Second harmonic imaging: good reverberations.
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Echocardiography↗
Biomedical subjects
L J Crouse
Publications and source records attributed to L J Crouse.
Accreditation of echocardiography laboratories.
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Accreditation↗
Use of exercise echocardiography to evaluate patients after coronary angioplasty.
Exercise echocardiography is a sensitive, specific, and highly accurate method for detecting coronary restenosis and progressive compromise of untreated arterial segments in patients who have undergone percutaneous transluminal coronary angioplasty. It is far more reliable in predicting the status of the coronary anatomy in such patients than exercise electrocardiography or symptomatic status.
Adult↗
Are there gender differences related to stress or pharmacological echocardiography?
Coronary artery disease (CAD) is the leading cause of adult mortality in the United States. Data collected from the era preceding contemporary revascularization techniques indicated that chest pain syndromes among women carried a more favorable cardiac prognosis than such symptoms in men. More recent information indicates that many women with chest pain do not have CAD and that, among those who do, clinical manifestations first appear an average of 10 years later than in men, at a time when risk factors and comorbidities such as diabetes, hypertension, and hypercholesterolemia are more prevalent. The toll that this disease exacts among women catches up with that among men after women go through menopause, so that coronary heart disease accounts for nearly equal annual mortality rates in the two genders and for more deaths among women than is attributable to all cancers. The initial, widely held impression that chest pain is more benign in women is being replaced by a growing awareness that coronary disease is not. It appears from published experience that any potential bias in the management of women with possible CAD is overcome once the diagnosis is established. It is clear that a reliable method for the evaluation of women with known or suspected CAD is required. Stress electrocardiography, perfusion imaging, and radioventriculography suffer from a number of limitations, particularly in women. This paper discusses the rationale for and performance of stress echocardiography. Although the specific application of this method in females has been the subject of relatively limited clinical investigations, we believe that it holds great promise as the diagnostic test of choice for women.
Adrenergic beta-Agonists↗
Exercise echocardiography: coming of age.
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Coronary Disease↗
Comparison of results of coronary angioplasty during acute myocardial infarction with and without previous coronary bypass surgery.
Six hundred one consecutive patients undergoing reperfusion within 6 hours of acute myocardial infarction were studied with regard to impact of previous coronary artery bypass grafting (CABG) on direct coronary angioplasty performance and results. Forty-nine patients (8%) had previously undergone CABG, whereas 552 (92%) had not. Direct angioplasty was used for reperfusion in 35 patients (71%) in the CABG group, and in 258 (47%) in the non-CABG group (p < 0.01). No significant differences between these groups were noted with regard to gender, age, infarction site, time to reperfusion or angioplasty success (34 of 35 CABG patients [97%] vs 236 of 258 non-CABG patients [92%]). CABG patients were more likely to have had previous infarction (17 of 35 [49%] vs 35 of 258 [14%] [p < 0.001]), multivessel disease (34 of 35 [97%] vs 127 of 258 [49%] [p < 0.001]) and lower mean ejection fraction (0.36 +/- 0.13 vs 0.46 +/- 0.12, p < 0.001). Over a mean follow-up of 151 weeks, 24 patients (69%) in the CABG group were restudied versus 112 (43%) in the non-CABG group (p < 0.01). Restenosis occurred in 14 patients (40%) in the CABG group versus 58 (22%) in the group without previous CABG (p = 0.04). In the CABG group, restenosis occurred significantly more often in saphenous vein grafts than in native vessels (12 of 17 [71%] vs 2 of 11 [18%] [p < 0.02]). There was no significant difference in the overall performance of repeat angioplasty between the 2 groups.(ABSTRACT TRUNCATED AT 250 WORDS)
Aged↗
Opacification and border delineation improvement in patients with suboptimal endocardial border definition in routine echocardiography: results of the Phase III Albunex Multicenter Trial.
