Showing papers by "José Luis Zamorano published in 2002"

Reason for discrepancies in identifying myocardial viability by thallium-201 redistribution, magnetic resonance imaging, and dobutamine echocardiography.

Abstract: Dobutamine echocardiography (DE), magnetic resonance imaging (MRI), and thallium redistribution (TS) are used to assess cardiac viability. However, these modalities sometimes yield contradictory results. Our aim was to establish the degrees of agreement among DE, MRI, and TS in identifying myocardial viability and to analyze the minimum critical mass of live (viable) cells required for each test to identify viability. A prospective study was done in which DE, MRI, and TS were consecutively performed in 10 ischemic patients scheduled for heart transplantation. The explanted heart was analyzed to quantify the amount of live cells per segment. The pathologic data were compared with the test results to analyze the minimum mass of viable cells required by each technique to identify viability. Mean age was 58 ± 8 years (8 men). The mean ejection fraction was 0.27 ± 0.04. Seven patients had severe cardiac failure (New York Heart Association functional class IV) and 6 patients had refractory angina. A total of 150 cardiac segments were analyzed. Among the 150 segments, 107 (71.3%) showed some degree of myocardial necrosis. Mean total area, mean fatty area, and mean necrotic area per segment were 2.53 ± 0.7, 0.13 ± 0.2, and 0.55±0.5 cm 2 , respectively. As expected, a higher amount of necrotic tissue was found in nonviable segments. From the 150 segments, DE identified 90 as viable and 60 as nonviable. These data were similar to that of MRI (98 viable and 52 nonviable). A higher proportion of viable segments was found by TS (117 viable vs 33 nonviable). The concordance between DE and TS was only moderate (κ 0.49). The agreement between MRI and TS also showed moderate concordance (κ 0.56). The highest agreement was found between DE and MRI (κ 0.73). Thus, discrepancies in assessing viability by DE, MRI, and TS may be due to differences in the minimum critical mass of live myocytes required by each technique to diagnose viability. Thallium requires a lesser amount of live tissue than DE or MRI to detect viability; also, its maximum diagnostic efficiency is obtained with lesser amounts of live tissue on each segment. These considerations should be taken into account when these diagnostic tests are used for the detection of viability before revascularization procedures.

Influence of diabetes mellitus on short- and long-term outcome in patients with active infective endocarditis.

Abstract: BACKGROUND AND AIM OF THE STUDY The incidence and severity of certain infections appear to be increased in patients with diabetes mellitus (DM). The study aim was to evaluate the effect of DM on short- and long-term outcome in patients with active infective endocarditis (IE). METHODS A total of 151 patients with IE was included and followed up for a mean of 3.1 years. Of these patients, 13 (9%) were diabetics. The outcome of patients with or without DM was compared at short-term (in-hospital) and long-term follow up. RESULTS Patients with DM were older (66 +/- 11 versus 50 +/- 19 years, p < 0.01) and had a lower frequency of intravenous drug abuse (0 versus 30%, p <0.01) and tricuspid valve involvement (0 versus 20%, p = 0.02) than non-DM patients. Mortality was higher in DM patients both in hospital (31% versus 15%, p = NS) and at a mean follow up of 3.1 years (54% versus 31%, p = 0.002). DM patients also had a significantly higher rate of cardiac failure (69% versus 38%, p = 0.03) and renal failure (62% versus 20%, p <0.01) during hospitalization. Incidences of anatomic complications (abscess, pseudoaneurysm) (15.4% versus 20.3%), valve rupture or perforation (7.7% versus 16.7%) and need for surgical repair (46.2% versus 45.7%) were similar in both DM and non-DM patients. DM, without secondary pathology like renal failure, did not appear to be an independent risk factor for mortality at either short- or long-term follow up. CONCLUSION Although mortality and morbidity in IE were greater in DM than in non-DM patients, diabetes itself does not constitute an independent risk factor.

Better prognosis of elderly patients with infectious endocarditis in the era of routine echocardiography and nonrestrictive indications for valve surgery.

