65, P < 0.05) and predicted a cardiac index of >2.2 L/min/m(2) (sensitivity, 91%; specificity, 71%). In conclusion, a peak summation left ventricular filling pattern is common in patients with CHF. Pulmonary venous flow provides useful information about the hemodynamic profile of these patients.

Influence of systematic echodoppler arterial survey on hepatic artery thrombosis after liver transplantation in adults.

Hepatic artery thrombosis after liver transplantation remains a major problem which may lead to graft loss and retransplantation. Hepatic artery diseases were compared in two matched groups of liver grafted patients. In Group I (67 patients), echodoppler examinations of the graft hepatic artery were carried out after clinical or biological abnormalities became evident. In Group II (85 patients), echodoppler examinations were systematically made during the follow-up at 2 weeks, 1, 3, 6, and 12 months after liver transplantation. In cases of an abnormal echodoppler examination, arteriography was carried out in order to confirm hepatic artery stenosis and to perform endoluminal angioplasty. In Group I, echodoppler examinations revealed no arterial blood flow in three cases and reduction of hepatic blood flow in two cases. Hepatic artery thromboses were always confirmed by angiography, in the latter two cases, a collateral arterial revascularization of the graft was developed. In this group, two retransplantations, one choledocojejunostomy, and four percutaneous radiological biliary drainages were necessary. In Group II, echodoppler results showing a resistive index below 0.5 and a systolic acceleration time above 0.08 s involved 13 arteriographies. Ten stenoses were diagnosed without any biological abnormalities. Nine endoluminal angioplasties were made without any complication. There was no recurrence of stenosis. One pseudoaneurysm of the femoral artery was cured by compression. The early and non-aggressive detection of hepatic artery stenoses after liver transplantation by echodoppler allows treatment by angioplasty in order to prevent hepatic artery thrombosis and reduce retransplantation.

Influence of systematic echodoppler arterial survey on hepatic artery thrombosis after liver transplantation in adults

Abstract Hepatic artery thrombosis after liver transplantation remains a major problem which may lead to graft loss and retransplantation. Hepatic artery diseases were compared in two matched groups of liver grafted patients. In Group I (67 patients), echodoppler examinations of the graft hepatic artery were carried out after clinical or biological abnormalities became evident. In Group II (85 patients), echodoppler examinations were systematically made during the follow-up at 2 weeks, 1, 3, 6, and 12 months after liver transplantation. In cases of an abnormal echodoppler examination, arteriography was carried out in order to confirm hepatic artery stenosis and to perform endoluminal angioplasty. In Group I, echodoppler examinations revealed no arterial blood flow in three cases and reduction of hepatic blood flow in two cases. Hepatic artery thromboses were always confirmed by angiography, in the latter two cases, a collateral arterial revascularization of the graft was developed. In this group, two retransplantations, one choledocojejunostomy, and four percutaneous radiological biliary drainages were necessary. In Group II, echodoppler results showing a resistive index below 0.5 and a systolic acceleration time above 0.08 s involved 13 arteriographies. Ten stenoses were diagnosed without any biological abnormalities. Nine endoluminal angioplasties were made without any complication. There was no recurrence of stenosis. One pseudoaneurysm of the femoral artery was cured by compression. The early and non-aggressive detection of hepatic artery stenoses after liver transplantation by echodoppler allows treatment by angioplasty in order to prevent hepatic artery thrombosis and reduce retransplantation.

Mid-term results of the Ross procedure.

Fifty patients underwent a Ross operation between June 1991 and October 1996. Preoperative diagnosis was: congenital aortic valve disease (31 patients), complex left ventricular outflow tract (LVOT) obstruction (11 patients), outgrowth of a small aortic valve prosthesis (five patients) and valve endocarditis (three patients). Half of the interventions were reoperations. All operations were root replacements. A pulmonary homograft was used in 45 patients. An aorticoventriculoplasty was combined with the root replacement in the 16 patients with LVOT obstruction and a too small aortic valve prosthesis. An enlargement or reduction plasty of the ascending aorta was necessary in seven patients. The mean age was 20.9 years (range: 2.5-54 years). The mean follow up was 34.2 +/- 21 months and was 94% complete. Two patients died after 8 days (low cardiac output due to myocardial fibrosis) and 17.4 months (sudden death), respectively, resulting in a survival of 95 +/- 4% at 4 years. Those two deaths occurred in the group of patients undergoing Ross procedure and aorticoventriculoplasty. Two autografts were replaced after respectively 2 days (technical failure) and 44 months (progressive root dilatation) resulting in a reoperation-free incidence of 93 +/- 6% at 4 years. Other postoperative major complications occurred in six patients. All survivors had regular echo-Doppler examination. All autografts except one had a systolic gradient below 10 mmHg at the last examination. Thirty-four autografts had no leak, ten showed grade 1-2 regurgitation. Two patients showed a higher than grade 3 regurgitation: one leak remains stable with normal left ventricular dimensions and function, one autograft was replaced by a mechanical valve. This experience demonstrates that the medium-term results of the Ross procedure are excellent even in complex LVOT obstructions.

