Role of orthotopic heart transplantation in the management of patients with recurrent ventricular tachyarrhythmias following myocardial infarction

Objective—To report the outcome of an intention to treat by heart transplantation strategy in two groups of patients after infarction, one with both left ventricular failure (LVF) and ventricular tachyarrhythmias (VTA) (group A) and the other with progressive LVF following antiarrhythmic surgery for VTA (group B).
Patients and methods—Group A comprised 17 consecutive patients for whom transplantation was considered the best primary non-pharmacological treatment; group B comprised five consecutive patients assessed and planned for transplantation after antiarrhythmic surgery.
Results—In group A, eight patients underwent transplantation and all survived the first 30 day period. At median follow up of 55 months (range 11 to 109) seven of this subgroup were still alive. Five patients died of recurrent VTA before transplantation, despite circulatory support. In the face of uncontrollable VTA, four of these underwent "high risk" antiarrhythmic surgery while awaiting transplantation: three died of LVF within 30 days and one was saved by heart transplantation two days after arrhythmia surgery. Mortality for the transplantation strategy in group A patients was 47% by intention to treat analysis. Quality of life in the eight actually transplanted, however, was good and only one died during median follow up of 56 months. The five patients in group B were accepted for transplantation for progressive LVF at a median of 21 months (range 12 to 28) after antiarrhythmic surgery. One died of LVF before transplantation, 22 months after initial surgery; another died of high output LVF three days after transplantation. Thus mortality of the intended strategy was 40%. The three transplanted patients are alive and well at 8-86 months.
Conclusions—Although the short and medium term outcome in category A or B patients who undergo transplantation is good, the overall success of the transplantation strategy in category A patients is limited by lack of donors in the short time frame in which they are required.

Keywords: heart transplantation;  ventricular arrhythmias;  myocardial infarction     

Myocardial ischaemia in a case of a solitary coronary ostium in the right aortic sinus with retroaortic course of the left coronary artery: documentation of the underlying pathophysiological mechanisms of ischaemia by intracoronary Doppler and pressure measurements

Only a few cases of a single coronary ostium and retroaortic course of the coronary artery have been described. Almost all cases reported so far had additional coronary artery or valvar disease. However, myocardial ischaemia may be caused by the coronary malformation alone. A 40 year old woman with severe myocardial ischaemia in the absence of clinically relevant coronary atherosclerosis is described. To clarify the origin and mechanisms of ischaemia, intracoronary Doppler, pressure and ultrasound studies were performed using microtransducers. In its outer portion along the course behind the ascending aorta, coronary blood flow velocities were increased, there was an external elliptical compression, and distal coronary flow reserve was reduced. Furthermore, an overshoot in diastolic pressure above aortic pressure was detectable within this portion. Dobutamine stimulation exaggerated the observed intracoronary haemodynamics and induced myocardial ischaemia. The intracoronary diagnostic procedures performed were helpful in clarifying the pathophysiological mechanisms of functional coronary obstruction and ischaemia in this malformation. Bypass surgery was successfully performed with symptomatic improvement.

Keywords: coronary anomaly;  Doppler;  intravascular ultrasound;  single coronary ostium;  congenital disorders     

Diverging effects of postextrasystolic potentiation on left ventricular segmental wall motion in coronary heart disease

The effects of postextrasystolic potentiation (PESP) on regional left ventricular (LV) wall motion were evaluated in 40 coronary artery disease (CAD) patients. Of the 40 CAD patients, 20 had a prior myocardial infarction and 20 had a history of angina pectoris. PESP was obtained by applying programmed atrial stimulation during LV angiography, in a way that basal cycle length, premature beat, and postextrasystolic pause were almost identical in all patients. Segmental wall motion was evaluated by calculating regional ejection fraction (EF) of 5 different areas with a computerized method before and after the premature beat. The results were compared to those obtained in a group of 8 normal subjects. LV areas were classified as normokinetic, mildly hypokinetic, severely hypokinetic, and hyperkinetic, on the basis of their regional EF in respect to normals, and classified as "responder" (R) and "nonresponder" on the basis of the magnitude of the increase of regional EF with PESP. Of a total of 200 areas 129 were normokinetic (68% R), 45 were mildly hypokinetic (78% R), 17 severely hypokinetic (76% R), and 9 were hyperkinetic (78% R). Infarcted patients had a higher percentage of hypokinetic areas in basal conditions (p less than 0.001), however, the percentage of hypokinetic areas that responded to PESP was not significantly different from noninfarcted patients. In CAD patients, as a whole, a significant direct correlation was found between basal regional EF and regional EF after PESP (r = 0.88, p less than 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)     

