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Biomedical subjects

R Montisci

Publications and source records attributed to R Montisci.

At least 19 recordsLinked to original sources
PubMed2006

Non-invasive coronary flow reserve is correlated with microvascular integrity and myocardial viability after primary angioplasty in acute myocardial infarction.

OBJECTIVE: To test whether preserved coronary flow reserve (CFR) two days after reperfused acute myocardial infarction (AMI) is associated with less microvascular dysfunction (" no-reflow" phenomenon) and is predictive of myocardial viability. DESIGN: 24 patients with anterior AMI underwent CFR assessment in the left anterior descending coronary artery (LAD) with transthoracic echocardiography and myocardial contrast echocardiography (MCE) 48 h after primary angioplasty in the LAD (mean 4 (SD 2) and 3 (1) days, respectively). Low-dose dobutamine echocardiography was performed 6 (3) days after AMI and follow-up echocardiography at three months. RESULTS: No-reflow extent was greater in patients with impaired CFR (< 2.5) than in those with preserved CFR (> 2.5) (55 (35)% v 11 (25)%, p < 0.001). MCE reflow was more common in patients with preserved CFR (8/12) than in those with reduced CFR (1/12, p < 0.05). Wall motion score index in the LAD territory (A-WMSI) was similar at the first echocardiography (2.14 (0.39) v 2.32 (0.47), NS), although it was better in patients with preserved CFR at dobutamine (1.38 (0.45) v 1.97 (0.67), p < 0.05) and follow-up echocardiography (1.36 (0.40) v 1.97 (0.64), p < 0.05). An inverse correlation was found between CFR and A-WMSI at dobutamine and follow-up echocardiography (r = -0.49, p = 0.016 and r = -0.55, p = 0.005) and between MCE and A-WMSI at dobutamine and follow-up echocardiography (r = -0.75, p < 0.001 and r = -0.75, p < 0.001). By multivariate analysis MCE reflow remained the only predictor of recovery at both dobutamine and follow-up echocardiography (odds ratio 1.06, 95% CI 1 to 1.1, p = 0.009). CONCLUSION: CFR is inversely correlated with the extent of microvascular dysfunction at MCE two days after reperfused AMI. CFR and MCE reflow early after AMI are correlated with myocardial viability at follow up.

Angioplasty, Balloon, Coronary↗
PubMed2006

Bosentan therapy of pulmonary arterial hypertension in connective tissue diseases.

BACKGROUND: Pulmonary arterial hypertension (PAH) is a life-threatening and debilitating complication of several connective tissue diseases. We aimed to evaluate the effects of long-term treatment with bosentan, an oral dual endothelin ET(A)/ET(B) receptor antagonist, in a cohort of patients with PAH related to connective tissue diseases. MATERIALS AND METHODS: In the present prospective, noncontrolled study, 13 patients (nine with systemic sclerosis, two with systemic lupus erythematosus, one with mixed connective tissue disease and one with overlap syndrome including scleroderma and myositis), mostly nonresponders to prostanoids therapy, were treated for 1 year with bosentan. Cardiac haemodynamics and the diagnosis of PAH were performed by Doppler ultrasound examination. Exercise capacity was assessed by 6-min walking test at baseline and at 3, 6 and 12 months of therapy. RESULTS: During bosentan treatment, progressive improvement of exercise capacity was observed. Walk distance increased in seven patients, remained unchanged in three and slightly decreased in three patients. A progressive significant decrease of right ventricular systolic pressure was also observed, whereas pulmonary artery mean pressure remained unchanged. Adverse effects related to bosentan (elevation of hepatic aminotransferases) were noted in two patients. CONCLUSION: Long-term treatment with bosentan was effective in improving exercise capacity and pulmonary haemodynamics in patients with PAH related to connective tissue diseases.

Administration, Oral↗
PubMed2006

Coronary flow reserve by contrast-enhanced echocardiography: a new noninvasive diagnostic tool for cardiac allograft vasculopathy.

