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Biomedical subjects

I Vilacosta

Publications and source records attributed to I Vilacosta.

At least 37 records · Page 2Linked to original sources
PubMed1998

Penetrating atherosclerotic aortic ulcer: documentation by transesophageal echocardiography.

OBJECTIVES: This study sought to describe the ability of transesophageal echocardiography (TEE) to document the presence of penetrating atherosclerotic aortic ulcers and their complications. BACKGROUND: TEE has greatly enhanced our ability to assess patients with suspected aortic disease. However, the utility of this technique in the diagnosis of penetrating atherosclerotic aortic ulcers is still undefined. METHODS: TEE was performed prospectively in 194 patients to evaluate aortic disease. Twelve patients with the diagnosis of aortic ulcers or their complications were specifically studied. The diagnosis was confirmed by pathologic studies in six patients and by an additional diagnostic technique (angiography, computed tomography or magnetic resonance imaging) in the other six. All 12 patients were hypertensive and presented with chest or back pain; the mean age was 65 years (range 56 to 79). The initial working diagnosis was acute aortic dissection in nine patients. Aortic ulcers were located in the descending thoracic aorta in eight patients, the aortic arch in two and the ascending aorta in two. RESULTS: TEE could detect aortic ulcers or their complications in 10 patients but failed to detect these lesions in the remaining 2 (1 with aortic ulcers in the distal ascending aorta and 1 with aortic ulcers in the aortic arch). In four patients, aortic ulcers were detected as a calcified focal outpouching of the aortic wall and were associated with concomitant aneurysmal dilation of the aorta in two patients and with a small localized intramural hematoma in one. TEE visualized a partially thrombosed pseudoaneurysm complicating an aortic ulcer in the descending thoracic aorta of two patients. Four patients had an aortic ulcer complicated by a "limited aortic dissection" in the descending aorta that could be detected by TEE. Five patients underwent operation, two because of aneurysmal dilation of the aorta and three because of aortic dissection; two patients died of aortic rupture; the remaining five did well (11-month follow-up) without operation. CONCLUSIONS: Aortic ulcers should be included in the differential diagnosis of chest or back pain, especially in elderly hypertensive patients. These ulcers and their complications may be recognized by TEE.

Aged↗
PubMed1998

Primary mycotic aneurysm of the ascending aorta diagnosed by transesophageal echocardiography.

Primary mycotic aneurysms are rare, and they can be difficult to diagnose before rupture. Early diagnosis is the cornerstone to effective management. Preoperative diagnosis has traditionally involved angiography and computed tomography. We report a case of Staphylococcus aureus aortitis with an aortic wall abscess and posterior pseudoaneurysm formation involving the ascending aorta in which transesophageal echocardiography was fundamental in diagnosis and patient management.

Abscess↗
PubMed1998

Prevalence and relevance of a septal diastolic notch during dobutamine stress echocardiography.

BACKGROUND: Dobutamine stress echocardiography has become an accepted simple and inexpensive method of detecting coronary artery disease. In this pharmacological stress test, particular attention has been paid to transient systolic wall motion abnormalities. Our group has noted an abnormal diastolic ventricular septal motion, a 'diastolic notch', during dobutamine stress echocardiography that has not been previously described. METHODS AND RESULTS: To find out whether this anomalous septal motion is related to coronary artery disease we have analysed the stress studies of 125 patients (69 men, age 61 +/- 9 years) with chest pain, no previous myocardial infarction and no left bundle branch block, who underwent a dobutamine stress test. Dobutamine was infused up to 40 mu.kg.l-1 min-1 in 3 min stages. A positive stress test was defined as the appearance of transient asynergy. Dobutamine time was the time from the infusion of dobutamine to the appearance of transient asynergy. The diastolic notch time was the time at which diastolic notch was first detected. Diastolic notch was detected in 21 patients with single coronary artery disease, 19 of whom had a severe left anterior descending artery stenosis. Diastolic notch was present in 19 out of 27 patients (70%) with single left anterior descending stenosis. Twenty-six out of 44 patients with multivessel coronary artery disease had evidence of a diastolic notch and 20 of these 26 had severe stenosis of the left anterior descending artery. Finally, all three patients with left main coronary artery disease had a diastolic notch while no patient with angiographically normal coronary arteries had this sign. In patients with a diastolic notch and a positive dobutamine stress test, diastolic notch time was shorter than dobutamine time (9 +/- 4 min vs 11 +/- 3 min, P < 0.05). CONCLUSIONS: In patients without previous myocardial infarction and without left bundle branch block (1) the appearance of a septal diastolic notch during dobutamine stress echocardiography is very specific for the presence of coronary artery disease; (2) the detection of diastolic notch is mostly related to the existence of severe left anterior descending artery stenosis; (3) diastolic notch precedes the development of ventricular asynergy.