Abstract: Objective: It has been reported that endocarditis in the elderly may have a poor outcome. Our aim was to assess the different features and prognosis, if any, in the present time. Methods: Of 103 patients with proven endocarditis, 31 were 65 years or older and 72 were younger than 65 years. Degenerative heart disease was seen more frequently in the elderly (22.5% vs 2.7%, P =.003). Drug abuse and immunodeficiency virus infection were more common in the younger group, as was tricuspid endocarditis (26.3% vs 0%, P P =.02) and leukocytosis (61.2% vs 40.2%, P =.049) were seen more frequently in the elderly. Results: Despite other similar clinical features, it took longer to diagnose older patients (7.2 ± 6.2 vs 3.2 ± 3.5 days, P Enterococcus infected the aged more often (32.2% vs 13.1%, P =.001). During hospitalization, heart failure and embolization tended to be more common in the elderly and the younger group, respectively. There were no significant differences in the incidence of anatomic complications, the need for operation, and overall mortality. Conclusion: Although a worse prognosis has been reported in elderly patients with infective endocarditis, the early use of transesophageal echocardiographic examinations and equal therapeutic options provides a similar outcome when compared with younger subjects. (J Am Soc Echocardiogr 2002;15:702-7.)

Espasmo coronario tras infusión de propranolol durante un ecocardiograma de estrés con dobutamina

Abstract: Dobutamine stress echocardiography, a highly useful and safe challenge test for myocardial ischemia, is being used increasingly We report the case of a 37-year-old man with rest angina, repolarization abnormalities in precordial leads and normal coronary arteries who was referred for dobutamine-atropine stress echocardiography, which was negative for ischemia However, after testing, upon injection of propranolol, the patient suffered chest pain associated with ST elevation and severe regional systolic abnormalities After intravenous nitroglycerin administration, chest pain and electrocardiographic abnormalities disappeared quickly, and systolic motion became normal This complication was interpreted as a coronary spasm We discuss the causes for the spasm and the role that might have been played by the drugs employed

Ecocardiografía de estrés en el preoperatorio de cirugía vascular: ¿son comparables los resultados con dipiridamol y dobutamina?

Abstract: Introduction. Perioperative cardiovascular complications are an important cause of post-surgical morbility and mortality in patients undergoing major vascular surgery. Dobutamine Stress Echo is considered one of the methods of choice in the detection of coronary artery disease in this subgroup of patients. Objectives. Our aim was to analyze if dipyridamole stress echocardiography could be used as an alternative to Dobutamine Stress Echo in the perioperative evaluation of patients in need of major vascular surgery. Patients and method. The result of consecutives dypiridamole and dobutamine stress exams prior to vascular surgery were reviewed. We analyzed if those patients with a positive stress echo presented a higher number of cardiac events during and after surgery than those with negative stress echo. The negative and positive predictive values were calculated for both techniques. Results. 133 stress exams were analysed: 39 with dobutamine and 94 with dipyridamole. Of the 39 dobutamine studies 2 were positive, 29 negatives and 8 non conclusive. Of the 94 dypiridamole studies 13 were positive and 81 negatives. None of the patients with a positive dobutamine echo underwent surgery. The negative predictive value for dobutamine echo was 96.5%, quite similar to that of dypiridamole stress echo (97.5%). Conclusion. Dipyridamole stress echocardiography is a valid alternative to dobutamine echocardiography in the pre-surgical evaluation of patients undergoing major vascular surgery.

Rotura de la pared libre del ventrículo izquierdo durante prueba de estrés con dobutamina

Abstract: Dobutamine stress echocardiography is associated with a very low rate of serious complications, lower than 0.5% (death, infarction or sustained ventricular tachycardia). We report the case of a 75 year-old female patient that suffered a fatal left ventricular free wall rupture during a dobutamine stress echocardiography after acute myocardial infarction.

Contrast agents provide a faster learning curve in dipyridamole stress echocardiography.

Abstract: Aim: Interobserver variability is an important limitation of the stress echocardiography and depends on the echocardiographer training. Our aim was to evaluate if the use of contrast agents during dipyridamole stress echocardiography would improve the agreement between an experienced and a non-experienced observer in stress echo and therefore if contrast would affect the learning period of dypyridamole stress echo. Methods and results: Two independent observers without knowledge of any patient data interpreted all stress studies. One observer was an experienced one and the other had experience in echocardiography but not in stress echo. Two observers analysed 87 non-selected and consecutive studies. Out of the 87 studies, 46 were performed without contrast administration, whereas i.v. contrast (2.5 g Levovist® by two bolus at rest and at peak stress) was administered in 41. In all cases, second harmonic imaging and stress digitalisation pack was used. The agreement between observers showed a κ index of 0.58 and 0.83 without and with contrast administration, respectively. Conclusions: The use of contrast agents provides a better agreement in the evaluation of stress echo between an experienced and a non-experienced observer in stress echo. Adding routinely contrast agents could probably reduce the number of exams required for the necessary learning curve in stress echocardiography.