Noninvasive tests have proven unsatisfactory in cardiac allograft vasculopathy (CAV) diagnosis. We assessed coronary flow reserve (CFR) by contrast-enhanced transthoracic echocardiography (CE-TTE) in heart transplantation (HT). CFR was assessed in the left anterior descending coronary artery in 73 HT recipients (59 male, aged 50+/-12 years at HT), at 8+/-4.5 years post-HT. CFR measurements were taken blindly from coronary angiographies. CFR cut points were the standard value of <or=2 and those defined by receiver operating characteristics (ROC) curve analysis. CFR was lower in patients with CAV (2.3+/-0.7 vs. 3.2+/-0.5, p<0.0001). The <or=2 cut point was 100% specific and 38% sensitive. The <or=2.7 cut point, optimal by ROC analysis, was 87% specific and 82% sensitive. Accuracy rose from 71% with the standard<or=2 cut point to 85% with the optimal cut point of <or=2.7. CFR by CE-TTE may offer promise as a novel, easily repeatable and accurate noninvasive tool in CAV detection. However, further longitudinal studies in larger patient cohorts are warranted before widespread adoption can be advocated.

Adult↗
PubMed2003

Detection of early impairment of coronary flow reserve in patients with systemic sclerosis.

OBJECTIVE: To investigate whether coronary flow reserve (CFR), measured by a new non-invasive method, is impaired early in patients with systemic sclerosis (SSc) and whether CFR impairment correlates with clinical or functional measures, or both. METHODS: 27 patients with SSc without clinical evidence of ischaemic heart disease and 23 control group subjects matched for age and sex were studied. CFR was evaluated in the left anterior descending coronary artery (LAD) with a new non-invasive method: contrast (Levovist) enhanced transthoracic Doppler during adenosine infusion. The pulsed wave Doppler examination of blood flow velocity was recorded in the LAD at rest and after maximum vasodilatation by adenosine infusion. RESULTS: In patients with SSc, without clinical evidence of ischaemic heart disease, CFR was impaired (p=0.0001). 14/27 patients with SSc had severe reduction of the CFR (< or =2.5) compared with controls (p=0.002). A non-significant trend between mean CFR and the severity and duration of the disease was also seen. CONCLUSIONS: CFR is often reduced in patients with SSc, suggesting early preclinical cardiac involvement in SSc. This impairment in coronary microvasculature is detectable by a non-invasive echocardiographic method and in this study was more common in the diffuse form of SSc.

Adult↗
PubMed2003

Chronic venous ulcer treatment with fascial pedunculated graft.

AIM: Chronic venous ulcer treatment is often time consuming and requires a high degree of compliance from the patient. This derives not only from venous hypertension but also from chronic structural and metabolic changes of underlying tissues which impair the healing process. It therefore becomes necessary to improve the ulcer tissue condition in order to accelerate the healing process. This is obtained mainly with the improvement of local haemodynamics and secondly by direct action on the ulcer. The aim of the study is to evaluate the efficacy of a treatment with a pedunculated flap of fascia as an additional treatment of chronic venous ulcer. METHODS: Four patients classified C6 according to the CEAP classification were treated for chronic venous ulcer with correction of venous hypertension (saphenectomy or ligature of incompetent perforating veins). The patients also underwent rotation of a fascial pedunculated flap transferred from the sural area to the perimalleolar area. After 7-15 days they had a free skin graft in the treated area. RESULTS: All patients were discharged on the 3(rd) postoperative day after the flap rotation. In 3 patients the ulcer healed within 30 days and in a 4(th) patient within 45 days. No recurrence was observed. CONCLUSION: With this method the healing time seems to be shortened compared to the typical evolution in patients treated with only reflux control followed by conservative therapy. Associating fascial flap in the treatment of chronic venous ulcers improves the bed on which the free skin graft is applied. We can also hypothesize that this procedure restores the aponeurotic barrier between deep venous circulation and superficial microcirculation with the ensuing improvement in local venous hypertension.

Chronic Disease↗
PubMed2001

Contrast-enhanced harmonic color Doppler for left ventricular opacification: improved endocardial border definition compared to tissue harmonic imaging and optimization of methodologyin patients with suboptimal echocardiograms.