OBJECTIVES: This study was designed to assess the safety and efficacy of intravenously administered sonicated human serum albumin for enhancing echocardiographic delineation of the left ventricular endocardium and improving assessment of wall motion in patients with incomplete depiction of noncontrast echocardiography. BACKGROUND: Echocardiographic regional wall motion analysis is impaired by incomplete endocardial definition in as many as 10% of patients. Sonicated human serum albumin is a stable contrast material that, unlike other agents, opacifies the left ventricle when administered intravenously. METHODS: One hundred seventy-five patients were enrolled at eight centers on the basis of incomplete echocardiographic endocardial depiction. Sonicated 5% human serum albumin, a stable preparation of air-filled microspheres (size range 1 to 10 microns), was administered intravenously in divided doses: 0.08 ml/kg body weight in all patients, followed by 0.14 and 0.08 ml/kg or a single dose of 0.22 ml/kg, depending on the result of the initial dose. Investigators and independent reviewers blinded to the protocol scored the echocardiograms for degree of left ventricular opacification and improvement of endocardial border depiction. RESULTS: Overall, 81% of patients had at least moderate left ventricular chamber opacification with at least one contrast dose, and endocardial definition was improved in 83%. In the subgroup with inadequate left ventricular opacification from the initial dose, a second, larger dose (0.22 ml/kg) improved endocardial depiction in 64%. No significant side effects occurred. CONCLUSIONS: In patients with incomplete echocardiographic endocardial definition, sonicated human serum albumin is a safe, effective contrast agent that, when administered intravenously, produces left ventricular chamber opacification, improves endocardial depiction and enhances regional wall motion analysis.
Adult↗
Sex-related differences in patients undergoing direct angioplasty for acute myocardial infarction.
Important sex-related differences have been recognized in several coronary artery disease presentation and treatment subsets. Little data exist describing the relative findings and outcome in women versus men who received direct percutaneous transluminal coronary angioplasty for acute myocardial infarction. We studied 670 such patients of whom 464 (69%) were men and 206 were women. The women were significantly older (67 +/- 11 years vs 61 +/- 11, p < 0.001) but had undergone less prior coronary artery bypass graft surgery (6% vs 12%, p = 0.02), whereas prior myocardial infarction (17% women vs 22% men) and coronary artery disease distribution were not significantly different. Forty-one percent of women and 43% of men had single-vessel disease (p = NS). Both women and men had 1.5 lesions/patient dilated acutely, with similar success rates (95% women, 91% men; p = 0.08). Mean ejection fractions were similar (48% in both groups), and a similar percentage in each group had an ejection fraction < 30% (10% women vs 13% men). Over a mean follow-up period of 86 weeks, the need for repeat catheterization was frequent and was similar in both groups (44% women, 47% men; p = NS), whereas documented restenosis was less common in women (20% vs 28% of patients, p < 0.05). The need for coronary artery bypass grafting was similar (15% women, 17% men; p = NS), as was the need for repeat percutaneous transluminal coronary angioplasty in the infarct vessel (14% women, 18% men; p = NS) and overall mortality (7% women, 9% men; p = NS).(ABSTRACT TRUNCATED AT 250 WORDS)
Aged↗
Exercise echocardiography after coronary artery bypass grafting.
Exercise echocardiography was used to assess the adequacy of regional myocardial perfusion in 125 patients who had undergone coronary artery bypass grafting. There were 108 men and 17 women (mean age 65 years) evaluated from 6 weeks to 16 years (mean 7 years) after surgery. Resting parasternal long- and short-axis and apical 4- and 2-chamber echocardiograms were recorded, digitized and stored. Maximal, symptom-limited upright treadmill exercise was then performed with continuous electrocardiographic monitoring. Repeat echocardiographic imaging and digitization were repeated within 1 minute of exercise termination. Resting and postexercise digitized echocardiograms were compared. A normal regional wall motion response to exercise consisted of improved segmental contraction and was used to predict uncompromised regional vascular supply. Unimproved or worsened segmental contraction after exercise was abnormal and was used as a predictor of regional vascular insufficiency. All patients underwent cardiac catheterization within 1 month after exercise testing. Regional coronary insufficiency was considered to exist when a segment's major vascular conduit exhibited greater than or equal to 50% luminal diameter reduction. Compared with the simultaneously acquired stress electrocardiogram, exercise echocardiography had superior sensitivity (98 vs 41%), specificity (92 vs 67%), positive predictive value (99 vs 91%), and negative predictive value (86 vs 12%) (p less than 0.001, 0.1, 0.01 and less than 0.001, respectively). In addition, exercise echocardiography correlated closely with the extent and regional distribution of compromised vascular supply. Exercise echocardiography is a highly sensitive, specific and accurate screening test for abnormal global and regional myocardial vascular supply in patients who have undergone coronary artery bypass grafting.