Perioperative mortality and long-term outcome of infective endocarditis.

Abstract: Introduction and objectives: Infective endocarditis (IE) is a disease with a high morbidity and mortality during the active phase and a considerable risk of complications during follow-up. The aim of this study is to describe the clinical features of IE associated with perioperative mortality in patients undergoing surgery and the short-and long-tern prognosis of this disease after surgical treatment. Patients and methods: The clinical files of 150 patients (pts) admilted to our institution between 1989 and 2001 and whose final diagnosis was IE (Duke criteria) were retrospectively reviewed. Thus all patients included underwent at least 1 transthoracic examination, and a transesophageal examination if indicated. The study population was 69 patients i with IE, 62 of whom (90 %) underwent prosthetic valve replacement and 7 (10 %) underwent explantation of pacemaker electrocatheter. In the statistical analysis, quantitative variables are expressed as means′SD and qualitative variables as proportions (percentages). Differences in survival were determined using the Kaplan-Meier log rank method. Associations were considered statistically significant when the p value was <0.05. Results: The mean age was 56′15 years. Thirty-five cases (51 %) had prosthetic valve endocarditis, 30 (39 %) had native valve IE and 7 (10 %) pacemaker electrocatheter IE. Fifty-two patients (75 %) had positive blood cultures. The most frequent agents were S. epidermidis (14.%), S. aureus (14.5 %), Enterococci (13 %) and S. viridans (10%). Total perioperative mortality was 17.4 % (n=12), and surgical mortality was 19.4 %. Our study shows a statistical tendency for higher mortality in diabetic patients (50 % vs. 14 %, p=0.052) and in women (29 % vs, 11 %, p=0.065). In multivariate analysis, the presence of heart failure was an independent predictor of perioperative mortality (OR=11.4; 95 % CI: 2.0-215.2; p=0.024). Accumulated mortality in the first year was 28 % and 5-year mortality was 48 %. Conclusions: Prosthetic valve replacement in patients with IE is associated with high perioperative mortality (17.4 %). Despite good early postoperative results, the mortality rate increases during the first year as well as the need for reoperation.

New imaging techniques in the assessment of patients with aortic stenosis.

Abstract: Currently, conventional Doppler echocardiography is the noninvasive diagnostic technique to be used in the evaluation of the vast majority of patients with aortic stenosis. However, several more recent imaging techniques are being progressively introduced in the cardiologist's diagnostic armamentarium. Some of these techniques may offer additional information that could be of help in some patients with aortic stenosis.

Value of automated segmental motion analysis in the assessment of aortic stenosis severity.

Abstract: BACKGROUND AND AIMS OF THE STUDY Left ventricular (LV) contraction is slowed in patients with aortic stenosis (AS). Although the possible role of LV systolic function abnormalities in the assessment of AS severity has been evaluated, current echocardiographic techniques cannot offer precise quantification of LV motion velocity. The study aim was to evaluate an automated segmental motion analysis (ASMA) system to assess AS severity. METHODS Twenty-two patients with AS, sinus rhythm and preserved LV ejection fraction were studied prospectively. Patients underwent both conventional Doppler echocardiography to measure transaortic gradient and aortic valve area by the continuity equation, and ASMA of the interventricular septum. The ASMA line graph mode displays changes in area through the cardiac cycle. The RR interval and time from the R-wave to peak maximum area shortening were measured, and an ASMA index was calculated. RESULTS A significant and strong inverse correlation was found between aortic valve area and ASMA index (r = -0.78; 95% CI -0.90 to -0.55; p 0.40 were 100, 91.7, 92.3, 100 and 95.8%, respectively. CONCLUSION The ASMA system may be valuable in evaluating AS, as it offers a strong correlation with aortic valve area calculated by the continuity equation, and very high sensitivity and specificity in the diagnosis of severe AS.