Coronary flow reserve in the contralateral artery increases after successful coronary angioplasty in patients with spontaneously visible collateral vessels

Objective—To test the hypothesis that coronary flow reserve could increase in the angiographically normal contralateral artery after successful coronary angioplasty of an ipsilateral coronary artery.
Design—Coronary flow reserve was estimated using a Doppler flow guide wire, by giving intracoronary adenosine in the contralateral artery, before and 15 minutes after the end of angioplasty.
Setting—Tertiary referral centre.
Patients—31 patients, mean (SD) age 56 (11) years, with stable angina and single vessel disease, undergoing angioplasty of the right coronary or the left anterior descending artery.
Results—In the contralateral artery baseline average peak velocity was 21 (9) cm/s before angioplasty and decreased to 12 (6) cm/s after (p < 0.005), while hyperaemic average peak velocity was 47 (19) cm/s before and decreased to 34 (15) cm/s after (p < 0.005). However, coronary flow reserve in the contralateral artery was 2.4 (0.7) before angioplasty and increased to 2.9 (0.6) after (p < 0.05). The contralateral coronary flow reserve after angioplasty increased by 0.8 (0.4) in 11 patients with visible collaterals before angioplasty and by 0.3 (0.6) in the remaining patients without visible collaterals (p < 0.05). Blood pressure and heart rate were unchanged after the procedure.
Conclusions—Coronary flow reserve in an angiographically normal contralateral artery increases after successful coronary angioplasty of the ipsilateral artery in patients with spontaneously visible collateral vessels before the procedure.

Keywords: coronary flow reserve; contralateral coronary artery; angioplasty     

Endoluminal vessel reconstruction by stent placement in patients with obstructive coronary artery disease who are poor surgical candidates

Objective—To investigate the safety and efficacy of endoluminal vessel reconstruction by intracoronary stenting in patients with single or multivessel disease who have been turned down for surgical revascularisation.
Design—An observational, single centre trial of consecutive patients being followed up clinically.
Setting—Tertiary referral centre.
Patients—43 patients treated between 1995 and 1996 with a clinical follow up period of at least six months.
Main outcome measures—Acute procedural success following intervention (defined as a residual stenosis of < 30% with normal antegrade flow and without acute clinical complications); major adverse clinical events (death, myocardial infarction, repeat intervention, clinical restenosis); and functional status during follow up.
Results—Acute procedural success was achieved in 39 patients. Failures resulted from a refractory no reflow phenomenon with Q wave myocardial infarction (two patients), and from subacute stent thrombosis (one patient) and saphenous vein graft rupture at stent site (one patient), both manifesting by non-Q wave myocardial infarction. During a follow up period of 17 (8) months (mean (SD)), three of these patients died. Clinical restenosis was treated by repeat percutaneous intervention in 11 patients, while 28 patients remained asymptomatic. On a Kaplan-Meier estimate, the proportion of patients without adverse clinical events at two years was 65%.
Conclusions—Percutaneous reconstruction of diseased coronary arteries in patients with single or multivessel disease turned down for surgical revascularisation may be considered as a valuable treatment option. On follow up, more events seem to be encountered than after elective de novo stenting of discrete coronary lesions. This is probably related to higher clinical restenosis rates.