OBJECTIVES: This study compared the efficacy of contrast-enhanced harmonic color Doppler (C-HCD) and tissue harmonic imaging (THI) for left ventricular endocardial border delineation and explored the optimal methodology of C-HCD in patients with suboptimal echocardiograms. BACKGROUND: The value of C-HCD in improving endocardium remains unknown. Effects of harmonic velocity-encoded color Doppler (HVD) and harmonic power Doppler (HPD) as well as contrast administration and image acquisition modalities on left ventricular opacification (LVO) have not been established. METHODS: One hundred (50 HVD, 50 HPD) patients with suboptimal echocardiograms during conventional fundamental echocardiography were studied with THI and C-HCD using Levovist. Each patient underwent different random contrast administration and image acquisition modalities. Endocardial border definition score index (EBDI), blooming artifacts, contrast destruction, and salvage of suboptimal echocardiograms were calculated in each patient after contrast enhancement. RESULTS: EBDI improved from 2.05 +/- 0.61 in THI to 2.73 +/- 0.48 in HVD, and 1.98 +/- 0.73 in THI to 2.69 +/- 0.51 in HPD (both P < 0.001). The conversion of a nondiagnostic image from fundamental echocardiography to an optimal diagnostic image was 33 (33%) patients in THI compared to 77 (77%) patients in C-HCD (P < 0.001). Blooming artifacts were seen more commonly in HVD than HPD, intermittent than continuous image acquisition, and bolus than infusion administration (all P < 0.001). There was less contrast destruction in intermittent compared with continuous image acquisition (P < 0.001). Contrast destruction was similar in HVD and HPD, bolus and infusion injection of contrast. The highest salvage rate of a nondiagnostic image from THI to an optimal diagnostic image was 45.5% and 42.4% in HPD mode, with intermittent image acquisition during bolus and infusion contrast administrations. CONCLUSIONS: C-HCD seems more effective in demonstrating improved endocardial border definition compared to THI. HPD has less blooming artifacts compared with HCD. The optimal method for LVO was to use HPD with intermittent image acquisition during bolus or infusion administration of Levovist.

Adolescent↗
PubMed2001

Quantification of left ventricular function with contrast-enhanced harmonic colour Doppler and a semiautomated boundary detection algorithm in technically difficult patients: feasibility, accuracy, and inter-observer variability.

AIMS: Patients with poor quality echocardiograms impede the application of available automatic boundary detection technologies. Tissue harmonic imaging and contrast media can allow optimal differentiation of left ventricular blood pool and tissue, making it possible to utilize automatic boundary detection software for automatic non-operator-dependent computation of left ventricular volumes. We integrated contrast-enhanced harmonic colour Doppler with a semiautomated boundary detection algorithm to explore the feasibility, accuracy and inter-observer variability for left ventricular volume assessment in technically difficult patients. METHODS AND RESULTS: Twenty-six patients with more than two segments not clearly visualized in tissue harmonic imaging were studied with contrast-enhanced harmonic colour Doppler using Levovist. Twenty patients (77%) achieved full left ventricular contrast filling without apparent blooming artefacts. Contrast-enhanced harmonic colour Doppler-automatic boundary detection was successfully implemented in these 20 patients, despite three (15%) in which it was not possible to acquire more than three cardiac cycles' values. Contrast-enhanced harmonic colour Doppler-automatic boundary detection measurements agreed closely with the manually drawn data. Among the three independent readers in the three techniques, the best correlation, lowest SEE, smallest limits of agreement and inter-observer variability were obtained in contrast-enhanced harmonic colour Doppler-automatic boundary detection. CONCLUSION: Contrast-enhanced harmonic colour Doppler-automatic boundary detection was feasible and accurate in estimation of left ventricular volume and function in patients with poor acoustic windows. This technique significantly reduced inter-observer variability, thus improving reliability and confidence of investigators in left ventricular function assessment. Contrast-enhanced harmonic colour Doppler-automatic boundary detection may have great potential in clinical evaluation of left ventricular volume and function, especially when on-line software is available.

Algorithms↗
PubMed2001

[Medico-legal features of early discharge in acute myocardial infarction and chest pain].