Aged↗
PubMed1998

Selection of the optimal stress test for the diagnosis of coronary artery disease.

OBJECTIVE: To compare the value and limitations of exercise testing, dipyridamole echocardiography, dobutamine-atropine echocardiography, and MIBI-SPECT (technetium-99m methoxyisobutyl nitrile single photon emission computed tomography) during dobutamine infusion in the diagnosis of coronary artery disease. DESIGN: The performance of these four tests was assessed in random order on a consecutive cohort of patients. The presence or absence of coronary artery disease was confirmed by coronary angiography. SETTING: Two tertiary care and university centres. PATIENTS: 102 consecutive patients with chest pain and no previous history of coronary artery disease. Ten patients with left bundle branch block were excluded for further analysis of exercise testing and scintigraphy results. RESULTS: MIBI-SPECT was the most sensitive (87%) but the least specific test (70%). Exercise stress testing had a sensitivity of 66%, which increased to 80% when patients with inconclusive results were excluded. Dipyridamole and dobutamine echocardiography had similar sensitivity (81%, 78%) and specificity (94%, 88%). All four tests had similar accuracy and positive and negative predictive values. Agreement between the echocardiographic techniques was excellent (detection of coronary artery disease 87%, kappa = 0.72; regional analysis 93%, kappa = 0.72; diagnosis of the "culprit" vessel 95%, kappa = 0.92), and it was good between echocardiographic techniques and MIBI-SPECT (diagnosis of the culprit vessel 90%, kappa = 0.84 with dobutamine and 92%, kappa = 0.85 with dipyridamole). CONCLUSIONS: Exercise stress testing has a sensitivity comparable to other tests in patients capable of exercising and with no basal electrical abnormalities. The greatest sensitivity is offered by MIBI-SPECT and the greatest specificity is obtained with stress echocardiography. Redundant information is obtained with dipyridamole echocardiography, dobutamine echocardiography, and MIBI-SPECT.

Adrenergic beta-Agonists↗
PubMed1998

[MIBI-echocardiography with dobutamine: Significance of changes of contractility in patients with changes in perfusion].

BACKGROUND AND OBJECTIVES: In the presence of coronary artery disease and with an appropriate stressor, perfusion defects precede contractility abnormalities. Perfusion defects without contractility abnormalities may be due to the absence of ischemia or mild ischemia. Our purpose has been to compare the clinical characteristics, hemodynamic response and severity of perfusion defects in patients with coronary artery disease and perfusion defects with and without wall motion abnormalities during dobutamine infusion. PATIENTS AND METHODS: Eighty two patients with significant coronary artery disease demonstrated by angiography without previous myocardial infarction underwent dobutamine infusion (up to 40 mg/kg/min). Atropine was given when necessary. Stress scientigraphic MIBI-SPECT images were acquired 1 hour after peak stress and rest studies were obtained 24 hours after stress testing. The perfusion score was calculated by dividing the total uptake score between the number of segments affected. RESULTS: Among the 73 patients with perfusion defects, stress echocardiography was positive in 59 (Group A) and was negative in the remaining 14 (Group B). There were more hypertensive patients in Group A (33 vs 4; p = 0.04). There was no significant difference between the two groups with respect to other clinical characteristics. The peak rate-pressure product was similar in both groups (18.520 +/- 5.691 vs 18.680 +/- 5.329; p = NS). The development of electric abnormalities and angina was more common in Group A (42 vs 3, p < 0.001 and 33 vs 1; p < 0.001). Perfusion defects were not more extensive in Group A (abnormal segments 2.15 vs 2.21; p = NS) but they were more severe (segments with severe uptake reduction or no uptake 1.10 vs 0.28; p < 0.05; perfusion score 2.62 vs 2.21; p < 0.05). CONCLUSION: In patients with severe coronary artery disease and perfusion defects during dobutamine-MIBI-SPECT, the presence of wall motion abnormalities defines patients with more severe perfusion defects.

