Background: Transthoracic enhanced echo Doppler of coronaries (CED) has the potential to detect coronary flow and its acceleration at the stenosis site over the entire left anterior descending coronary artery (LAD). CED has recently enhanced its feasibility thanks both to new technologies (convergent color Doppler mode) and new tomographic planes. As blood flow velocity (BFV) is inversely related to vessel radius elevated to the power, we hypothesized that even mild coronary narrowing plaque, as assessed by intravascular ultrasound (IVUS), can cause enough acceleration to be detected by CED. Methods: Fifty consecutive patients (pts) (age 55±12years, males 74%, BMI =28±4) scheduled for cath and IVUS were evaluated by CED in convergent color Doppler mode . Color guided pulsed waved Doppler mapping of the whole LAD (specifically the proximal, mid and distal part) was performed in order to attain for each segment maximal and reference BFV. Results: CED feasibility was 100%. IVUS showed 45 patients with mild severity atherosclerosis involving one or more segments of LAD and 5 with totally normal LAD. Maximal velocity was higher in the diseased segment than in the normal segments (54±25 cm/s vs 31±6 cm/s; p<0.001); as the reference velocity was similar (30±6cm/s vs 29±6cm/s; p=ns), the percentage increase in velocity was also higher (77±56% vs 4±9%; p<0.001). Using a cutoff value of a 22% increase in velocity, sensitivity and specificity to detect at least one plaque involving LAD was respectively 82% (37/45 pts) and 100% (5/5 pts) The location of the BFV acceleration (aliasing zone at color Doppler) strictly corresponded to IVUS plaque location in proximal and mid LAD: 34 pts showed concordant location (11 with proximal plaque, 10 with mid plaques and 15 with both segments plaques) and 11 discordant (8 pts with plaques missed and 3 with plaques misplaced by CED) (Cramer’s V = 0,84, P<0,001). In corresponding segments lumen area stenosis (%) as assessed by CED (continuity equation) concurred with that assessed by IVUS (44±14 % vs. 37±16%) with r = 0,42 (p=0.014). Conclusion: BFV evaluation in the LAD by means of CED is feasible and reliable in assessing LAD mild atherosclerosis in a totally non-invasive way.

BACKGROUND: Coronary restenosis is the most important clinical limitation after percutaneous coronary intervention (PCI), and coronary flow reserve (CFR) is reduced in the presence of significant coronary stenosis. This study evaluated whether detection of early reduction of Doppler echocardiographically derived CFR in the left anterior descending coronary artery can identify patients at high risk for developing restenosis after successful PCI. METHODS: Doppler echocardiographically derived CFR was studied in 124 consecutive patients at 1-month and 6-month follow-up after PCI in the left anterior descending coronary artery, together with coronary angiography. RESULTS: Restenosis was detected in 39 angiographic examinations (group A) and no coronary restenosis in the remaining 85 (group B) at 6 months. At 1 month, CFR was reduced in group A compared with group B (P < .0001), and a significant reduction of CFR in group A (P < .0001) but not in group B (P = .89) was detected at 6 months. CFR </= 2.5 at 1 month was 67% sensitive and 87% specific for predicting significant restenosis, with positive and negative predictive values of 67% and 87%, respectively. CONCLUSIONS: CFR </= 2.5 detected 1 month after PCI in the left anterior descending coronary artery has the potential to identify patients at higher risk for developing coronary restenosis and indicates the need for close clinical follow-up.

