Jeane Tsutsui

Myocardial contrast echocardiography has been used for determination of infarct size (IS) in experimental models. However, with intermittent harmonic imaging, IS seems to be underestimated immediately after reperfusion due to areas with preserved, yet dysfunctional, microvasculature. The use of exogenous vasodilators showed to be useful to unmask these infarcted areas with depressed coronary flow reserve. This study was undertaken to assess the value of adenosine for IS determination in an open-chest canine model of coronary occlusion and reperfusion, using real-time myocardial contrast echocardiography (RTMCE). Nine dogs underwent 180 minutes of coronary occlusion followed by reperfusion. PESDA (Perfluorocarbon-Exposed Sonicated Dextrose Albumin) was used as contrast agent. IS was determined by RTMCE before and during adenosine infusion at a rate of 140 mcg.Kg(-1).min(-1). Post-mortem necrotic area was determined by triphenyl-tetrazolium chloride (TTC) staining. IS determined by RT...

The diagnosis of coronary aneurysms has already been described using transthoracic and transesophageal echocardiography. In the present report we demonstrated the use of real-time three-dimensional echocardiography for the diagnosis of a large left circumflex coronary aneurysm. The improved spatial resolution of this new imaging technique provided valuable information for anatomic characterization of the coronary aneurysm, allowing for distinction between the lumen and lining thrombus. The findings were confirmed by magnetic resonance imaging and coronary angiography.

Left ventricular free wall rupture occurs in up to 10% of the in-hospital deaths following myocardial infarction. It is mainly associated with posterolateral myocardial infarction and its antemortem diagnosis is rarely made. Contrast echocardiography has been increasingly used for the evaluation of myocardial perfusion in patients with acute myocardial infarction, with important prognostic implications. In this case, we reported its use for the detection of a mechanical complication following myocardial infarction. A 50-year-old man with acute myocardial infarction in the lateral wall underwent myocardial contrast echocardiography for the evaluation of myocardial perfusion in the third day post-infarction. A perfusion defect was detected in lateral and inferior walls as well as the presence of contrast extrusion from the left ventricular cavity into the myocardium, forming a serpiginous duct extending from the endocardium to the epicardial region of the lateral wall, without communi...

Although dobutamine stress echocardiography has been used for the preoperative evaluation of patients with advanced liver disease (ALD), no data exist regarding the value of myocardial perfusion imaging (MPI) with real-time myocardial contrast echocardiography (RTMCE) in this patient population. We sought to determine the value of MPI during dobutamine stress RTMCE for predicting prognosis in patients with ALD. We examined both wall motion and MPI in 230 patients with ALD who underwent dobutamine stress RTMCE using intravenous commercially available contrast agents (Optison, GE-Amersham, Princeton, NJ; or Definity, Bristol-Myers Squibb Medical Imaging, North Billerica, MA). The prognostic value of clinical variables, including the Model for End-Stage Liver Disease (MELD) score, and echocardiographic data were examined using a Cox Hazard model. The primary endpoint was mortality of all causes. Among the 85 patients who underwent orthotopic liver transplantation, 4 had abnormal MPI and 81 had normal perfusion. The hospital mortality rate was 50% (2/4) in patients with abnormal MPI and 2% (2/81) in patients with normal MPI (P = 0.01). Among patients with abnormal MPI, 1 died from myocardial infarction in the first postoperative day and the second 1 from hemorrhagic shock. During a median follow-up of 15 months, 53 (23%) patients died. The independent predictors of death were an age of > or = 65 yr (RR = 2.2; 95% confidence interval (CI) = 1.1-4.4; P = 0.03), MELD score of > or = 25 (RR = 3.2; 95% CI = 1.8-5.5; P < 0.0001), and abnormal MPI (RR = 2.4; 95% CI = 1.1-5.2; P = 0.02). The 2-yr mortality was 24% for patients with normal MPI and 45% for those with inducible MPI abnormalities (P = 0.003). In conclusion, MPI obtained by RTMCE appears to be a useful tool in predicting mortality in patients with ALD. Further studies are required to verify its independent value.