Keywords: coronary artery disease;  stents;  restenosis     

Comparison between segmental wall motion and wall thickening in patients with coronary artery disease using quantitative gated SPECT software

This study was performed to evaluate regional wall motion (WM) and wall thickening (WT) using gated myocardial perfusion single photon emission computed tomography (SPECT) and to determine their similarity and disparity in patients with coronary artery disease (CAD). A total of 44 patients underwent 1 day stress/rest (MIBI) gated SPECT. Commercially available quantitative analysis of gated SPECT (QGS) software was used to generate 3D surface display and cine-mode SPECT display. Left ventricle was divided into nine segments to score WM and WT from 0 (no abnormality) to 4 (severe abnormality) by six independent observers. Finally a mean score was calculated for each segment from the scores of six observers. There was fairly good correlation between WM and WT of individual segments (r = 0.62, p < 0.0001). Concordance rate (|WM – WT|1) was 85%. A large difference between WM and WT (WM – WT2) was observed in 15 segments, including 12 segments with greater WM abnormalities and 3 segments with greater WT abnormalities (lateral and inferior walls). Greater WM abnormalities were most commonly observed in anteroseptal segments especially in post coronary artery bypass grafting (CABG) patients. In conclusion, WM and WT showed similarity on QGS studies. However, these two parameters may be determined separately in gated SPECT studies for comprehensive and robust evaluation of the functional status of myocardium. Analyses based on WM assessment alone may lead to erroneous results especially in septal regions.     

Effect of puerarin on myocardial perfusion and ventricular wall motion in patients with acute coronary syndrome

Objective To investigate the effects of puerarin (Pur) on myocardial perfusion and ventricular wall motion in patients with acute coronary syndrome (ACS).Methods Thirty-seven patients with ACS were randomly divided into two groups:conventional treatment group (n= 17,11 males,range of age:32-80 years,average age:60.9±4.9 years) and Pur treatment group (n=20,12 males,range of age:40-76 years,average age:62.7±3.5 years).Patients in the conventional treatment group received standard treatment according to the current guidelines,while patients in the Pur treatment group received intravenous administration of Pur (500 mg/day) for 10 days plus conventional treatment.Real-time myocardial contrast echocardiography (RT-MCE) was performed to evaluate the change in myocardial perfusion index (MPI) and ventricular wall motion index (VWMI) at admission and 10 days after treatment.Results At 10 days after treatment,MPI was significantly higher (P<0.01) and VWMI significantly lower (P<0.01) in the Pur group comparing with those in the conventional group.Conclusions Puerarin might improve myocardial microcirculation perfusion and ventricular wall motion in patients with ACS.     

Effect of Puerarin on the myocardial perfusion and ventricular wall motion in patients with acute coronary syndrome

Objective The purpose of the present study was to investigate the effect of Puerarin (Pur) on the myocardial perfusion and ventricular wall motion in patients with acute coronary syndrome (ACS). Methods Thirty-seven patients with ACS were randomly divided into two groups: conventional group (n=17, 11 men and 6 women, with a range of age from 32 to 80 years, and with a mean age 60.9±4.9 years) and Pur group (n=20, 12 men, 8 women, with a range of age from 40 to 76 years, and with a mean age 62.7±3.5 years). Course of treatment for all patients was 10 days. Real-time myocardial contrast echocardiography (RT-MCE) was applied to two groups before and after the therapy to evaluate myocardial microcirculation and ventricular wall motion by observing the change of myocardial perfusion index (MPI) and ventricular wall motion index (VWMI). Results The level of MPI increased and VWMI decreased after 10 days of the therapy, which is significant difference between the Pur group and conventional group (P<0.05). Conclusions Puerarin can increase the level of MPI and decrease the level of VWMI in patients with ACS. Myocardial microcirculation perfusion and ventricular wall motion could be improved probably in patients with ACS treated by Puerarin.     