Aged↗
Sonicated serum albumin in contrast echocardiography: improved segmental wall motion depiction and implications for stress echocardiography.
We undertook to study the ability of intravenously administered sonicated albumin microbubbles to opacify the left ventricular (LV) cavity, enhance endocardial delineation, and thereby improve the interpreter's confidence in evaluating regional wall motion in patients whose baseline echocardiograms were believed to be technically difficult because of limited endocardial resolution. We studied 30 adult patients with endocardial border dropout of greater than or equal to 20% on routine echocardiography. Efficacy was evaluated by the investigator and 2 blinded observers using an opacification grading system of 0 (no appearance in LV cavity) to 3+ (full LV chamber opacification). Effective opacification was indicated by a score of greater than or equal to 2+. Border delineation improvement equaled a change from grade A (not well delineated) to grade B, C, or D (well delineated) of at least 1 of 6 LV wall segments. Initially all patients received a 0.08 mL/kg injection. The patient received 2 additional injections of 0.14 and 0.08 mL/kg given 5 minutes apart if the initial volume produced at least 2+ LV opacification. Otherwise, a final injection of 0.22 mL/kg was given. In all cases, the patients' arms were raised after injection to enhance venous passage. When graded by the investigator, 29 patients (97%) exhibited greater than or equal to 2+ opacification. When graded by the blinded observers, 27 patients (90%) exhibited greater than or equal to 2+ opacification. Improved border delineation was noted by the investigator in 90% of patients, and the blinded observers noted improvement in 97% (excluding 1 patient who, if scored by a blinded observer, would have received a higher dose of contrast agents).(ABSTRACT TRUNCATED AT 250 WORDS)
Adult↗
Direct angioplasty versus initial thrombolytic therapy for acute myocardial infarction: long-term follow-up and changes in practice pattern.
We retrospectively studied the outcomes of patients with acute myocardial infarction who were treated with either direct angioplasty or thrombolytics followed by angioplasty. Two patient cohorts were analyzed: a previously reported (in regard to short-term follow-up) group of 371 patients who now have long-term follow-up (mean, 3.4 years) of survival and event-free survival and a second group of 202 patients who have been treated since publication of our initial data. Both 1-year and 2-year survival were significantly better (p = 0.01 and 0.02, respectively) in the group that was treated with thrombolytics first. Event-free survival (i.e., no myocardial infarction, coronary artery bypass graft surgery, repeat angioplasty) was better overall (p < 0.01) for the group that was treated with thrombolytics first. The more recently treated group of patients also showed benefit in regard to both survival (p = 0.002) and event-free survival (p < 0.01) over a short-term follow-up period (mean, 39 weeks) for patients who were treated initially with thrombolytics as compared with those who were treated with direct angioplasty. Although the initial cohort was very similar to the treatment groups except for age (mean age for the direct angioplasty group was 62 +/- 12 years vs 57 +/- 11 years for thrombolytics first group, (p = 0.0002), several differences existed in the more recent treatment groups. The patients who were more recently treated with direct angioplasty were older, had lower mean ejection fraction, had more extensive coronary artery disease, and were more likely to have had prior coronary artery bypass grafting.(ABSTRACT TRUNCATED AT 250 WORDS)
Aged↗
Hypotension during dobutamine stress echocardiography: initial description and clinical relevance.
Hypotension during exercise treadmill testing is correlated with the presence of coronary artery disease, its severity, and prognosis. The importance of hypotension during dobutamine stress testing has not been previously reported to our knowledge. We reviewed 43 cases of hypotension occurring in 42 patients out of a total of 116 consecutive stress dobutamine echocardiographic procedures performed in a total of 112 patients. Of the 42 patients with hypotension, 20 underwent cardiac catheterization. Regional wall motion abnormalities induced by dobutamine infusion were found in 13 of these patients, all of whom had significant (greater than or equal to 70% diameter reduction) coronary artery disease. The remaining seven patients without regional wall motion abnormalities did not have significant coronary artery disease at catheterization. Of the remaining 22 patients with dobutamine-induced hypotension, 20 had no induced regional wall motion abnormalities, were not catheterized, and were followed clinically. None of these patients had a cardiac event during a mean follow-up period of 11.5 months. We conclude that hypotension during dobutamine stress echocardiography in the absence of regional wall motion abnormalities does not indicate significant coronary artery disease or portend an adverse prognosis.