Adrenergic beta-Agonists↗
PubMed1997

Retrograde atrial kick in acute aortic regurgitation. Study of mitral and pulmonary venous flow velocities by transthoracic and transesophageal echocardiography.

BACKGROUND AND HYPOTHESIS: The purpose of this study was the comprehensive evaluation of the changes in pulmonary venous and mitral flow velocities of patients with acute and chronic severe aortic regurgitation. Transmitral flow velocities obtained with pulsed-wave Doppler echocardiography have been used to provide information on left ventricular (LV) filling and diastolic function. Pulmonary venous flow tracings are an important adjunct to LV inflow pattern in assessing LV diastolic function. METHODS: Fourteen patients with severe aortic regurgitation (8 chronic and 6 acute) and in sinus rhythm were examined by transthoracic and transesophageal pulsed Doppler echocardiography. Mitral and pulmonary flow velocities were recorded and compared. All patients had ejection fractions > 40%. RESULTS: Early mitral flow peak velocity was higher in patients with acute regurgitation (p < 0.001). The mitral A wave was absent in five patients with acute regurgitation. In contrast, a prominent reverse atrial pulmonary systolic wave AR was demonstrated in these patients. Peak diastolic velocity of the pulmonary venous flow was greater in patients with acute aortic regurgitation (0.76 +/- 0.13) than in patients with chronic aortic regurgitation (0.40 +/- 0.09) (p < 0.001). Peak systolic velocity did not differ significantly between the two groups. The systolic fraction of pulmonary venous flow in patients with acute aortic regurgitation was lower (0.43 +/- 0.05) than that of patients with chronic regurgitation (0.63 +/- 0.1) (p < 0.01). All patients with acute aortic regurgitation had an S/D ratio < 1, while those with chronic regurgitation had an S/D > 1 (p < 0.001) and an E/A < 1. CONCLUSION: Patients with severe acute aortic regurgitation showed a retrograde atrial kick (absence of transmitral A wave with prominent pulmonary AR wave). These patients had an S/D ratio < 1 (restrictive Doppler pattern). Patients with chronic aortic regurgitation exhibited a Doppler pattern of abnormal LV relaxation (E/A < 1, S/D > 1).

Acute Disease↗
PubMed1997

Natural history and serial morphology of aortic intramural hematoma: a novel variant of aortic dissection.

BACKGROUND: Acute aortic dissection is a cardiovascular emergency that requires prompt diagnosis and treatment. Transesophageal echocardiography is the current standard diagnostic imaging modality in many medical centers. Aortic intramural hematoma is a variant of aortic dissection whose natural history and prognosis have not been well studied. We performed transesophageal echocardiography in patients with aortic intramural hematoma to determine the echocardiographic characteristics and echocardiographic evolution of this lesion, impact on patient management, and patient outcome. METHODS AND RESULTS: Twenty-one consecutive patients with aortic intramural hematoma confirmed anatomically (four patients) or with an additional diagnostic imaging technique (17 patients) underwent a transesophageal echocardiographic examination. Fifteen patients with longstanding hypertension had chest or back pain, and the intramural hematoma was visualized in the ascending aorta (n = 4), along the whole aorta (n = 4), in the descending aorta (n = 6), or in the aortic arch (n = 1). The thickening of the aortic wall was crescentic. Patients with ascending aortic intramural hematoma had the following results: two patients died suddenly, three patients underwent surgery because of increased aortic wall thickening (one patient) or secondary intimal tear (two patients), and the remaining three patients had regression of the hematoma. Patients with hematoma confined to the descending aorta and the patient with aortic arch involvement (n = 7) had a different result: one patient died from aortic rupture and the remaining six patients did well. Six patients had a traumatic aortic injury, and the intramural hematoma was located along the descending thoracic aorta. The thickening of the aortic wall was circular in five patients and crescentic in one. Three of these patients had normalized thickness of the aortic wall on follow-up transesophageal echocardiographic studies. The other three patients died from multiorgan system failure. Aortography showed a reduction of the diameter of the aortic lumen in four patients; diameter in the remaining 17 patients was normal. CONCLUSIONS: Aortic intramural hematoma can be detected and monitored by transesophageal echocardiography but not by aortography. Two types of aortic intramural hematoma can be distinguished: (1) traumatic of good prognosis and (2) nontraumatic, which can be an early stage of the classic aortic dissection, with bad prognosis in cases involving the ascending aorta.

