Transesophageal Echocardiography Screening in Subjects with a First Cerebrovascular Ischemic Event.
J Stroke Cerebrovasc Dis. 2010 Aug 31;
Authors: Young KC, Benesch CG
Our goal was to develop decision guides to predict the presence of a high-risk source of embolus and to predict a change in management following transesophageal echocardiography (TEE) in subjects who present with a first cerebral ischemic event. We conducted a retrospective review of subjects age >/=18 years who underwent TEE after a first ischemic event and were admitted to our stroke service between 2004 and 2007 (n = 287). A high-risk source of embolus and a change in clinical management (including medication changes or subsequent testing) were analyzed as separate endpoints, using multivariate techniques and receiver operating characteristic curves. We found that 14.3% of the subjects had a high-risk source, and an additional 61.3% had a potential (or low-risk) source of embolus. Increasing age and no history of diabetes mellitus were independently associated with a high-risk source of embolus. TEE would be recommended for nondiabetic individuals age >/=66 years (sensitivity, 68%; specificity, 76%). The area under the curve (AUC) for detecting a high-risk source was 0.773. TEE results changed medications or clinical management in 30.3% of the subjects. Current smokers were less likely to undergo a change in management. The AUC was uninformative (0.56) for predicting changes in management. Subjects presenting with a first ischemic event age >/=66 years may benefit from TEE. Although changes in management occurred in at least 30% of our cohort, no factors that predicted a change in management better than chance alone could be identified.
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Comparison of Computed Tomography Angiography and Transesophageal Echocardiography for Evaluating Aortic Arch Disease.
J Stroke Cerebrovasc Dis. 2010 Aug 31;
Authors: Barazangi N, Wintermark M, Lease K, Rao R, Smith W, Josephson SA
Aortic arch (AA) atheroma is a common source of artery-to-artery embolism. Identification of AA atherosclerotic disease is an important component of the embolic stroke workup. Transesophageal echocardiography (TEE) is the gold standard for AA evaluation, but it has associated risks and is not always readily available. Computed tomography angiography (CTA) is a rapid and noninvasive alternative. This study was conducted to compare the sensitivity and specificity of CTA and TEE for detecting AA disease. We performed a retrospective review of 250 consecutive patients at a tertiary stroke center who underwent both TEE and CTA within a 90-day period. We compared the presence and characteristics of AA plaques using a predetermined grading system for plaques in the ascending, transverse, and descending arch for both modalities (grades 1-4). Out of 750 AA segments (ascending, transverse, and descending AA in 250 patients), 494 were adequately imaged by CTA and TEE. The sensitivity of CTA in detecting grade 1-4 AA atheromas was 53%, and the specificity was 89%. For only high-grade atheromas, the specificity improved to 99%, but the sensitivity decreased to 23%. The negative predictive value of CTA for detection of AA atheromas was 60% (range 54%-65%) for all grades and 95% (range 92%-96%) for high-grade atheromas. CTA has a high negative predictive value for AA atheromas, especially for higher-grade atheromas, and thus may be a useful screening tool to exclude high-grade plaques, indicating a possible complementary role for CTA in detecting AA atheromas.
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Negative predictive value of normal adenosine-stress cardiac MRI in the assessment of coronary artery disease and correlation with semiquantitative perfusion analysis.
J Magn Reson Imaging. 2010 Sep;32(3):615-21
Authors: Pilz G, Eierle S, Heer T, Klos M, Ali E, Scheck R, Wild M, Bernhardt P, Hoefling B
PURPOSE:: To prospectively determine the negative predictive value of normal adenosine stress cardiac MR (CMR) in routine patients referred for evaluation of coronary artery disease (CAD), predominantly with intermediate to high pretest risk. MATERIALS AND METHODS:: Consecutive patients referred for coronary angiography were examined in a 1.5 Tesla whole-body scanner before catheterization. A total of 158 patients with normal CMR on qualitative assessment were included, and semiquantitative perfusion analysis was performed. Significant CAD was regarded as luminal narrowing of >/=70% in coronary angiography. RESULTS:: In the 158 study patients, negative predictive value of normal adenosine-stress CMR for significant CAD was 96.2% (for stenosis >/=90%: 98.1%). True-negative and false-negative patients were comparable regarding clinical presentation, risk factors, and CMR findings. Semiquantitative perfusion analysis gave significantly prolonged arrival time index and peak time index in the false-negative group. Using cutoff values >1.8 for arrival time index or >1.2 for peak time index, the CMR negative predictive value increased to 98.7% (for stenosis >/=90%: to 100%). CONCLUSION:: The very high negative predictive value for CAD supports CMR-based decision making for the indication to coronary angiography. Semiquantitative perfusion analysis seems promising to identify the small group of CAD patients not detectable by qualitative CMR assessment. J. Magn. Reson. Imaging 2010;32:615-621. (c) 2010 Wiley-Liss, Inc.