急性心肌梗死患者室壁运动及心功能损害与发病-超声检查时间的关系

目的 探索急性心肌梗死患者室壁运动及心功能损害与发病-超声检查时间的关系.方法 收集初发急性心肌梗死患者219例,均已排除陈旧性心肌梗死、早期心肌再梗死、严重的瓣膜性心脏病、先天性心脏病、心肌病等影响室壁运动及心功能的疾病.所有患者均在予冠状动脉介入干预前行经胸超声心动图检查,采用二维超声等方法测量或（和）计算左心室舒张末期内径（left ventricular diameters in diastasis,LVDd）、收缩末期内径（left ventricular diameters in systole,LVDs）、左心室射血分数（left ventricular ejection fraction,LVEF）、室壁运动计分指数（wall motion index,WMI）及运动正常节段（fragments with normal wall motion,FM）百分比等参数,并精确记录发病-超声检查时间.结果 WMI、LVDd、LVDs、LVEF、FM百分比与发病-超声检查时间的相关关系均有统计学意义（P＜0.05）,相关系数分别为0.167,0.235,0.258,-0.196,-0.144.在WMI的多重线性回归分析结果显示,变量FM百分比、LVEF、左回旋支和（或）右冠状动脉进入方程（R2=0.878,justed R2=0.876）,偏回归系数分别为-1.103,-0.030,-0.001.结论 对于未予冠状动脉介入干预的急性心肌梗死患者,其室壁运动及心功能均随发病-超声检查时间的增加而减弱.     

Incidence of exertional right ventricular wall motion abnormalities in patients with coronary artery disease

To evaluate the role of analysis of right ventricular function with exercise in patients with presumed coronary artery disease referred for radionuclide ventriculography, the records of 55 patients referred to our laboratory over a 19-month period were reviewed. All underwent rest and exercise first-pass radionuclide stress testing and cardiac catheterization within a period of four months. Three groups were identified: (1) patients with normal exercise right ventricular function (n = 24); (2) patients with exercise-induced right ventricular regional wall motion abnormalities (n = 15); and, (3) patients with abnormal resting right ventricular function without new exercise abnormalities (n = 16). Patients in each group were similar in age, sex, baseline left ventricular function, medication usage, and indication for study. The incidence of right coronary artery disease was identical in the three groups, as was the incidence of left ventricular functional abnormalities with exercise. Patients with proximal right coronary artery disease were more likely to have reduced left ventricular ejection fraction and more extensive coronary artery disease than those without disease at this site. We conclude that: (1) analysis of rest and exercise right ventricular function does not allow prediction of coronary anatomy in an unselected group of patients; (2) normal right ventricular function with exercise is compatible with extensive coronary artery disease, including proximal right coronary artery disease; and (3) abnormal exercise right ventricular function may be due to exertional left ventricular dysfunction in the absence of proximal right coronary artery disease.     

The relation between left ventricular asynchrony, relaxation, outward wall motion and filling characteristics during control period and pacing-induced myocardial ischaemia in coronary artery disease

To assess the relation between left ventricular asynchrony, relaxation, outward wall motion and filling in patients with coronary artery disease and normal systolic function, pressure measurements and left ventricular angiography were performed at rest and after pacing. Asynchrony and outward wall motion were quantified by segmental area-time curves. At rest, there were no differences in asynchrony and time constant between 10 patients with coronary artery disease and 10 normal subjects, while the early-filling rate was less in patients with coronary artery disease than in normal subjects. Six coronary artery disease patients with isolated left anterior descending disease displayed anterior outward wall motion which was less than that of normal subjects. In 10 coronary artery disease patients with pacing-induced angina, asynchrony increased, time constant prolonged and the early-filling rate decreased. In 6 coronary artery disease patients with isolated left anterior descending disease, anterior outward wall motion decreased after pacing. Thus, impaired early diastolic filling at rest in patients with coronary artery disease and normal systolic function may result not from asynchrony nor impaired relaxation, but from reduced regional outward wall motion of the affected area supplied by diseased coronary artery during early diastole. However, during ischaemia temporal asynchrony and impaired relaxation possibly add to left ventricular filling impairment in patients with coronary artery disease.     