Interobserver, interequipment and intersubject variability of echo-Doppler examination of the common carotid and vertebral arteries

Objective: We evaluated interobserver and interequipment variability in common carotid and vertebral flow measurements, using seven female members of nursing staff as subjects, four different ultrasound machines and three different radiologists as operators. Methods: The flow of the common carotid and vertebral arteries in each subject was examined at 0, 10, 20 and 30 min after lying down in a supine position. Peak velocity, end-diastolic velocity, mean velocity, systolic acceleration, cross-sectional area of the vessel, flow volume/min, resistance index and Doppler angle were measured. Results: A large proportion of the variance of peak velocity, cross-sectional area of the vessel and flow volume was patient-related. Significantly different values of end-diastolic velocity, mean velocity, resistance index, Doppler angle and systolic acceleration were obtained with different equipment. Significantly different values of systolic acceleration, vertebral peak velocity, common carotid artery flow and Doppler angle were obtained by different operators. However, part of the variability may be physiological due to the study protocol. Conclusion: The use of the same operator and equipment is recommended in follow-up examinations.

In vivo association between low wall shear stress and plaque in subjects with asymmetrical carotid atherosclerosis.

It is known that atherosclerosis does not involve both carotid arteries to the same extent. Pathological investigations have demonstrated that lesions develop in regions of low wall shear stress. The aims of the present study were to verify the degree of carotid atherosclerosis asymmetry in a population-based study and to evaluate whether wall shear stress is lower in carotids with atherosclerotic lesions than in carotids without lesions. Participants in a cardiovascular disease prevention campaign (n = 1166) were screened for carotid atherosclerosis by echo-Doppler examination. Of these, 23 subjects who presented plaque in the common carotid or bulb of one side and no plaque in the contralateral carotid tree were enrolled for common carotid wall shear stress measurement. Shear stress was calculated according to the following formula: Shear Stress = Blood Viscosity x Blood Velocity/Internal Diameter. Of the 1166 subjects screened, 400 (34%) had plaque and/or stenosis in the carotids. Ninety subjects had lesions exclusively in the right carotid, 111 had lesions exclusively in the left, 70 had lesions in both carotids but with different degrees of severity, and only 129 had similar lesions in both carotids. In the 23 subjects in whom wall shear stress was measured, peak shear stress was 18.7 +/- 4.1 and 15.3 +/- 4.0 dynes.cm-2 (mean +/- SD) (P < .0001) in the side without and the side with plaque, respectively. Mean shear stress yielded similar results. The present results demonstrate that the atherosclerotic involvement of carotid arteries is usually asymmetrical and that wall shear stress is lower in the carotid arteries where plaques are present than in plaque-free arteries. These findings provide in vivo evidence for a strong association between shear stress and atherosclerotic lesions.

Early impairment of systolic and diastolic function in asymptomatic HIV-positive patients: a multicenter echocardiographic and echo-Doppler study. The Gruppo Italiano Per lo Studio Cardiologico dei Pazienti Affetti da AIDS.

Human immunodeficiency virus (HIV) possesses an intrinsic cardiopathogenic action that may be detected even in the early stages of HIV disease. To assess an early impairment of systolic and diastolic function in asymptomatic HIV-positive patients (CD4+ > or = 600/mm3), we performed a multicenter echocardiographic and echo-Doppler trial on 1236 asymptomatic NYHA class I HIV-positive patients (885 M and 351 F; mean age 28 years) compared with 1230 healthy subjects (922 M and 308 F; mean age 30 years). The sample size was established considering, as null hypothesis, a difference less than 10% in the values of the principal echocardiographic and echo-Doppler parameters between groups with a 90% statistical power (alpha = 0.01; beta = 0.10). Analysis of echocardiographic and echo-Doppler data revealed a reduction of 19.7% in ejection fraction, an increase of 55.7% in wall motion score, a reduction of 34.6% in the E/A ratio, and an increase of 19.7% in the isovolumetric relaxation time in HIV-positive subjects compared with healthy controls (p < 0.001). Baseline electrocardiographic alterations were observed in 707 (57.2%) HIV-positive subjects and in 169 (13.7%) of the subjects of the control group (p < 0.001). The results of our study have demonstrated that in asymptomatic HIV-positive subjects a significant impairment of systolic and diastolic function may be detected by echocardiographic and echo-Doppler examination, confirming an early involvement of the heart in HIV disease.