Background Post-treadmill digital echocardiography (post-TME) is the most widely used form of exercise echocardiography, but ischemia can rapidly resolve in the postexercise period; peak upright bicycle digital echocardiography (UBE) has the advantage of providing images at peak exercise that reflect normal physiology. However, the comparative accuracy of the two methods in detecting ischemia in the same patients is unknown. To compare the relative diagnostic value of peak UBE and post-TME in detecting coronary artery disease, both tests were performed in 86 consecutive patients undergoing coronary angiography. Methods Eighty-six patients referred for evaluation of coronary disease underwent peak UBE (starting at 25 W, with 25-W increments every 3 min) and post-TME (Bruce protocol) in a random sequence. Digitized images of peak UBE and post-TME were interpreted in a random and blinded fashion. Results More transient wall motion abnormalities were detected with peak UBE than post-TME (55 vs 42, P <.001), and such exercise-induced wall motion abnormalities were more extensive (5.5 ± 3.0 vs 3.4 ± 2.1 dyskinetic segments, P <.001) and more severe (regional wall motion score index, 2.7 ± 0.5 vs 2.5 ± 0.5; P =.003). By angiography, 59 patients had coronary artery disease (a coronary stenosis of ≥50% diameter narrowing); the sensitivity of peak UBE for detecting coronary artery disease was greater than that of post-TME in the population as a whole (88% vs 66%, P <.01) and in the single-vessel subgroup (72% vs 44%, P <.05), with no worsening in specificity (89% vs 89%, P = NS). Conclusions Peak UBE is more capable of detecting ischemia than post-TME, and this is achieved with no worsening of specificity. Thus, peak UBE should be preferred in patients able to perform bicycle exercise.

Purpose. Aim of our study was to evaluate in a group of patients with dilated cardiomyopathy (DC) the evolution of systolic and diastolic ventricular function (specifically LV ejection fraction [EF] and the S/D pulmonary waves) after 15 years of follow-up. Methods. In this prospective study, in 122 patients with DC, EF and S/D were evaluated for the first time in 1995 and the second time 15 years after in the survivors. After 15 years, the vital status was ascertained by contacting patients or their relatives by phone. Results. At baseline we enrolled 92 males and 30 females with DC, with mean age 58±11 years,. LVEF=28.6±6.5% and LV end diastolic diameter= 65.41±7.1 mm. After 15 years, only 37 survived; of whom 18 accepted to undergo a second echocardiographic study. In the survivors revaluated LVEF, and S/D ratio did not show significant variation with respect to the baseline study (Figure 1 and 2). In Figure 1 you can appreciate that LVEF remained stable or mildly improved. In 2 cases it worsened but in 2 cases, it normalized, probably because of a reversible myocardial injury (probably a myocarditis improperly defined as cardiomyopathy at the time of accrual). In figure 2 you can see that S/D ratio tends to worsen toward a restrictive physiology. Conclusion. In these preliminary data, patients with dilated cardiomyopathy with every etiology had a poor long term prognosis, irrespective to the medical treatment. Patients who survived after 15-years, showed, on average, a rather stable systolic and diastolic function. Of interest, in few cases LV function may striking improve, probably because of reversible pathological process unidentified at the first evaluation.

Introduction. Pulmonary venous flow transesophageal Doppler recording is a reliable marker of LV diastolic function. However, there are only few data in literature concerning its prognostic role. Furthermore, to date, no study with long-term follow up compared the relative prognostic value of Transmitral and Pulmonary venous flow Doppler recordings. Purpose. Aim of our study was to establish the prognostic impact of LV diastolic function as assessed by Transmitral flow and Pulmonary Venous Flow (PVF) transesophageal Doppler recording in patients with dilated cardiomyopathy (DC). Methods. One hundred and twenty two patients affected by DC with different etiologies were consecutively enrolled in 1995. They were all on optimized therapy. They underwent a TEE Doppler study. Thus PVF was evaluated with the most reliable approach. The following parameters were measured: peak systolic and diastolic PV wave ratio (S/D), E and A mitral wave ratio (E/A), mitral E deceleration time (EDT) and the time difference between PV atrial reversal (Ar) and mitral A wave duration (A). After 15 years the vital status was ascertained by contacting patients or their relatives by phone. Results. During the follow-up period (mean 13,5 +/- 0,8 years) 81 pts (66%) had events (71 died and 10 underwent heart transplantation); no pts were lost to follow-up. LVEF was 28.6±6.5%, LVEDD 65.41±7.1 mm. E/A ratio couldn’t be evaluated in 21 cases because of E and A wave fusion secondary to high heart rate. The multivariate analysis showed that a 2-strata composite variable (diastolic risk) attained by pulmonary waves and A mitral wave (worse category= S/D ratio &lt;1 or S/D&gt;=1 and Ar-A &gt;0) was the best single diastolic variable that predicts hard events in the long term follow-up (hazard ratio = 3,13 with CI = 1,8-5,3, p&lt;0.001, see graph). Other Doppler indexes of diastolic function were not significant at the multivariate analysis. This was due to better prediction of death of the worse category of diastolic risk with respect to the E/A ratio. Conclusion. Our data show that LV diastolic function has important prognostic role in dilated cardiomyopathy when it is best assessed by Pulmonary Venous flow (S/D) combined with A-Ar.