Aged↗
Clinical applicability of echocardiographically detected regional wall-motion abnormalities provoked by upright treadmill exercise.
Exercise electrocardiography is the time-honored screening test for coronary artery disease but has serious limitations in many patient subgroups. A number of adjunctive modalities have been coupled to exercise ECG to increase the diagnostic accuracy of noninvasive testing, including thallium scintigraphy and gated blood pool radioventriculography. Exercise echocardiography has more recently emerged as a tool that can detect exercise-induced regional wall-motion abnormalities as an indicator of provoked myocardial ischemia. While there are conceptual advantages to performing echocardiography during maximal exercise, we have found that regional wall-motion analysis performed with echocardiograms obtained before and immediately after upright treadmill exercise allows highly accurate prediction of the extent and distribution of coronary artery disease as detected by angiography. This monograph summarizes our experience with this form of exercise echocardiography in three important patient groups: (1) patients being screened for the presence or absence of coronary artery disease; (2) patients who have undergone previous coronary artery bypass surgery and who are being evaluated for graft failure and/or progression of native-vessel disease; and (3) patients who have undergone coronary angioplasty and are at risk for restenosis and/or progression of disease. We believe, based on our experience and that of other investigators, that exercise echocardiography is a uniquely valuable tool in these and other patients for assessing the status of the coronary vascular anatomy. Not only can the presence or absence of obstructive disease be assessed, but the extent and distribution of disease can be accurately predicted, and other, noncoronary causes of chest pain such as aortic stenosis, mitral valve prolapse, hypertrophic cardiomyopathy, and pericardial disease can readily be identified.
Angioplasty, Balloon, Coronary↗
Anticoagulant effect of iohexol vs. ioxaglate during cardiac catheterization.
Contrast agent safety during cardiac catheterization (CC) may relate in part to anti- or procoagulant effect. We studied these effects in 177 patients who underwent standard CC (N=112) or percutaneous transluminal coronary angioplasty (PTCA) (N=65) and received either iohexol (N=111) or ioxaglate (N=66). Patients received either 0 or 2000u heparin for CC or 10,000u for PTCA. The groups were similar in regards to age, sex, amount of contrast used, and procedure time. Partial thromboplastin time (PTT) and activated clotting time (ACT) were both significantly increased (P less than .01) in patients who received 10,000u heparin irrespective of type of contrast agent although larger increases were seen in the iohexol group. With 2000u of heparin, ACT and PTT increased significantly (P less than .01) only in the iohexol group. PTT and ACT actually decreased to similar and significant (P less than .01) degrees after both iohexol and ioxaglate when heparin was not used. We conclude: 1) commonly used measures of anticoagulant (ACT and PTT) show greater prolongation after either 2000 or 10,000u of heparin with iohexol than ioxaglate, 2) ACT and PCT appear to shorten with both iohexol and ioxaglate if no heparin is used. This data would suggest that ioxaglate does not have an anticoagulant advantage over iohexol.
Aged↗
Exercise echocardiography as a screening test for coronary artery disease and correlation with coronary arteriography.
We evaluated exercise echocardiography as a screening test for coronary artery disease in 228 patients, all of whom underwent subsequent coronary angiography. After an echocardiogram at rest was obtained, each patient performed maximal, symptom-limited, upright treadmill exercise, immediately after which repeat imaging was performed. The exercise echocardiogram was abnormal if any segment failed to become hypercontractile with exercise, and these regional wall motion abnormalities were used to predict the extent and distribution of coronary disease. At subsequent angiography, coronary stenosis was defined as significant if luminal diameter was reduced greater than or equal to 50%. Compared with electrocardiography, exercise echocardiography was more sensitive (97 vs 51%) and specific (64 vs 62%), and had higher positive (90 vs 82%) and negative (87 vs 28%) predictive accuracies. Exercise echocardiography was also highly predictive of the extent (no, 1-, 2- or 3-vessel disease) and distribution (which vessel) of coronary stenoses. It is concluded that exercise echocardiography is an excellent screening test for the presence, extent and distribution of coronary artery disease.
Constriction, Pathologic↗
Opacification and border delineation improvement in patients with suboptimal endocardial border definition on routine echocardiography: results of a phase III trial of sonicated albumin microspheres.
