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S Konstantinides

Publications and source records attributed to S Konstantinides.

At least 37 records · Page 2Linked to original sources
PubMed1997

Management strategies and determinants of outcome in acute major pulmonary embolism: results of a multicenter registry.

OBJECTIVES: The present study investigated current management strategies as well as the clinical course of acute major pulmonary embolism. BACKGROUND: The clinical outcome of patients with acute pulmonary embolism who present with overt or impending right heart failure has not yet been adequately elucidated. METHODS: The 204 participating centers enrolled a total of 1,001 consecutive patients. The inclusion criteria were based on the clinical findings at presentation and the results of electrocardiographic, echocardiographic, nuclear imaging and cardiac catheterization studies. RESULTS: Echocardiography was the most frequently performed diagnostic procedure (74%). Lung scan or pulmonary angiography were performed in 79% of clinically stable patients but much less frequently in those with circulatory collapse at presentation (32%, p < 0.001). Thrombolytic agents were given to 478 patients (48%), often despite the presence of contraindications (193 [40%] of 478). The frequency of initial thrombolysis was significantly higher in clinically unstable than in normotensive patients (57% vs. 22%, p < 0.001). Overall in-hospital mortality rate ranged from 8.1% in the group of stable patients to 25% in those presenting with cardiogenic shock and to 65% in patients necessitating cardiopulmonary resuscitation. Major bleeding was reported in 92 patients (9.2%), but cerebral bleeding was uncommon (0.5%). Finally, recurrent pulmonary embolism occurred in 172 patients (17%). CONCLUSIONS: Current management strategies of acute major pulmonary embolism are largely dependent on the degree of hemodynamic instability at presentation. In the presence of severe hemodynamic compromise, physicians often rely on the findings of bedside echocardiography and proceed to thrombolytic treatment without seeking further diagnostic certainty in nuclear imaging or angiographic studies.

Acute Disease↗
PubMed1997

Association between thrombolytic treatment and the prognosis of hemodynamically stable patients with major pulmonary embolism: results of a multicenter registry.

BACKGROUND: Thrombolytic treatment has been shown to accelerate resolution of major pulmonary embolism and lead to a rapid improvement of right-side hemodynamics. However, the association between these favorable effects and the clinical outcome of patients who have no severe hemodynamic compromise at presentation remains unknown. METHODS AND RESULTS: The present multicenter registry included 719 consecutive patients with major pulmonary embolism according to clinical, echocardiographic, scintigraphic, and cardiac catheterization criteria. Symptom onset was acute (<48 hours) in 63% of patients. All patients were hemodynamically stable (ie, without evidence of cardiogenic shock) at presentation. Primary thrombolytic treatment (within 24 hours of diagnosis) was given to 169 patients (23.5%), whereas the remaining 550 patients were initially treated with heparin alone. Overall 30-day mortality was significantly lower in the patients who received thrombolytic agents (4.7 versus 11.1%, P=.016). Clinical factors associated with a higher death rate were syncope (P=.012), arterial hypotension (P=.021), history of congestive heart failure (P=.013), and chronic pulmonary disease (P=.032). However, only primary thrombolysis was found by multivariate analysis to be an independent predictor of survival (odds ratio for in-hospital death, 0.46; 95% confidence interval, 0.21 to 1.00). Patients who underwent early thrombolytic treatment had a reduced rate of recurrent pulmonary embolism (7.7 versus 18.7%, P<.001) but also a higher frequency of major bleeding episodes (21.9% versus 7.8%, P<.001). Cerebral bleeding occurred in 2 patients in each treatment group, and 1 patient in each group died of a bleeding complication. CONCLUSIONS: The results of our study suggest that thrombolysis may favorably affect the clinical outcome of hemodynamically stable patients with major pulmonary embolism.

Adolescent↗
PubMed1997

["Myxoma syndrome"--a "benign" disease with "malignant" course].