Nine patients (pts) with angiographically normal coronary arteries were submitted to absolute coronary flow reserve (CFR) in the distal left circumflex (LCx) coronary artery (specifically in the marginal branch that was insonified by a modified four-chamber view) using a novel non-invasive method (base-adenosine transthoracic echo Doppler in convergent color Doppler mode ). CFR in the distal left anterior descending coronary artery was attained as well using the same Doppler modality. Results: In this non consecutive series of patients blood flow velocity in LCx was adequately recorded at baseline and during adenosine infusion. However blood flow velocity recording in the LCx was more difficult to attain during hyperemic phase than during the basal one; in fact it was attained only in the pre-tachicardic phase of the hyperemia in 4 pts (45%). CFR attained in the LCx strictly concorded with that attained in the left anterior descending coronary artery territory (R= 0.94, p&lt;0.001) (see graph) so relative CFR was close to 1 (0,96 +/-0.08). Conclusion: In this preliminary non-consecutive study CFR in LCx seems feasible enough to have clinical potential value. Its strict agreement with LAD CFR over a wide range of values in patients with angiographically normal coronary arteries and expected homogeneous microcirculatory function indicate its potential higly reliability in terms of pathophysiology assessment of coronary function.

Background: Adenosine intravenous infusion is used to evaluate Coronary Flow Reserve (CFR) in patients with coronary artery disease. However, the proposed duration of adenosine infusion ranges from 90 seconds to 5 minutes. Therefore the optimal duration of Adenosine infusion to obtain maximal vasodilator effect still remains uncertain. Aim: Purpose of this study was to define the optimal duration of adenosine intravenous (iv) infusion to elicit maximal coronary hyperemic effect. Materials and Methods: We consecutively enrolled 101 patients between June 2009 and May 2011. The mean age was 53±11 years (64% male, 36% female), and ejection fraction (EF) was 59±13%. All patients underwent blood flow velocity Doppler recording in the distal left anterior descending coronary artery (LAD) at baseline and during adenosine iv infusion via a pump at the dosage of 0.14 mg/Kg/min over 5 minutes. Coronary blood flow velocity in LAD was continuously recorded by a well-validated non invasive approach: enhanced transthoracic Color-guided Pulsed-Wave Doppler recording. The time to maximal hyperaemic effect was obtained by activating a built-in chronometer at the starting of adenosine infusion. Results: We found that the peak effect occurred at 72 ± 32 seconds (see histogram). The peak effect occurred within 90 sec in 80 pts (66%) and after 90 sec in 46 pts (34%). In no pt, peak hyperaemic effect took place beyond 3 minutes. In addition in the vast majority of cases (90%) the maximal vasodilatatory effect was reached before the tachycardic phase of adenosine effect. Conclusions: The results of this study seem to indicate that the optimal duration of adenosine infusion to evaluate CFR should be at least 3 minutes.