Prediction of coronary artery disease by left ventricular regional wall motion abnormalities in patients with stenosis of the aortic valve

To identify predictive factors for coronary artery disease in patients with stenosis of the aortic valve the clinical histories, haemodynamic measurements, biplane contrast left ventriculograms, and coronary angiograms of 83 consecutively catheterised patients with valvar aortic stenosis were examined retrospectively. The mean (SD) age was 66.4 (9.1) years and 78% were men. Fifty five patients had significant coronary artery disease (greater than or equal to 50% diameter narrowing). Forty five (82%) of 55 patients with and 23 (82%) of 28 patients without coronary disease had angina. Heart failure occurred in a third of the patients; these patients were on average older, were more likely to be female, and had lower ejection fractions and cardiac outputs than patients in whom failure did not occur. Calculated valve area, transvalvar gradient, and left ventricular end diastolic pressure did not discriminate between patients with and without coronary disease. Syncope was less common than angina and heart failure and was associated with significantly lower valve areas and higher gradients than those found in patients without syncope. Left ventricular regional wall motion abnormalities were equally common in the groups with and without angina and predicted coronary artery disease with 94% accuracy. The absence of regional wall motion abnormality was an insensitive marker of normal coronary arteries as 45% of such patients had coronary disease. Five of the 83 patients had significant coronary disease without angina or regional wall motion abnormality. In patients with aortic stenosis angina did not predict the presence of coronary artery disease; therefore, it is advisable to have the results of coronary angiography before aortic valve replacement in a population such as this. Two of the patients with heart failure and severe aortic stenosis had regional wall motion abnormality with normal coronary arteries. Thus in some patients left ventricular failure produced by increased afterload may itself be a cause of left ventricular regional wall motion abnormality.     

Left ventricular diastolic filling in patients with coronary artery disease without myocardial infarction

Left ventricular diastolic dysfunction at rest was studied in 24 patients with coronary artery disease but no evidence of previous myocardial infarction. Seven patients with normal coronary arteries were studied as control. Diastolic filling was analyzed by the serial left ventricular volume and 14 radial axes from the gravity point of the left ventricle with cine left ventriculography. There were no differences in the systolic function between coronary artery disease and the normal control. Peak filling rate was decreased significantly in the groups with left anterior descending artery disease (LAD, p less than 0.05) and multivessel disease (MVD, p less than 0.05), but not in the group with right coronary artery disease (RCA). Time to peak filling rate was prolonged in each group of LAD (p less than 0.05), RCA (p less than 0.05), and MVD (p less than 0.001), compared with controls. The time-volume curve showed disturbed rapid filling in the LAD and RCA groups, and also both depressed rapid and slow filling in the MVD group. In the LAD group, the filling fraction was decreased significantly at the time of 25% of the diastolic period (p less than 0.001) and radial distension to the anterior wall was decreased at the time of 25%, 50%, and 75% of the diastolic period, compared with controls. In the RCA group, the filling fraction (p less than 0.001) and radial distension to the posterior wall were decreased only at the time of 25% of the diastolic period. In the MVD group, filling fraction and radial distension to the most wall were decreased at 25%, 50%, and 75% of the diastolic period.(ABSTRACT TRUNCATED AT 250 WORDS)     

Prediction of coronary artery disease by left ventricular regional wall motion abnormalities in patients with stenosis of the aortic valve.