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Familial amyloidotic polyneuropathy with muscle, vitreous, leptomeningeal, and cardiac involvement: Phenotypic, pathological, and MRI description.
Ann Indian Acad Neurol. 2010 Apr;13(2):142-4
Authors: Prashantha DK, Taly AB, Sinha S, Yasha TC, Gayathri N, Kovur JM, Vijayan J
Familial amyloidotic polyneuropathy (FAN type 1) is a rare systemic disease that causes severe and disabling peripheral neuropathy. We describe the phenotypic, radiological, and pathological characteristics of a patient with familial amyloid polyneuropathy type 1 who had evidence of motor-sensory-autonomic neuropathy, ocular vitreous deposits, diffuse leptomeningeal involvement, and hypertrophic cardiomyopathy. Muscle involvement, an infrequently reported feature, was also observed. Early recognition of the disease has significant therapeutic implications.
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Differences of Myocardial Systolic Deformation and Correlates of Diastolic Function in Competitive Rowers and Young Hypertensives: A Speckle-Tracking Echocardiography Study.
J Am Soc Echocardiogr. 2010 Aug 30;
Authors: Galderisi M, Lomoriello VS, Santoro A, Esposito R, Olibet M, Raia R, Dario Di Minno MN, Guerra G, Mele D, Lombardi G
BACKGROUND: The aim of this study was to compare speckle-tracking echocardiography-derived left ventricular (LV) systolic mechanics and their relationships with LV diastolic properties in young patients with hypertension and in young competitive athletes in relation to their respective alterations of LV structure. METHODS: Nineteen sedentary controls, 22 top-level rowers, and 18 young newly diagnosed, never-treated patients with hypertension, all male, underwent Doppler echocardiography including pulsed tissue Doppler of the mitral annulus and speckle-tracking echocardiography. Peak longitudinal strain was calculated in apical long-axis, four-chamber, and two-chamber views, and values of the three views were averaged (global longitudinal strain [GLS]). Regional circumferential and radial strain were calculated at the LV basal, middle, and apical levels, and values were averaged (global circumferential strain and global radial strain). LV torsion was determined as the net difference in the mean rotation between the apical and basal levels. RESULTS: The three groups were comparable for age, whereas body mass index and blood pressure were higher in patients with hypertension, and heart rate was lower in rowers. LV mass index was higher in rowers and in patients with hypertension than in controls, without differences in relative wall thickness, ejection fraction, and midwall shortening. Left atrial volume index was greater in rowers than in controls and patients with hypertension. Annular systolic velocity (s’) (P < .001) and early diastolic velocity (e') (P < .0001) were lower and the E/e' ratio was higher (P < .0001) in patients with hypertension. GLS was lower in patients with hypertension (-17.5 +/- 2.8%) than in rowers (-22.2 +/- 2.7%) and in controls (-21.1 +/- 2.0%) (P < .0001). Global circumferential strain, global radial strain, and torsion were similar among the three groups. In the pooled population, GLS was an independent contributor to E/e' ratio (P < .0001) after adjusting for age, heart rate, meridional end-systolic stress, LV mass index and left atrial volume index. By receiver operating characteristic curve analyses, both GLS and E/e' ratio appeared to be accurate in discriminating patients with hypertension from healthy controls, with the E/e' ratio being more sensitive (77.8%) and GLS more specific (89.5%). CONCLUSIONS: The hearts of young patients with hypertension are characterized by reduced GLS, whereas global circumferential strain, global radial strain, and torsion are similar to those of athletes' hearts. The extent of GLS is strongly associated with LV diastolic function, independently of afterload changes and the degree of LV hypertrophy.
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