Adult↗
PubMed1997

Right ventricular asynergy during dobutamine-atropine echocardiography.

OBJECTIVES: We sought to analyze right ventricular contractility during dobutamine infusion in patients with right coronary artery disease and to elucidate whether the development of right ventricular asynergy aids in characterizing a right coronary artery stenosis. BACKGROUND: Clinical investigations are emphasizing the importance of right ventricular function in patients with coronary artery disease. Thus, prognosis of patients with inferior myocardial infarction is influenced by right ventricular function. This study describes the echocardiographic and electrocardiographic findings during dobutamine-atropine echocardiography in patients with right coronary artery disease. METHODS: We studied 31 patients with isolated right coronary artery disease and no previous myocardial infarction. Six patients with poor acoustic window were excluded (feasibility 80%). The remaining 25 patients underwent dobutamine-atropine echocardiography. A right coronary artery stenosis located before the origin of the right ventricular branches was considered proximal; otherwise, it was considered distal. RESULTS: Right ventricular asynergy during dobutamine-atropine testing developed in 17 patients (sensitivity 68%); 14 had proximal and 3 had distal right coronary artery disease. The following segments were involved: inferior (n = 17), lateral (n = 5) and outflow tract (n = 1). No patient showed anterior asynergy. All 17 patients had left ventricular asynergy as well. Ischemia-free time was 10.7 +/- 6.2 (mean +/- SD) min for the right ventricle and 8.9 +/- 5.2 min for the left ventricle (p < 0.05). Ischemic ST changes were recorded in 15 patients (in standard leads in 14 and in right precordial leads in 8). All patients with right precordial changes showed ST elevation and had right ventricular asynergy (sensitivity and specificity for right ventricular asynergy 47% and 100%, respectively). A control group of 25 patients with no right coronary artery disease (5 with no disease, 15 with left anterior descending and 5 with left circumflex coronary artery disease) underwent dobutamine echocardiography. Right ventricular asynergy developed in two patients with left anterior descending artery stenosis (specificity 92%); in both, the anterior wall was affected. CONCLUSIONS: Echocardiography during dobutamine infusion is a reliable technique for assessing right ventricular dysfunction in patients with right coronary artery disease. Right ventricular contractility can be assessed during dobutamine echocardiography in selected patients.

Aged↗
PubMed1997

[A non-invasive test choice for the diagnosis of coronary disease in women].

BACKGROUND AND PURPOSE: Regarding coronary heart disease, women have often been excluded from clinical trials. Current practical recommendations are thus based on studies in men. To identify the non invasive technique of choice in detecting coronary artery disease in women, a study with different diagnostic tests has been undertaken. METHODS: Exercise stress test, dipyridamole echocardiography (0.84 mg/kg), dobutamine echocardiography (up to a total dose of 40 micrograms/kg per minute and atropine if necessary), MIBI-SPECT during dobutamine infusion and coronary angiography, were performed in 40 consecutive women with chest pain and no previous history of coronary artery disease. RESULTS: The four tests had similar sensitivity: exercise stress test (80%; CI 95%, 52-94), dipyridamole echocardiography (80%; CI 95%, 56-93), dobutamine echocardiography (80%; CI 95%, 56-93) and scintigraphy MIBI-SPECT (85%; CI 95%, 61-95). The specificity of dipyridamole echocardiography (100%; CI 95%, 83-100) and dobutamine echocardiography (90%; CI 95%, 67-98) was higher than that of exercise stress test (50%; CI 95%, 22-78) and MIBI-SPECT (65%; CI 95%, 41-84). The positive predictive values of dipyridamole and dobutamine echocardiography were 100% and 88% respectively. CONCLUSIONS: The feasibility of exercise stress test in women is inferior to that of the other techniques. The sensitivity of the four tests to diagnose coronary artery disease is similar. The specificity of dipyridamole echocardiography and dobutamine echocardiography is higher than that of exercise stress test and MIBI-SPECT. Stress echocardiography can be considered the non invasive technique of choice for diagnosing coronary artery disease in women.