To identify predictive factors for coronary artery disease in patients with stenosis of the aortic valve the clinical histories, haemodynamic measurements, biplane contrast left ventriculograms, and coronary angiograms of 83 consecutively catheterised patients with valvar aortic stenosis were examined retrospectively. The mean (SD) age was 66.4 (9.1) years and 78% were men. Fifty five patients had significant coronary artery disease (greater than or equal to 50% diameter narrowing). Forty five (82%) of 55 patients with and 23 (82%) of 28 patients without coronary disease had angina. Heart failure occurred in a third of the patients; these patients were on average older, were more likely to be female, and had lower ejection fractions and cardiac outputs than patients in whom failure did not occur. Calculated valve area, transvalvar gradient, and left ventricular end diastolic pressure did not discriminate between patients with and without coronary disease. Syncope was less common than angina and heart failure and was associated with significantly lower valve areas and higher gradients than those found in patients without syncope. Left ventricular regional wall motion abnormalities were equally common in the groups with and without angina and predicted coronary artery disease with 94% accuracy. The absence of regional wall motion abnormality was an insensitive marker of normal coronary arteries as 45% of such patients had coronary disease. Five of the 83 patients had significant coronary disease without angina or regional wall motion abnormality. In patients with aortic stenosis angina did not predict the presence of coronary artery disease; therefore, it is advisable to have the results of coronary angiography before aortic valve replacement in a population such as this. Two of the patients with heart failure and severe aortic stenosis had regional wall motion abnormality with normal coronary arteries. Thus in some patients left ventricular failure produced by increased afterload may itself be a cause of left ventricular regional wall motion abnormality.     

Significance of echocardiographic atrioventricular plane displacement for the evaluation of left ventricular filling and end-diastolic pressure in patients with coronary artery disease

The aim of this study is to assess the left ventricular filling and estimate the end-diastolic pressure of the left ventricle in patients with coronary artery disease (CAD) by echocardiographic measurement of the atrioventricular plane displacement (AVPD). In 101 patients (mean age 59 ±12 years) with CAD, a complete transthoracic echocardiographic study was performed, just prior to cardiac catheterization. The AVPD was recorded by Mmode echocardiography, from apical four and two chamber views. The recordings were obtained at four sites, corresponding to the septal, lateral, anterior and inferior walls of the left ventricle. The mean AVPD resulting from atrial systole (At), the mean total (T) diastolic AVPD, the ratio At/T(%) and the ratio of mitral annulus excursion during early and late diastole [(T-At)/At] were calculated. Firty-two age-matched healthy subjects served as control group. Both At and At/T were significantly greater in patients with CAD than in the controls (6.06 ±0.94 vs 5.53 ±0.55 mm, p<0.01 and 43.4 ±5.9% vs 33.49 ±4.45%, p<0.001 respectively). The ratio [(T-At)/At] correlated with the E/A ratio of transmitral flow, both in healthy subjects (r=0.850, p<0.001) and in patients with CAD (r = 0.722, p<0.001). Correlation also existed both in patients with segmental wall motion abnormality (SWMA) (r = 0.691, p<0.001) and in patients with SWMA (r=0.818, p<0.001). In patients with CAD, At/T further correlated with the left ventricular end-diastolic pressure (r=0.517, p<0.001). In patients with SWMA and in patients without, a correlation was also found (r=0.516, p<0.001 and r=0.566, p<0.001 respectively). In conclusion, AVPD measured by echocardiography can be used as a simple noninvasive parameter to evaluate left ventricular filling in patients with CAD and for the gross estimation of end-diastolic pressure of left ventricle.     

Value of tissue Doppler imaging to predict left ventricular filling pressure in patients with coronary artery disease

Assessment of left ventricular (LV) diastolic filling pressure provides important information on the hemodynamic status in the general population. The aim of our study was to investigate the reliability of tissue Doppler imaging (TDI) in estimating left ventricular filling pressure in patients with coronary artery disease (CAD). We prospectively studied 32 consecutive CAD-patients, mean age 64 +/- 12 years, in sinus rhythm. All patients underwent cardiac catheterization and echocardiography within the same hour. Catheterization investigated pre-A-wave pressure (preA) and LV ejection fraction (LVEF). Echocardiographic LVEF was calculated using wall motion indexes (WMI) with segmental division of LV wall. The following Doppler parameters were assessed: (1) PW Doppler signals from the mitral inflow (E), (2) PW TDI of the mitral annulus (E'), thus allowing to obtain the mitral inflow to annulus ratio (E/E'). The best correlation between invasive and echocardiographic LVEF was observed using WMI (r = 0.91). The correlations between preA and E, E', and E/E' were significant (r = 0.36, r = 0.38, and r = 0.60, respectively). In patients with LVEF >50%, no correlation between E/E' and preA was found (r = 0.18, P = 0.44), whereas with LVEF <50%, this correlation was strong (r = 0.76, P < 0.001). In patients with myocardial infarction, the correlation between E/E' and preA was significant whatever the localization of myocardial infarction (r > 0.71, P < 0.05). ROC curve analysis identified an E/E'>9 to be the best cut-off value related to preA > 15 mmHg. We conclude that the mitral inflow-to-annulus ratio is a reliable method in CAD patients and allows determination of LV filling pressure when LVEF <50%.     