The exact determination of acute myocardial infarction (AMI) extent is still a challenging issue. Quantitative myocardial perfusion echocardiography (MPE) with parametric imaging (PI) and gray scale (GS) has been shown to accurately measure infarcted area in animals, but not in human beings. We sought to validate MPE quantification of transmural extent and size of AMI using magnetic resonance imaging (MRI) as a gold standard. Twenty patients (12 men, 64 +/- 13 years) underwent MPE and MRI between the second and fifth day post-AMI. Infarct area and location, number of involved segments, and transmural extent in each segment were determined by PI using beta value and GS. Results were compared with late enhanced MRI. There was 99% agreement between both methods regarding the segmental location. The correlation between infarct area by MRI and GS was 0.82 (P < .001) whereas MRI and beta PI was 0.92 (P < .001). The correlation between transmural extent by MRI and GS was 0.77 (P < .001), and between MRI and beta PI was 0.93 (P < .001). There was a good correlation between MPE, in special beta PI, with MRI in measuring infarcted area and its transmural extent in patients with AMI.

To determine the safety and cardiac chronotropic responsiveness to early atropine dobutamine stress echocardiography (DSE) in the elderly. Retrospective study of 258 patients >or= 70 years who underwent early atropine DSE and 290 patients >or= 70 years who underwent conventional DSE. In the early atropine protocol, atropine was started at 20 microg/kg/min of dobutamine if heart rate was < 100 beats/min, up to 2 mg. The cardiac chronotropic responsiveness in the elderly was compared with a control group of patients < 70 years matched for sex, myocardial infarction, diabetes, and treatment with beta blockers and calcium channel blockers. The dose of dobutamine given to elderly patients was lower during early atropine than during conventional DSE (mean (SD) 29 (7) v 38 (4) microg/kg/min, p = 0.001). Early atropine DSE resulted in diminished incidence of ventricular extrasystoles, non-sustained ventricular tachycardia, bradycardia, and hypotension compared with conventional DSE. In comparison with patients < 70 years, elderly patients required lower doses of dobutamine and atropine and achieved a higher percentage of predicted maximum heart rate (92 (9)% v 88 (10)%, p = 0.0001). Except for more common hypotension (16% v 10%, p = 0.004), no other difference in adverse effects was observed between patients >or= 70 and < 70 years. Early atropine DSE is a safe strategy in the elderly resulting in lower incidence of minor adverse effects than with the conventional protocol. Elderly patients presented adequate cardiac chronotropic responsiveness to early injections of atropine, requiring lower doses of drugs to reach test end points.

International Society of Cardiovascular Ultrasound in cooperation with ... 1 DIFFERENT CLINICAL FEATURES OF AORTIC INTRAMU-RAL HEMATOMA VERSUS DISSECTION INVOLVING THE DE-SCENDING THORACIC AORTA F. Mariano, O. Pablo, C. Vicente, D. Alberto, B. ...