We are reporting on a 36 year-old woman who presented with recurrent cardiac myxomas over a period of nine years. Two of the tumors typically originated in the left atrium and one in the right atrium. Tumor embolization was the presenting symptom twice, leading to reversible cerebral ischemia and minor pulmonary embolism, respectively. The third tumor remained asymptomatic and was detected during routine echocardiographic examination. Based on a positive family history of cardiac tumors, a facially pronounced hyperpigmentation of the skin and the presence of a thyroid adenoma, the diagnosis of a "myxoma syndrome" was established. Patients with "myxoma syndrome" are generally younger than their counterparts with "sporadic myxoma" (mean age at diagnosis 25 vs. 56 years) and have a high frequency of unusual skin freckling (68%). Familial clustering of cardiac myxomas is also frequent (25%). The tumors may be located in any of the cardiac chambers (87% in the atrias, 13% in the ventricles, 50% at multiple sites simultaneously) and have relatively high (18%) 5-year recurrence rate after surgical excision. Since the clinical signs of cardiac tumors are non-specific, diagnosis essentially relies on cardiac imaging by echocardiography, computer tomography, or angiography. The superiority of transesophageal echocardiography is emphasized in this report.

Adult↗
PubMed1997

Noninvasive estimation of right ventricular systolic pressure in postinfarction ventricular septal rupture: an assessment of two Doppler echocardiographic methods.

OBJECTIVE: To evaluate the diagnostic accuracy of Doppler echocardiography in the assessment of right heart hemodynamics and the diagnosis of pulmonary hypertension in patients with ventricular septal rupture due to acute myocardial infarction. DESIGN: A prospective, echocardiographic and right-heart catheterization study. SETTING: Medical intensive care unit (ICU) of a university hospital. PATIENTS: Twelve consecutive patients admitted to the ICU with the diagnosis of ventricular septal rupture in the setting of acute myocardial infarction. Confirmation of diagnosis was made during surgery (11 patients) or by autopsy (one patient). INTERVENTIONS: All patients were examined by two-dimensional and Doppler echocardiography on admission and subsequently underwent bedside right-heart catheterization. MEASUREMENTS AND MAIN RESULTS: After identification and localization of the rupture site by two-dimensional echocardiography and/or color flow Doppler mapping, the maximal flow velocity of the transseptal jet was measured by continuous-wave Doppler and was used to calculate the peak interventricular pressure gradient by the modified Bernoulli equation. This value was subtracted from the systolic arterial blood pressure value to estimate right ventricular systolic pressure. The values obtained correlated well with catheter-derived measurements (r2 = .71; p = .001). Furthermore, in eight (67%) patients, right ventricular systolic pressure could also be determined by Doppler interrogation of the tricuspid regurgitant jet. Direct comparison of the results of the two echocardiographic methods yielded a good correlation (r2 = .66; p = .016). CONCLUSION: Doppler examination of the transseptal and tricuspid regurgitant jets is applicable to patients with ventricular septal rupture for rapid, noninvasive prediction of right ventricular hemodynamics.

Aged↗
PubMed1997

Prognostic significance of right ventricular afterload stress detected by echocardiography in patients with clinically suspected pulmonary embolism.

OBJECTIVE: To investigate the prognostic value of echocardiographic findings in patients who present with symptoms suggestive of acute pulmonary embolism. DESIGN: 317 patients with clinically suspected pulmonary embolism were prospectively evaluated by echocardiography for the presence of right ventricular afterload stress and right heart or pulmonary artery thrombi. Objective confirmation of pulmonary embolism by lung scan or pulmonary angiography was obtained in 164 (52%). The presence of deep venous thrombosis was established in 90 of 158 patients (57%) who underwent phlebographic or Doppler sonographic studies. RESULTS: Right ventricular afterload stress was diagnosed in 87 patients (27%). Objective confirmation of pulmonary embolism and diagnosis of deep venous thrombosis was more common in patients with right ventricular afterload stress than in those without (83% v 40% and 46% v 22%, respectively; P < 0.001). This was also true for the detection of thrombi in the right heart and major pulmonary arteries (12 patients v 1 patient; P < 0.001) as well as for the in-hospital mortality from venous thromboembolism (13% v 0.9%; P < 0.001). One year mortality from pulmonary embolism was 13% in patients with right ventricular afterload stress at presentation compared with 1.3% in those without (P < 0.001). CONCLUSIONS: The presence of right ventricular afterload stress detected by echocardiography is a major determinant of short term prognosis in patients with clinically suspected acute pulmonary embolism.

Acute Disease↗
PubMed1996

Diagnosis, localization and evaluation of malignancy of heart and mediastinal tumors by conventional and transesophageal echocardiography.