To determine whether contrast medium in the left ventricle improves endocardial border delineation, enabling better assessment of left ventricular (LV) wall motion, a 5% solution of sonicated albumin microspheres was administered in 30 adult patients who exhibited endocardial border drop-out of 20% or more on routine echocardiography. The investigator and two blinded reviewers evaluated efficacy using an opacification grading system of 0 to 3+, with 0 indicating no contrast effect and 3+ indicating full opacification of the left ventricle. A score of 2+ or greater indicated effective opacification. Border delineation improvement was defined as a change from grade A (not well delineated) to grade B, C, or D (well delineated) of at least 1 of 6 LV wall segments. All patients received an initial injection of 0.08 cc/kg. If this volume produced LV opacification of at least 2+, the patient received two additional injections of 0.14 cc/kg and 0.08 cc/kg, each given 5 minutes apart. Otherwise, the patient received a final injection of 0.22 cc/kg. In all cases, the patient's arm was raised after injection to enhance venous passage. The total number of patients exhibiting 2+ or greater opacification was 29 (97%) when graded by the investigator and 27 (90%) when graded by the blinded observers. The investigator noted improved border delineation in 90% of patients, and the blinded observers noted improvement in 97% (excluding 1 patient who would have received a higher dose of contrast agents if scored by a blinded observer). Investigator confidence in assessing LV wall motion improved in 24 (80%) of the 30 studies.(ABSTRACT TRUNCATED AT 250 WORDS)
Adult↗
Exercise echocardiography follow-up in percutaneous transluminal coronary angioplasty.
Exercise echocardiography has emerged as an excellent tool in the diagnosis of coronary artery disease and has proven to correlate very closely with the distribution and extent of coronary stenoses. In this report we describe our experience with the use of this noninvasive technique in evaluating patients at various stages before, shortly after, and later after percutaneous transluminal coronary angioplasty (PTCA). Coronary restenosis following PTCA occurs at rates between 25% and 40% and currently available screening tests including clinical history, routine exercise electrocardiography, and thallium scintigraphy have proven disappointing correlating with the presence or absence of restenosis. We have found that exercise echocardiography is useful not only in identifying patients who have coronary disease and in predicting the extent and distribution of this disease, but also in demonstrating even very early after angioplasty left ventricular functional improvement both at rest and with exercise. Once patients are discharged from the hospital and followed serially over 5 years, we have found that this tool is extremely valuable in predicting not only coronary restenosis at the site(s) of angioplasty but is also highly predictive of the development of new coronary stenoses. The capabilities of exercise echocardiography to predict restenosis and new disease far exceed the reliability of exercise electrocardiography or the presence or absence of symptoms as indicators of these problems. We have found exercise echocardiography to be an unexcelled screening test in the management of angioplasty patients.
Angioplasty, Balloon, Coronary↗
A prospective evaluation of 68 patients suffering blunt chest trauma for evidence of cardiac injury.
The prevalence and significance of cardiac injury following blunt chest trauma is largely unknown. Although electrocardiography (ECG) and creatinine phosphokinase isoenzyme (CPK-MB) determination have traditionally been used in determining cardiac injury, recent developments in two-dimensional echocardiography (ECHO) as a noninvasive diagnostic tool have led to its use in detecting structural cardiac damage following trauma. In an attempt to determine the occurrence and consequences of cardiac injury we prospectively evaluated 68 patients at one institution using ECHO, serial ECG, and serial CPK-MB determinations in the first 3 days following hospital admission. Patients were selected who had evidence of blunt chest injury on examination or by mechanism of injury. The mean age of the 68 patients was 36.3 +/- 19.6 years and the mean Injury Severity Score, 21.5 +/- 11.6. Forty-nine patients (72%) were found to have an abnormal ECHO, ECG, or CPK-MB (greater than 3%). Eighteen patients (26%) had abnormal ECHOs consisting of seven right ventricular contusions, three left ventricular contusions, three contusions of both chambers, four pericardial effusions, and one small ventricular septal defect. Only three contusions were associated with elevated CPK-MB and seven with abnormal ECGs. Abnormalities of ECG included 18 patients with S-T, T wave changes, axis shifts (11 patients), and bundle branch or hemiblocks (10 patients). No patient died or experienced serious morbidity as a result of their cardiac injury, including 12 patients who underwent surgical procedures with general anesthesia within 30 days of admission.(ABSTRACT TRUNCATED AT 250 WORDS)
Adolescent↗