Aged↗
PubMed1996

Transesophageal echocardiographic assessment of papillary muscle rupture.

BACKGROUND: In some patients with papillary muscle rupture, the ruptured head may not prolapse into the left atrium, which makes diagnosis by transthoracic or transesophageal echocardiography difficult. METHODS AND RESULTS: In an attempt to find additional or more definite diagnostic echocardiographic features, we analyzed intraoperative transesophageal echocardiograms of 21 consecutive patients with papillary muscle rupture (20 involved the left ventricle and 1 involved the right ventricle) confirmed at surgery. In 7 (35%) of 20 patients with left ventricular papillary muscle rupture, the ruptured head was not seen to prolapse into the left atrium. In these patients, examination of the left ventricle proved most useful. Abnormal, large-amplitude erratic motion (1 to 5 cm in 17 patients; 0.5 cm in 1 patient) of a large echo density in the left ventricle consistent with the ruptured head was noted in 18 (90%) of these 20 patients. This included all 7 patients with non-prolapse of the ruptured papillary muscle head into the left atrium. Less prominent erratic motion or flutter of the papillary muscle still attached to the left ventricular wall was also noted but was less sensitive in the diagnosis of papillary muscle rupture. The single patient with right ventricular papillary muscle rupture showed erratic motion as well as prolapse of the ruptured head into the right atrium. CONCLUSIONS: Transesophageal echocardiographic examination of the left ventricle is useful in the diagnosis of papillary muscle rupture, especially in those patients in whom the ruptured head does not prolapse into the left atrium. The left ventricle should be scrutinized thoroughly during transesophageal echocardiographic examination for erratic papillary muscle motion in all patients with suspected rupture.

Adult↗
PubMed1996

Dipyridamole and dobutamine-atropine stress echocardiography in the diagnosis of coronary artery disease. Comparison with exercise stress test, analysis of agreement, and impact of antianginal treatment.

STUDY OBJECTIVES: To compare the usefulness of dipyridamole echocardiography, dobutamine-atropine echocardiography, and exercise stress testing in the diagnosis of coronary artery disease and to analyze the agreement among the tests. DESIGN: Performance of these three tests in random order on a consecutive cohort of patients. SETTING: A tertiary care and university center. PATIENTS: One hundred two consecutive patients with chest pain and no history of coronary artery disease. INTERVENTIONS: Dipyridamole echocardiography, dobutamine-atropine echocardiography, exercise stress testing, and coronary angiography. MEASUREMENTS AND RESULTS: Dobutamine-atropine test was positive in 49 (77%) of 63 patients with coronary artery disease, dipyridamole test in 49 (77%), and exercise stress test in 44 (68%; p = NS). Both echocardiographic tests showed an overall specificity (dipyridamole, 97%; dobutamine, 95%) higher than exercise stress test (79%; p < 0.05). Sensitivity of dipyridamole testing decreased from 93 to 61% (p = 0.002) if patients were receiving antianginal treatment but sensitivity of dobutamine-atropine testing was not affected (77% in patients receiving and not receiving treatment). When results were considered as positive-negative, agreement between dipyridamole and dobutamine-atropine echocardiography was 85% (kappa = 0.70). With regards to regional analysis, concordance was good (93% for segments, kappa = 0.76; and 95% for coronary arteries, kappa = 0.92). Major complications were more frequent during dobutamine-atropine (n = 7) than during dipyridamole infusion (n = 2) (p = 0.06). CONCLUSIONS: Dobutamine-atropine and dipyridamole echocardiography have a similar sensitivity and a higher specificity than that obtained by exercise ECG for the diagnosis of coronary artery disease. Similar information is obtained with dipyridamole and dobutamine-atropine echocardiography. It is our thought that pharmacologic stress echocardiography should be used as a first-step test to rule out coronary artery disease in patients not capable of exercising.