The importance of different atrioventricular delay for left ventricular filling in sequential pacing: clinical implications.

We assessed the influence and clinical consequences of different AV delay on ventricular filling in 30 patients (mean age 60 +/- 5 years) who had DDD pacemakers for AV block. All 30 patients presented a normal ejection fraction, but in 18 cases (Group I), an echo-Doppler examination revealed ventricular hypertrophy (mean end-diastolic wall thickness of 1.4 +/- 0.16 cm, LV mass index 155 +/- 17 g/m2), and an abnormal relaxation pattern (isovolumetric relaxation time = 124.72 +/- 11.82; early to late peak velocity = 0.6 +/- 0.03; deceleration time = 296.83 +/- 34.02 ms). Group II included the remaining 12 patients who had a normal filling pattern. In all 30 patients, the pattern was reassessed following modification of the AV delay (200, 150, 100, and 75 ms). Patients at baseline (AV delay of 200 ms) also underwent an exercise test with determination of respiratory gas exchange. In Group I, 13 (72.5%) patients were classified as Weber class B (VO2 Max 16.8 +/- 1.7 mL/min per kg); and 5 (27.5%) were Class A (VO2 Max 22.5 +/- 1.4 mL/min per kg). In Group II, all 12 patients were classified as Weber Class A. In Group II, changes in AV delay caused no consistent variations in filling pattern, and therefore AV delay was not modified. In Group I patients, since reduction to 100 ms resulted in normalization of the filling pattern, the AV delay was programmed to 100 ms. A graded exercise test repeated after 6 months' follow-up showed an improved Weber class in 13 patients (from B to A) and greater VO2 Max in the remaining five already in Class A. We concluded that, in sequential paced patients with normal ejection fraction but abnormal relaxation pattern, modification in AV delay can induce normalization of filling and improvement in cardiac functional capacity.

Spontaneous echo-contrast of the internal jugular vein at echodoppler examination: clinical and prognostic significance

Objective: To investigate spontaneous echocontrast (SEC), which is a smoke-like appearance of a blood vessel. The lumen of the vessel appears to be hyperechogenic during the ultrasonographic exploration in real time. Method: This study correlates the frequency of this echotomographic finding in the internal jugular vein in various groups of patients with different pathologies of the carotid arteries from a retrospective analysis of 7000 echo-Doppler studies. Results: The data show that SEC of the internal jugular vein is significantly more frequent in patients with duplex scanning positive for atherosclerotic pathologies of the carotid arteries than in individuals with negative echo-Doppler examination; in addition, a clearly higher incidence was noticed in the subgroups with echotomographic signs of diffuse vascular carotid involvement and with high-grade stenoses (more than 50%) or occlusions. The origin and clinical significance of SEC of the internal jugular vein are briefly discussed. Conclusion: The authors suggest a correlation in further studies of presence of SEC and grade of echogenicity with diameter and flow velocity rate of the jugular vein and other blood parameters.

Echo-Doppler Evaluation of Left Ventricular Impairment in Chronic Cor Pulmonale

The effects of acute right ventricular (RV) pressure and volume overloads on left ventricular (LV) filling are well known, while the significance of chronic RV pressure overload on LV function has been less studied. To evaluate the LV impairment, 30 patients with chronic cor pulmonale and pulmonary arterial hypertension secondary to chronic obstructive lung diseases (COLDs) were studied. All patients underwent respiratory tests and arterial blood gas assessment. An echo-Doppler examination was made to measure LV ejection fraction (EF), RV and LV end-diastolic and end-systolic diameters and areas, RV/LV area indexes, LV diastolic and systolic eccentricity indexes, mitral and tricuspid flow patterns, and mitral flow velocity in late and early diastole (A/E) indexes. A right heart catheterization was carried out to determine the resting mean pulmonary arterial pressure (mPAP). The data showed a marked enlargement of RV, compressing the left through a leftward shift of interventricular septum. A linear regression analysis detected a significant correlation between mPAP and the following parameters: RV/LV diastolic and systolic area indexes (r=0.75, p<0.0001; r=0.84, p<0.000, respectively), mitral A/E index (r=0.61, p<0.0005), and LV diastolic and systolic eccentricity indexes (r=0.93, p<0.0001; and r=0.83, p<0.0001). No correlations were found between echo-Doppler data and functional respiratory parameters. From these results, we conclude that chronic RV pressure overload induces LV filling impairment despite a normal systolic phase, due to septal leftward shift. In fact, chronic RV pressure overload distorts early diastolic LV geometry delaying LV filling phase, and the functional diastolic impairment of the LV is closely correlated to pulmonary hypertension levels.