The authors' aim is to outline some of the main medico-legal problems in cardiology, especially those regarding the premature hospital discharge of patients with undefined chest pain and/or with acute myocardial infarction. After a brief overview on the etiology and clinical definition of chest pain and myocardial infarction, premature hospital discharge is defined and the incidental medico-legal risks that physicians operating in such situations are exposed to are pointed out. Next, the profiles regarding both the positive and negative views of professional medical responsibility are described. In the negative frame, the authors outline the most frequent civil and penal aspects of the unpremeditated responsibility. Then the physician's error, in both qualitative (generic or specific guilt) and quantitative (degree) terms, is considered; particularly, negligence, imprudence and inexperience, as qualitatively accepted meanings of generic guilt, are dealt with by adopting illustrative cases settled in the light of the right legal interpretation. The phases of the diagnostic or prognostic error are evaluated, and clinical protocols, as a reference parameter for the identification of error, are considered. Lastly, the problem of causality, essential condition for the judgment about the professional responsibility, and the problem of the patient's consent, including an evaluation of the legal capability or incapability about the declaration of consent, are examined closely.

Chest Pain↗
PubMed2000

Transmural heterogeneity of myocardial contraction and ischemia. Diagnosis and clinical implications.

Myocardial contraction behaves heterogeneously, being greater in subendocardial than in subepicardial layers. Similarly, during acute myocardial ischemia or infarction, the subendocardium is the first myocardial layer to suffer. Conventional two-dimensional echocardiography cannot distinguish the transmural extension of myocardial ischemia or infarction, showing akinesia also when only the subendocardium is affected. Novel ultrasonographic techniques (like tissue characterization with integrated backscatter or Doppler tissue imaging) and nuclear magnetic resonance tagging can investigate myocardial contraction in different transmural layers and distinguish subendocardial from transmural ischemia or infarction. With the advent of thrombolysis and primary angioplasty in the acute phase of myocardial infarction a correct diagnosis of the extension of myocardial necrosis cannot ignore its transmural wavefront development. The salvage of the subepicardial layer does not give direct information on overall myocardial thickening but is one of the major determinants of overall left ventricular dysfunction and size. Although it is still necessary to investigate this phenomenon, new ultrasonographic techniques give us important information and more opportunities to appropriate diagnosis and future treatment of cardiac patients.

Animals↗
PubMed1999

Effects of acute myocardial ischemia on intramyocardial contraction heterogeneity: A study performed with ultrasound integrated backscatter during transesophageal atrial pacing.

BACKGROUND: [corrected] Subendocardial thickening is greater than subepicardial thickening and acute myocardial ischemia mainly impairs the former. Integrated backscatter cyclic variations (IBScv) reflect regional myocardial contractility and are blunted during myocardial ischemia. We hypothesized that stress-induced myocardial ischemia mainly affects subendocardial IBScv. METHODS AND RESULTS: Multiplane transesophageal echocardiography and simultaneous atrial pacing were performed in 12 patients without coronary artery disease (CAD) and in 25 with significant CAD. In a transgastric 2-chamber view, we calculated IBScv in subendocardium and subepicardium and a heterogeneity index, both at rest and at peak-pacing. In 27 myocardial segments of patients with normal coronary arteries, and in 16 myocardial segments supplied by coronary artery without significant stenosis in patients with CAD, there was a transmural gradient of IBScv at rest and the heterogeneity index did not change during all the protocol steps. In the 53 myocardial segments related to a significantly narrowed coronary artery, the transmural gradient of IBScv, present at rest, significantly decreased at peak-pacing because of subendocardial blunting, but promptly recovered 5 seconds after pacing interruption. Moreover, the myocardial thickening at rest and peak pacing correlated with the subendocardial IBScv behavior and not with the subepicardial one. CONCLUSIONS: IBScv are greater in the subendocardium than in the subepicardium. Atrial pacing stress test does not affect IBScv in segments supplied by nonstenotic coronary arteries, whereas it affects segments supplied by diseased coronary arteries, blunting exclusively subendocardial IBScv. Heterogeneity of IBScv intramyocardial changes caused by stress-induced ischemia must be taken into account when using IBScv for investigating myocardial ischemia.

Acute Disease↗
PubMed1999

Contrast-enhanced transthoracic second harmonic echo Doppler with adenosine: a noninvasive, rapid and effective method for coronary flow reserve assessment.

