Mai Tone Lønnebakken

Hypertension is associated with atherosclerosis and cardiac and vascular structural and functional changes. Myocardial ischemia may arise in hypertension independent of coronary artery disease through an interaction between several pathophysiological mechanisms, including left ventricular hypertrophy, increased arterial stiffness and reduced coronary flow reserve associated with microvascular disease and endothelial dysfunction. The present case report demonstrates how contrast stress echocardiography can be used to diagnose myocardial ischemia in a hypertensive patient with angina pectoris but without significant obstructive coronary artery disease. The myocardial ischemia was due to severe resistant hypertension complicated with concentric left ventricular hypertrophy and increased arterial stiffness.

To evaluate whether lower stroke volume during antihypertensive treatment is a predictor of cardiovascular events independent of left ventricular geometric pattern. The association between left ventricular stroke volume and combined cardiovascular death, stroke and myocardial infarction, the prespecified primary study endpoint, was assessed in Cox regression analysis using data from baseline and annual follow-up visits in 855 patients during 4.8 years of randomized losartan-based or atenolol-based treatment in the Losartan Intervention For Endpoint reduction in hypertension (LIFE) echocardiography substudy. During follow-up, a total of 91 primary endpoints occurred. At baseline, lower left ventricular stroke volume was associated with smaller body size, female sex, lower left ventricular mass and stress-corrected midwall shortening, higher relative wall thickness and total peripheral resistance, more concentric left ventricular geometry and impaired diastolic relaxation (all P < 0.01). Baseline stroke volume did not predict outcome. However, in time-varying multivariable Cox regression analysis, lower in-treatment left ventricular stroke volume indexed for height was associated with higher risk of cardiovascular events {hazard ratio 1.69 per 1 SD (6 ml/m) lower stroke volume [95% confidence interval (CI) 1.35-2.11], P < 0.001} independent of in-treatment left ventricular mass and concentric geometry and in a secondary model also independent of stress-corrected midwall shortening, impaired diastolic relaxation, heart rate, new-onset atrial fibrillation and study treatment [hazard ratio 1.46 per 1 SD (6 ml/m) lower stroke volume (95% CI 1.13-1.88)]. Assessment of in-treatment left ventricular stroke volume may reflect cardiac and vascular remodeling and impairment and, hence, adds information on cardiovascular risk in treated hypertensive patients beyond assessment of left ventricular structure alone. NCT 00338260.

Internal jugular vein thrombosis is a serious event with potentially fatal outcome, where the clinical symptoms may be vague or absent. This paper refers to a rare case where routine carotid Doppler ultrasound prior to coronary artery bypass grafting (CABG) and aortic valve replacement (AVR) in a 76-year-old man, incidentally revealed thrombosis of the right internal jugular vein. Thoracic CT demonstrated an underlying, large, benign substernal multinodular goiter, mainly involving the right lobe, causing compression and displacement of the great vessels. A successful, one-stage operation including ligation of the internal jugular vein to avoid pulmonary embolism and hemithyroidectomy, combined with the scheduled CABG and AVR, was performed. This case illustrates that benign substernal goiter may be associated with asymptomatic internal jugular vein thrombosis. Carotid Doppler ultrasound should involve evaluation of the internal jugular vein concerning thrombosis as its presence may reveal space-occupying lesions in the thorax.

Contrast echocardiography is a safe, accurate, and reproducible method to assess left ventricular volumes and function. Based on current guidelines, ultrasound contrast is indicated for left ventricular opacification at rest in patients with suboptimal echocardiographic images, and in stress echocardiography when >or= 2 adjacent segments are poorly visualised. Adding contrast for assessment of regional myocardial perfusion expands the use of echocardiography in ischemic heart disease from detection of left ventricular dysfunction at rest or during stress to assessment of myocardial ischemia, extent of myocardial necrosis and re-flow after coronary revascularisation. Myocardial perfusion also adds prognostic information to that given by structural and functional assessment alone and may reduce the need for more time consuming, expensive cardiac imaging procedures associated with radiation as well as coronary angiography with the risk of vascular complications. This article gives an overview of ultrasound contrast agents and their impact on echocardiographic assessment of ischemic heart disease also discussing recent patents.