Adrenergic beta-Antagonists↗
PubMed1996

[Identification of intramural aortic hematoma by transesophageal echocardiography].

BACKGROUND AND AIM: The usefulness of transesophageal echocardiography in the diagnosis and assessment of patients with aortic dissection has been widely demonstrated. The aim of this study was to evaluate the role of this technique in the detection of intramural aortic hematoma and in the follow-up of these patients. METHODS: The records of 51 patients with aortic dissection by transesophageal echocardiography diagnosed between May 1990 and May 1994 were reviewed. RESULTS: The diagnosis of intramural aortic hematoma was established in 6 patients by transesophageal echocardiography (11%). This diagnosis was confirmed either anatomically (3 patients) or with an additional diagnostic technique (computed tomography or magnetic resonance imaging) and on the basis of echocardiographic follow-up changes (3 patients). CONCLUSIONS: Intramural aortic hematoma represents an infrequent variant of aortic dissection that can be detected by transesophageal echocardiography and is usually unrecognized by aortography.

Adult↗
PubMed1996

[Echocardiography with dobutamine in hypertensive patients with chest pain].

INTRODUCTION: The exercise stress test shows limited diagnostic accuracy for the detection of coronary artery disease in hypertensive patients. Echocardiography with dobutamine is a useful tool in the assessment of coronary artery disease. PURPOSE: Our purpose has been to compare dobutamine stress echocardiography and exercise stress test for diagnosing coronary disease in hypertensive patients. MATERIAL AND METHODS: Dobutamine stress echocardiography (administered up to 40 micrograms/kg/min, and atropine when necessary), exercise stress test and coronary arteriography were performed on 74 hypertensive patients with chest pain and no previous history of coronary artery disease. RESULTS: Forty-eight (65%) patients underwent a diagnostic exercise stress test and 66 (89%) a diagnostic dobutamine stress echocardiography. Coronary artery disease (> or = 70% stenosis in, at least, one major vessel) was demonstrated in 28 (58%) patients who underwent a diagnostic exercise stress test, and in 39 (59%) patients who completed a dobutamine stress echocardiography. Sensitivity for exercise stress test was 82%, and 79% for dobutamine stress echocardiography (p = NS). Specificity was higher for dobutamine stress echocardiography (100% vs 60%; p < 0.005). CONCLUSIONS: Dobutamine stress echocardiography has high sensitivity and specificity for the detection of coronary artery disease in hypertensive patients. Dobutamine stress echocardiography has higher feasibility and specificity than exercise stress test in this group of patients.

Aged↗
PubMed1996

[Echocardiography and aortic dissection].

Echocardiography is the technique most used in the diagnosis of aortic dissection. In this article the echocardiographic signs of aortic dissection are described. The following issues regarding the usefulness of echocardiography in aortic dissection are reviewed as well: detection of entry site, distinction between false and true lumen, assessment of aortic regurgitation, ventricular function, aortic branches involvement, pericardial effusion and follow-up.

Aortic Dissection↗
PubMed1996

[Aortic dissection: clinical evaluation, comparison of diagnostic techniques and treatment election].

Aortic dissection is a life-threatening disease with a high mortality in the first hours. The diagnosis must be established as promptly as possible and a high index of suspicion is needed. Then, a thorough evaluation of the patient is necessary for an adequate clinical decision making. In this article, the definition, classification, predisposing factors, clinical signs and symptoms, diagnostic methods and treatment are reviewed.

Aortic Dissection↗
PubMed1996

[Aortic intramural hematoma and penetrating aortic ulcer].

Two poor-defined acute aortic syndromes (intramural aortic hematoma and penetrating aortic ulcer) that must be distinguished from the classic dissection are reviewed in this article. Based on the literature and our own experience we describe the clinical characteristics, diagnostic aspects and treatment.

Aortic Dissection↗