Transesophageal echocardiography is well established in detecting and diagnosing heart tumors. In contrast, its role in assessing presence, growth and evidence of malignancy of tumors originating from the mediastinal site remains widely uncertain. In a prospective and investigator-blind study, we evaluated 72 consecutive patients with cardiac and/or mediastinal tumor lesions to assess the diagnostic impact of transthoracic and transesophageal echocardiography in determining localization, growth and malignancy. All tumor lesions were diagnosed and carefully evaluated by computer tomography and/or magnetic resonance imaging prior to the study. Biopsy demonstrated a malignant tumor in 49 patients and a benign tumor in 23 patients. Transthoracic and transesophageal echocardiography were equally effective in visualizing tumors of the heart in 24 patients (92% vs 100%; N.S.). Tumors originating from the mediastinum were 2.9 times less likely to be detected by the transthoracic approach (p < 0.001). In these patients, transesophageal echocardiography was also superior in diagnosing myocardial infiltration (18 vs 4 patients, p < 0.001) and invasion or intracardiac growth of the tumor (13 vs 6 patients, p < 0.05). When compared to histological findings, transesophageal echocardiography predicted malignancy from the presence of tumor spread both in- and outside the heart, infiltration and invasion in 21/49 patients (43%), a false positive result was obtained in only 1/23 patients with a benign tumor. Conventional echocardiography predicted malignancy in only 4/49 patients (8%, p < 0.005). In conclusion, transesophageal echocardiography is increasingly used in patients with suspected mediastinal tumor lesions. Our study demonstrates, that transesophageal echocardiography is effective and superior to the conventional approach in predicting localization and growth of mediastinal tumors, as well as in accessing evidence of malignancy of the tumor.

Echocardiography↗
PubMed1996

[Diagnostic value of various echo- and Doppler echocardiography methods in quantifying mitral valve stenosis].

UNLABELLED: Two-dimensional and Doppler echocardiography have been widely used for noninvasive determination of valve area in patients with mitral stenosis. Recent studies have indicated that the Doppler-echocardiographic pressure half-time method (PHT) does not accurately predict mitral orifice area (MOA). Therefore, applications of the continuity equation and the Gorlin formula have been used additionally to the PHT for Doppler-echocardiographic assessment of MOA. In a prospective study of 34 patients MOA determined by two-dimensional and Doppler echocardiography was compared with MOA measured by cardiac catheterization (range 0.40 to 1.90 cm2, mean 1.08 +/- 0.37 cm2). There was a moderate correlation between two-dimensional echocardiographic and invasive measurements (r = 0.65, SEE = 0.20 cm2). MOA calculated by the PHT showed only poor correlation with cardiac catheterization (r = 0.38 SEE = 0.37 cm2). We found better correlations for the continuity equation (r = 0.73, SEE = 0.35 cm2) and Doppler-echocardiographic application of the Gorlin formula (r = 0.81, SEe = 0.27 cm2). Doppler-echocardiographic use of the Gorlin formula yielded the best prediction of the severity of mitral valve stenosis (concordance with invasive measurement in 82%). CONCLUSION: Pressure half-time is only a poor predictor of the severity of mitral valve stenosis. More accurate results are obtained by Doppler-echocardiographic applications of the continuity equation and especially the Gorlin formula.

Adult↗
PubMed1995

A comparison of surgical and medical therapy for atrial septal defect in adults.

BACKGROUND: The surgical closure of an atrial septal defect is frequently recommended for patients over 40 years of age. However, the prognosis for such patients with unrepaired defects is largely unknown, and the outcome for patients operated on after the fourth decade of life has not yet been compared with that for medically treated patients in a controlled follow-up study. METHODS: In a retrospective study, we examined the clinical course of 179 consecutive patients with isolated atrial septal defects diagnosed after the age of 40. The 84 patients (47 percent) who underwent surgical repair were compared with the 95 patients (53 percent) who were treated medically. The mean (+/-SD) follow-up period was 8.9 +/- 5.2 years (range, 1 to 26). RESULTS: Multivariate analysis revealed that surgical closure of the defect significantly reduced mortality from all causes (relative risk, 0.31; 95 percent confidence interval, 0.11 to 0.85). The adjusted 10-year survival rate of surgically treated patients was 95 percent, as compared with 84 percent for the medically treated patients. In addition, surgical treatment prevented functional deterioration, as measured by the New York Heart Association class (relative risk, 0.21; 95 percent confidence interval, 0.08 to 0.55). However, the incidence of new atrial arrhythmias or of cerebrovascular insults in the two groups was not significantly different. CONCLUSIONS: The surgical repair of an atrial septal defect in patients over 40 years of age, as compared with medical therapy, increases long-term survival and limits the deterioration of function due to heart failure. However, surgically treated patients should be followed closely for the onset of atrial arrhythmias so as to reduce the risk of thromboembolic complications.