Pulmonary Venous Flow as Assessed by Transesophageal Echocardiography Independently Predicts Mortality in Patients With Dilated Cardiomyopathy. A Thirteen Year Follow-up Study Background: Pulmonary venous flow (PVF), optimally studied during transesophageal echocardiography is a better index of diastolic restricted physiology in dilated cardiomyopathy (DCM) but it’s not known if it has an incremental value over the more established prognosticators such as LV ejection fraction (LVEF) and peak VO2 in the long term. Methods: This study included 122 patients (pts) with DCM (92 males, 58+/-11 years, LVEF= 28%+/-6), stable and in sinus rhythm. All pts underwent transesophageal echocardiography with color guided pulsed wave Doppler recording of PVF and transmitral flow; peak systolic and diastolic PVF wave ratio (S/D), E and A mitral wave ratio (E/A), mitral E deceleration time and the time difference between PVF atrial reversal (Ar) and mitral A wave duration (A) were measured. Others parameters attained were: LVEF, inspiratory collapse of the inferior vena cava, mitral regurgitation peak VO2, creatininemia. Cardiac events were defined as death or heart transplantation. Results: During the follow-up period (mean 13. 5+/- 0. 8 years) 81 pts (66%) had events; no pts were lost to follow-up. A 4-strata composite variable (high risk) attained by both LVEF (worse category= LVEF&lt; 25%) and LV diastolic function (worse category= S/D ratio&lt;1 or S/D&gt;=1 and Ar-A &gt;0) was the best predictor of hard events (see table). Other Doppler indices of diastolic function were not significant at the multivariate analysis. Conclusion: In the long term PVF and LVEF are the best predictors of outcome in pts with DCM.

The meaning of angiographically assessed slow runoff in patients (pts) with angiographically normal coronary artery is controversial. Non-invasevely assessed absolute coronary flow reserve (CFR) in in the left anterior descending coronary artery (LAD) by Color guided pulsed-wave Doppler is a reliable parameter to assess coronary microcirculatory dysfunction (CMD). So this study aimed at assessing the value of slow runoff in predicting CMD. Results: We studied 38 consecutive pts with angiographically normal coronary artery that underwent non-invasive assessement of CFR in the LAD. We found that 9 pts out of 38 (group 1)had slow runoff and the remaining 29 had normal runoff (group 2). The CFR evaluated in the the 2 groups was not significantly different (see graph). CFR was infact, in the group 1 (Mean +/- SD) = 2,79+/- 0,8 and in the group 2= 2,89 +/- 0,7 (p= ns). In addition considering a CFR value =&lt; 2,5 as index of coronary microcirculatory dysfunction, we found CMD in 3 pts of group 1 (33%) and in 8 pts of group 2 (27%) (p=ns). The calculated sensitivity and specificity of slow runoff in predicting CMD was at 44% and 64% respectively. Conclusion: Slow runoff is not a good predictor of coronary microcirculatory dysfunction and its clinical value, if any, is uncertain and probably multifactorial.

Background. The meaning of the slow coronary flow phenomenon, (SCF) as visualized in patients (pts) with angiographically normal coronary arteries, is controversial. Non-invasively assessed absolute coronary flow reserve (CFR) in the left anterior descending coronary artery (LAD) by transthoracic colour guided pulsed-wave Doppler is a reliable parameter to assess coronary microcirculatory dysfunction (CMD). This study aimed to assess the value of SCF in predicting CMD. Methods. Seventy-three consecutive pts with angiographically normal coronary arteries underwent both non-invasive assessment of CFR in the LAD and TIMI frame count assessment of coronary contrast runoff. Results. We found that 13 pts out of 73 (group 1) had SCF and the remaining 60 had normal runoff (group 2). The CFR evaluated in both groups was not significantly different (see graph). CFR was 2.86+ 0.7 (Mean + SD) in group 1, and 2.89 + 0.8 in group 2 (p= ns). In addition, considering a CFR value &lt; 2.5 as an index of coronary microcirculatory dysfunction, we found CMD in 5 pts of group 1 (38%) and in 20 pts of group 2 (33%) (p=ns). The calculated sensitivity and specificity of SCF in predicting CMD was 20% (5/20) and 83% (40/48) respectively (p=ns). Conclusion: The slow coronary flow phenomenon is not a good predictor of coronary microcirculatory dysfunction as assessed by absolute CFR. It might reflect, however, only a resting microcirculatory abnormality and probably remains a multifactorial phenomenon.