ABSTRACT Background: The extent of myocardial salvage after acute myocardial infarction (AMI) treated with thrombolysis or percutaneous transluminal coronary angioplasty is variable and cannot be predicted based on either vessel patency or early regional wall motion assessment. Aim: To evaluate the predictor value of myocardial contrast echocardiography (MCE) using intermittent second harmonic imaging, in left ventricular remodeling and regional contractile function at rest and under stress during the first 48 hour after first anterior wall AMI treated with successful thrombolysis or angioplasty. Methods: We studied 31 patients with mean age 64 ± 12 years, 20 men. MCE was performed 34 hour, 5.5 days and 36 days after AMI, and evaluation of the change in left ventricular volumes and regional function was done in 6 months, using MCE at rest and dobutamine-atropine stress. In order to analyze the contraction and myocardial perfusion, left ventricular wall motion score index (WMSI) and myocardial perfusion score index (MPSI) were calculated using a 16-segment model. Patients were divided into two groups: ventricular remodeling group (RG)—20% increase in left ventricular end-diastolic and end-systolic volumes (19 patients) - and no ventricular remodeling group (NRG) (12 patients). patients were also classified according to the number of no-contrast opacification myocardial segments observed in the first MCE: reflow up to 2 segments and no reflow over 2 segments. Results: In the first echocardiography, no statistical difference was observed between groups regarding left ventricular volumes and ejection fraction, but WMSI (p = 0.049), MPSI (p = 0.006) and the number of no-contrast opacification myocardial segments (p = 0.018) were higher in RG. Left ventricular end-diastolic and end-systolic volumes and WMSI increased significantly (p < 0.001) in the GR from the first echo to that at 6 months follow-up, and decreased (p < 0.001) in the NRG. Left ventricular ejection fraction decreased in the RG (p < 0.001) and increased in the NRG (p < 0.001). There was a significant increase in the MPSI in the RG between the first echo and that at 36 days follow-up (p = 0.011). Logistic regression analysis showed that only the MPSI was an independent predictor of left ventricular remodeling (odds ratio of 1.8, p = 0.010). Twenty-eight patients performed dobutamine stress echocardiography, of whom 15 were no reflow and 13 patients were Reflow. Only 27.8 ± 19.9% of the anterior wall myocardial segments had functional recovery or contractile reserve at 6 months follow-up in no reflow patients, whereas, in reflow patients, 69.9 ± 31,2% of the anterior wall myocardial segments had functional recovery or contractile reserve (p < 0.001). Conclusion: Left ventricular MPSI analyzed at first 48 h after the anterior wall AMI treated with successful thrombolysis or angioplasty is an independent predictor of left ventricular remodeling. Moreover, patients with a maximum of 2 no-contrast opacification myocardial segments by MCE revealed a higher percentage of myocardial segments with functional recovery or contractile reserve.

ABSTRACT The aim of this study was to assess the accuracy of real-time myocardial contrast perfusion imaging (MCPI) during dobutamine stress in the diagnosis and localization of coronary artery disease (CAD) in patients with diabetes. Myocardial contrast echocardiography is a new technique that allows evaluation of myocardial perfusion. Its utility in diabetic patients has not been defined. Dobutamine-atropine stress test was performed in conjunction with MCPI using Optison or Definity at rest and at peak stress in 128 patients with diabetes and suspected CAD who underwent coronary angiography within 1 month. CAD was defined as > or =50% stenosis in one or more coronary artery. MCPI was considered diagnostic of CAD in the presence of reversible perfusion abnormalities. The normalcy rate of MCPI was additionally determined in 18 asymptomatic nondiabetic patients with low probability. CAD was detected in 101 (79%) patients by angiography. Reversible perfusion abnormalities were detected in 90 patients with and 13 patients without CAD. The overall sensitivity of MCPI was 89% (95% CI 83-95), specificity 52% (33-71), and accuracy 81% (75-88). Reversible abnormalities were detected in two or more vascular distributions in 44 of 56 patients with multivessel CAD and in 8 of 63 patients without (sensitivity 68%, specificity 87%, positive predictive value 84%, and accuracy 79%). Regional sensitivity was 75% (65-85) for left anterior descending CAD, 71% (60-83) for left circumflex, and 67% (55-78) for right CAD. MCPI was normal in 16 of the 18 patients with low clinical probability of CAD (normalcy rate 89%). MCPI is a useful noninvasive technique for the diagnosis and localization of CAD in diabetic patients. The extent of perfusion abnormalities can identify patients with multivessel CAD with a moderate sensitivity and high specificity.