OBJECTIVES: The purpose of this study is to evaluate the feasibility in detecting blood flow in the left anterior descending coronary artery (LAD) using transthoracic color Doppler (CD) imaging (in both second harmonic and fundamental mode) along with contrast enhancement and to verify if this new noninvasive method along with adenosine is safe, rapid and effective in assessing coronary flow reserve (CFR). BACKGROUND: Feasibility of contrast-enhanced transthoracic Doppler recording (in both second harmonic and fundamental mode) of blood flow velocity in the LAD has not been assessed. Adenosine has a greater vasodilator potency and more favorable kinetics than dipyridamole and thus it can be more suitable for assessing CFR in conjunction with this method. METHODS: Sixty-one patients with angiographically patent LAD underwent CD (both in fundamental and harmonic mode) as well as color-guided pulsed wave (PW) Doppler recording of blood flow velocity in the distal LAD before and after intravenous contrast injection. A second group of patients (n = 77), undergoing coronary angiography, was submitted to transthoracic contrast-enhanced PW Doppler recording of blood flow velocity in the LAD using harmonic CD as a guide, at rest and during adenosine-induced hyperemia. RESULTS: Harmonic CD along with echo contrast consistently improved blood flow detection in the LAD; the success rate in detecting flow of optimal quality was 88% with this approach, whereas it was 11% and 16% with CD in fundamental mode, respectively, before and after contrast. Pulsed wave Doppler results paralleled those of harmonic CD (p < 0.001 contrast harmonic vs. fundamental). In the second group of patients coronary angiography revealed 0% to <40% stenosis in 24 patients (group I), > or =40% to < or =75% in 17 patients (group II) and >75% stenosis in 34 patients (group III). There was a significant difference in CFR among the three groups of patients; CFR for peak diastolic velocity was (mean +/- SD): 2.88+/-0.7 (group I), 2.09+/-0.5 (group II) and 1.51+/-0.5 cm/s (group II) (p < 0.05 group I vs. both group II and group III; p < 0.05 group II vs. group III). The whole examination took less than 10 min. CONCLUSIONS: Contrast-enhanced second harmonic Doppler recording of blood velocity in the LAD is highly feasible and in combination with adenosine it is a rapid, safe and effective method for assessing CFR ratio.

Adenosine↗
PubMed1999

Validation of a new noninvasive method (contrast-enhanced transthoracic second harmonic echo Doppler) for the evaluation of coronary flow reserve: comparison with intracoronary Doppler flow wire.

OBJECTIVES: We tested the hypothesis that coronary flow reserve (CFR) in the left anterior descending coronary artery (LAD) as assessed by a new noninvasive method (contrast-enhanced transthoracic second harmonic echo Doppler) is in agreement with CFR measurements assessed by intracoronary Doppler flow wire. BACKGROUND: Contrast-enhanced transthoracic second harmonic echo Doppler is a novel noninvasive method to detect blood flow velocity and reserve in the LAD. However, it has not yet been validated versus a gold-standard method. METHODS: Twenty-five patients undergoing CFR assessment in the LAD by Doppler flow wire were also evaluated by contrast-enhanced transthoracic Doppler to record blood flow in the distal LAD at rest and during hyperemia obtained by adenosine i.v. infusion. In five patients CFR was evaluated twice (before and after angioplasty). RESULTS: As a result of the combined use of i.v. contrast and second harmonic Doppler technology, feasibility in assessing coronary flow reserve equaled 100%. The agreement between the two methods was high. In fact, in all but five patients the maximum difference between the two CFR measurements was 0.38. Overall, the prediction (95%) interval of individual differences was -0.69 to +0.72. Reproducibility of CFR measurements was also high. The limits of the agreement (95%) between the two measurements were -0.32 to +0.32. CONCLUSIONS: Coronary flow reserve in the LAD as assessed by contrast-enhanced transthoracic echo Doppler along with harmonic mode concurs very closely with Doppler flow wire CFR measurements. This new noninvasive method allows feasible, reliable and reproducible assessment of CFR in the LAD.

Adenosine↗
PubMed1999

[Coronary reserve].

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Angioplasty, Balloon↗