Adult↗
PubMed1993

Detection of left-to-right shunt in atrial septal defect by negative contrast echocardiography: a comparison of transthoracic and transesophageal approach.

The occurrence of a right atrial negative contrast effect as an indicator of left-to-right shunt was studied in 101 patients with atrial septal defect by peripheral venous contrast injection during transthoracic and transesophageal echocardiography. Confirmation of the diagnosis was provided by cardiac catheterization or by autopsy in 72 (72%) patients. The defect could be visualized directly in 57 (57%) patients during the transthoracic and in 93 (93%) during the transesophageal examination (p < 0.001). A negative right atrial echo contrast effect was observed in 53 of 92 (58%) patients from the transthoracic and in 86 of 92 (93%) patients from the transesophageal approach (p < 0.001). Among these were seven (7%) patients with an aneurysmal interatrial septum but no directly visible defect during conventional transesophageal imaging. Appearance of contrast in the left atrium indicating right-to-left shunting was seen in 70 of 92 (76%) patients from the transthoracic and in 91 of 92 (99%) patients from the transesophageal approach (p < 0.001). Contrast injection during transesophageal imaging also helped identify additional malformations in 12 (12%) patients. Thus transesophageal echocardiography with echo contrast injection is a very reliable diagnostic method in patients with suspected atrial septal defect.

Adolescent↗
PubMed1993

Distinguishing between acute and subacute massive pulmonary embolism by conventional and Doppler echocardiography.

OBJECTIVE: To determine the ability of conventional and Doppler echocardiography to distinguish between minor, acute massive, and subacute massive pulmonary embolism in patients with confirmed pulmonary embolism. DESIGN: Prospective study of a consecutive series of 47 patients with confirmed pulmonary embolism. SETTING: Department of internal medicine, university clinic. PATIENTS: 11 patients (23%) had minor, 23 patients (49%) had acute massive, and 13 patients (28%) had subacute massive pulmonary embolism. RESULTS: Dilatation of the right ventricular cavity (33 (92%)) and asynergy of the right ventricular free wall (29 (81%)) were seen only in patients with acute and subacute massive pulmonary embolism (n = 36). 23 (64%) with pulmonary hypertension had tricuspid regurgitation. The velocity of the tricuspid regurgitant jet correlated with the pulmonary arterial pressure (r = 0.88, SEE = 11.6 mm Hg) and was significantly lower in patients with acute massive pulmonary embolism (3.0 (0.4) m/s, n = 12) than in patients with subacute massive pulmonary embolism (4.2 (0.6) m/s; n = 11) (p < 0.001). The use of predefined indices (right ventricular free wall thickness > 5 mm; tricuspid regurgitant jet velocity > 3.7 m/s; and the occurrence of both a dilated right ventricular cavity with normal interventricular septal motion, or an inspiratory collapse of the inferior vena cava, or both) correctly identified 11 of 13 patients (85%) with subacute massive pulmonary embolism. CONCLUSION: Conventional and Doppler echocardiography were successful in evaluating the haemodynamic consequences of pulmonary embolism.

Acute Disease↗
PubMed1993

[Limitation of Doppler echocardiography in evaluation of aortic valve prostheses]].

Doppler echocardiography has been widely used as a noninvasive method to evaluate valvular heart diseases. However, the diagnostic impact of Doppler echocardiography in the evaluation of prosthetic valves is discussed controversially. Reasons are, on one hand, the high variabilities of transvalvular gradients observed for normal prosthetic devices and, on the other hand, results of experimental in vitro studies demonstrating an impressive discrepancy between Doppler-echocardiographic and invasive measurements of the transvalvular gradients in prosthetic valves. In a prospective study, we evaluated 11 out of 335 patients after aortic valve replacement who demonstrated an elevated transvalvular gradient over the prosthetic valve. Eight patients had a St. Jude medical prosthesis (19-23 mm), two patients had a Medtronic Hall prosthesis, and one patient a Björk-Shiley prosthesis. The maximal instantaneous gradient measured by Doppler-echocardiography was 74 +/- 15 mmHg, the mean gradient was 47 +/- 12 mmHg. The prosthetic orifice area calculated by the continuity equation using the left ventricular outflow tract diameter was 0.86 +/- 0.25 cm2, and that calculated by using the prosthetic ring diameter was 0.98 +/- 0.23 cm2. None of the patients had a severe aortic valve regurgitation. All patients were clinically asymptomatic. Transesophageal echocardiography and x-ray showed a normal prosthetic function. Angiographic examination performed in seven patients showed a peak-to-peak gradient of 26 +/- 9 mmHg, and demonstrated a marked discrepancy between Doppler-echocardiographic and invasive results. These results confirm the clinical limitations of Doppler echocardiography to distinguish between normal and disturbed prosthetic function.(ABSTRACT TRUNCATED AT 250 WORDS)