Hypertensive microvascular disease is speculated to be a limiting factor for the ability of left ventricular (LV) hypertrophy to maintain LV systolic function in systemic hypertension. The role of coronary reserve, which may be affected by microvascular disease, remains uncertain in the pathophysiology of hypertensive heart disease. A progressive impairment of coronary flow velocity reserve (CFVR) according to the presence and severity of LV systolic dysfunction is anticipated to occur in hypertension. According to the absence or presence of LV dysfunction (LV fractional shortening - FS% < 30), two groups of hypertensive patients were investigated: HP1 (n = 9, FS% = 36+/-6) and HP2 (n = 13, FS% = 18+/-6). Eight normal subjects (NL) served as controls (LVFS% = 35+/-3). Doppler blood flow velocity was obtained from the left anterior descending coronary artery using transesophageal echocardiography before, and during 6-min continuous adenosine infusion (140 microg x kg(-1) x min(-1) intravenous). The CFVR was calculated as the ratio of maximal to baseline peak diastolic flow velocities. The comparison among NL, HP1, and HP2 groups showed statistically different (p < 0.05) mass index (101+/-18, 172+/-46, and 257+/-54 g x m(-2)), end-systolic wall stress (76.9+/-14.4, 78.4+/-23.9, and 174.5+/-43.0 10(3) x dyn x cm(-2)), and CFVR (3.5+/-0.6, 3.2+/-0.4, and 2.6+/-0.8), respectively. The CFVR correlated significantly and directly with LVFS% (r = 0.40) and correlated inversely with both mass index (r = -0.54) and end-systolic stress (r = -0.40). These results indicate that CFVR impairment is weakly related to LV dysfunction in hypertension.

Perfluorocarbon-exposed sonicated dextrose albumin (PESDA) microbubbles bind the antisense to the c-myc protooncogene (anti-c-myc) which prevents neointimal hyperplasia following vascular endothelial injury. The microbubbles also adhere to sites of damaged vascular endothelium and thus may be a method of systemically targeting delivery of anti-c-myc. Laser scanning microscopy was performed on the aorta of 10 mice (five which were complement depleted) that received intravenous FITC-PESDA following aortic endothelial injury. C-myc expression was quantified following selective intracoronary injury in nine pigs that received intravenous (IV) anti-c-myc bound to PESDA. Finally, neointimal formation was measured following intracoronary stent deployment in 30 pigs that received either IV anti-c-myc alone or the same dose bound to PESDA. Fluorescent microscopy confirmed selective PESDA microbubble adherence to aortic endothelium in all mice with aortic injury. This binding was nearly abolished when serum complement was depleted prior to injury. C-myc expression at the site of coronary endothelial injury was significantly lower in pigs treated with systemic anti-c-myc bound to PESDA. There was a 33% reduction in % stenosis and a 28% reduction in intimal area at 45 days post-stent deployment in pigs that received IV antisense plus PESDA. The stent margins also had reduced neointimal formation. Systemic administration of anti-c-myc bound to PESDA microbubbles may be a good method for preventing coronary neointimal formation within and around implanted stents.

Exercise training has been shown to be effective in improving exercise capacity and quality of life in patients with heart failure and left ventricular (LV) systolic dysfunction. Real-time myocardial contrast echocardiography (RTMCE) is a new technique that allows quantitative analysis of myocardial blood flow (MBF). The aim of this study was to determine the effects of exercise training on MBF in patients with LV dysfunction. We studied 23 patients with LV dysfunction who underwent RTMCE and cardiopulmonary exercise testing at baseline and 4 months after medical treatment (control group, n = 10) or medical treatment plus exercise training (trained group, n = 13). Replenishment velocity (beta) and MBF reserves were derived from quantitative RTMCE. The 4-month exercise training consisted of 3 60-minute exercise sessions/week at an intensity corresponding to anaerobic threshold, 10% below the respiratory compensation point. Aerobic exercise training did not change LV diameters, volumes, or ejection fraction. At baseline, no difference was observed in MBF reserve between the control and trained groups (1.89, 1.67 to 1.98, vs 1.81, 1.28 to 2.38, p = 0.38). Four-month exercise training resulted in a significant increase in beta reserve from 1.72 (1.45 to 1.48) to 2.20 (1.69 to 2.77, p <0.001) and an MBF reserve from 1.81 (1.28 to 2.38) to 3.05 (2.07 to 3.93, p <0.001). In the control group, beta reserve decreased from 1.51 (1.10 to 1.85) to 1.46 (1.14 to 2.33, p = 0.03) and MBF reserve from 1.89 (1.67 to 1.98) to 1.55 (1.11 to 2.27, p…