Diagnostic accuracy of 2-D echocardiography for detection of exercise-induced wall motion abnormalities in patients with coronary artery disease: comparison to biplane cineventriculography

To determine the accuracy of two-dimensional echocardiography (2-D echo) for assessment of exercise-induced wall motion abnormalities in patients with coronary artery disease, the results of stress echocardiography were compared with exercise cineventriculography. In 56 consecutive patients, biplane cineventriculography at rest and immediately after supine bicycle exercise was performed. Cross-sectional echo was obtained using the apical two- and four-chamber-views for left ventricular imaging under identical conditions. In 6 of the 56 patients 2-D echo, in 8 patients cineventriculogram, and in 2 patients both methods were of inadequate quality at rest or during exercise. Of the remaining 40 patients, 34 had coronary artery disease. Local wall motion in 360 wall segments from these patients was analyzed. In 49 segments (14%) in 24 of these patients exercise-induced ischemic wall motion abnormalities were evident during cineventriculography. Only 24 of these 49 asynergies (49%) were also recognized by 2-D echo. Using cross-sectional echocardiography, ischemia-related wall motion abnormalities were best detected septal, whereas apical asynergies were identified in only 3 of 12 segments (25%). Thus, the clinical value of exercise 2-D echo as a screening method in patients suspected of having coronary artery disease is limited and restricted to patients where excellent visualization of the left ventricular endocardium is possible.     

Reproducibility of equilibrium radionuclide ventriculography in patients with coronary artery disease: Response of left ventricular ejection fraction and regional wall motion to supine bicycle exercise

To evaluate the reproducibility of ejection fraction (EF) and regional wall motion (RWM) analyses by rest and exercise equilibrium radionuclide ventriculography (RNV) in the presence of coronary artery disease (CAD), 18 patients underwent two maximum, multistage supine bicycle exercise studies separated by an interval of 2 weeks. There were no significant differences in EF between the two studies, both at rest (56.0 ± 13.8% vs 58.2 ± 11.7%, p = NS) and with exercise (51.1 ± 17.6% vs 54.3 ± 17.6%, p = NS) and a highly significant correlation was shown between the two groups of values (rest r = 0.90, exercise r = 0.93, p < 0.001). There was no significant difference in the change from rest to exercise (?4.9 ± 12.0% vs ?3.8 ± 11.5%, p = NS) between the two studies and the correlation was highly significant (r = 0.69, p < 0.01). The interstudy variabilities were 2.2 ± 6.1% and 1.2 ± 7.3% for rest and exercise, respectively, and 2.0 ± 9.2% for the change from rest to exercise. Ninety-four percent of both rest and exercise regions had similar RWM. Eighty-one percent of the abnormally contracting regions were common to both exercise studies. Utilizing conventional criteria for the diagnosis of CAD, 11 patients had abnormal EF response and nine had abnormal RWM response to exercise on both studies. Combining EF and RWM criteria resulted in the diagnosis of CAD in 15 patients in both studies. We conclude that: (1) there were no significant differences in rest and exercise radionuclide EF and RWM between two supine bicycle exercise studies performed 2 weeks apart in patients with stable CAD and there were significant correlations between the two studies; (2) despite these correlations, the interstudy variabilities emphasize the need for the inclusion of reproducibility studies in all evaluations of interventions by exercise radionuclide ventriculography; and (3) the variations in EF and RWM response to exercise result in a lack of uniformity between the two studies regarding the diagnosis of CAD based on conventional RNV criteria.