Aged↗
PubMed1991

The natural course of atrial septal defect in adults--a still unsettled issue.

Atrial septal defect is the most frequently encountered major congenital cardiac disorder in the adult population, with a prevalence of 0.2 to 0.7 per thousand. Several patients tolerate large unrepaired defects for 80 years or even longer without serious disability. However, it is assumed that, as a rule, atrial septal defect reduces life expectancy, the average age at death not exceeding 50 years. This estimation is based on studies derived mainly from necropsy series or from the admission profile of patients undergoing late operative repair. The onset of atrial fibrillation, with an incidence ranging from 13 to 52 percent among patients older than 40 years, as well as the progression of pulmonary arterial hypertension in up to 53 percent of patients, results in congestive heart failure and functional limitation. On the other hand, very few longitudinal studies thus far have directly and systematically followed the course of adults with unrepaired defects. Thus, many issues regarding the natural history and prognosis of atrial septal defect still remain unresolved. Follow-up series of older patients with nonoperated defects could yield valuable information even in an era when routine early surgical closure is increasingly being recommended.

Adult↗
PubMed1989

Sudden cardiac death during ambulatory ECG monitoring. A report of 2 cases.

Two cases of sudden cardiac death during ambulatory ECG monitoring, each with an episode of torsade de pointes as part of the terminal dysrhythmia, are reported. In the first case, pause-dependent changes of the TU waves favour early after-depolarisations and triggered activity as the initiating mechanism of torsade. Quinidine therapy was probably an aggravating factor. Torsade was not initiated in a pause-dependent fashion in the second patient, who had ECG evidence of an episode of ischaemia as trigger for the terminal dysrhythmia. Both patients had impaired left ventricular function and underlying coronary artery disease.

Coronary Disease↗
PubMed1989

Quantitative ECG changes and patency of infarct-related arteries after intravenous streptokinase.

Thirty-three patients with acute inferior myocardial infarction (MI), who were treated with intravenous streptokinase, were studied by serial 12-lead ECGs for 48 hours to determine the relationship between early changes in the sum of elevations above the baseline 40 ms after the end of the QRS complex in leads II, III and AFV (SumST), the sum of amplitude of R waves in leads II, III and AVF, the sum of the Q waves in leads II, III and AVF, the sum of ST-segment depression in leads V1-V4 as measured from the baseline to 80 ms after the J point (SumST (V1-V4] and the patency of the infarct-related artery at angiography after MI. Patients with patent arteries had a faster rate of decline in the SumST during the first 2.5 hours; reached the steady state earlier; had a more pronounced decrease in the SumST at 1.25 hours; a larger percentage drop in SumR at 4.5 hours and a more pronounced SumST (V1-V4) early on but resolution times similar to that of patients with closed arteries. Several ECG indices may indicate reperfusion of the infarct-related artery in patients with inferior MI.

Angiography↗
PubMed1988

Intravenous streptokinase in acute myocardial infarction.

The safety and efficacy of streptokinase (STK) (Kabikinase; Keatings) in restoring vessel patency in 70 patients with acute myocardial infarction are reported. Return of vessel patency occurred more frequently (76%) in patients receiving STK than in patients in a control group (12%) (P = 0.001). The main complication was bleeding, which invariably resulted from invasive procedures. Dangerous dysrhythmias were uncommon and no fatalities were caused by STK administration. It is recommended that thrombolytic therapy be started as early as possible in patients with acute myocardial infarction, who can then be referred to centres equipped for coronary angiography for further management. Unnecessary invasive procedures should be avoided.

Adult↗