A 72-year-old woman was hospitalized with recurrent acute coronary syndrome after initial successful treatment of acute ST-elevation myocardial infarction with percutaneous coronary intervention. Echocardiography demonstrated unexpectedly a 9 × 8 mm pendulating structure attached to the anterior, proximal interventricular septum in the left ventricular outflow tract 6 mm beneath the aortic valve annulus. Magnetic resonance imaging of the heart yielded the same findings. The patient underwent coronary artery bypass grafting and tumour excision. The histopathological findings were typical for papillary fibroelastoma (PFE) with a central zone of connective tissue and some elastic fibres without blood vessels and covered by endocardium. PFE is the third most common type of primary cardiac tumours, second to myxoma and lipoma. PFEs are avascular papillomas that predominantly occur on the aortic and mitral valves (90%). However, the present case demonstrates that PFE occasionally can be attached to the ventricular wall endocardium.

Aims Quantitative contrast stress echocardiography (CSE) can assess regional myocardial perfusion. The aim of this study was to evaluate the performance of quantitative CSE in the detection of restenosis after percutaneous coronary intervention (PCI). Methods and results Thirty-three patients with stable coronary artery disease, scheduled for PCI, underwent CSE and quantitative coronary angiography (QCA) before and 9 months after PCI. Regional myocardial perfusion was analysed blinded to QCA results. QCA identified 38 significant stenoses (≥50% diameter reduction). Before PCI, perfusion during stress was significantly reduced in regions supplied by stenotic arteries; blood flow velocity (Δβ) −3.9 (−9.0 to 0.5) s⁻¹, perfusion rate (ΔA×β) −175.0 (−518.0 to 58.5) s⁻¹, and refilling time (Δrt) 210 (−22 to 452)ms, compared with the perfusion increase seen in regions supplied by non-stenotic arteries; Δβ 1.6 (−0.7 to 4.4) s⁻¹, ΔA×β 151.7 (−67.0 to 300.5) s⁻¹, and Δrt −47 (−195 to 89) ms, all P < 0.05. At follow-up, regional stress-induced perfusion improved in 29 regions with successful PCI; Δβ 0.1 (−2.7 to 3.6), ΔA×β 30.5 (−133.3 to 232.1), and Δrt −99 (−247 to 125), all P ≤ 0.01, although there was no improvement in nine regions with restenosis; Δβ 0.9 (−1.5 to 5.3), ΔA×β 65.7 (−40.8 to 412.6), and Δrt −79 (−268 to 163), P = NS. Conclusion Quantitative CSE has the potential to detect angiographically significant coronary artery stenoses as well as angiographic success after PCI. Trial registration: ClinicalTrials.gov Identifier: NCT00354081.

Ultrasound is the preferred imaging modality in diagnosis of vascular complications following cardiac catheterization and intervention. In some cases, however, bleeding surrounding the femoral vessels, may severely distort the color Doppler images, making detection of venous complications especially difficult. This report refers to such a case where post-catheterization haematoma was suspected to cause an obstruction of the femoral vein. Spectral Doppler recordings of blood flow in the common femoral vein, up-stream, distal to the hemorrhagic area, confirmed the diagnosis of obstruction by demonstrating changes in the venous flow pattern in the common femoral vein, consistent with venous hypertension. Due to the poor quality of the ultrasound images, the exact cause of the obstruction had to be established by another imaging modality, not affected by haemorrhages. CT showed that the common femoral vein was compressed at the puncture site by surrounding haemorrhages. Thus, when bleeding due to cardiac catheterization is associated with possible venous obstruction and findings by color Doppler are equivocal due to degradation of the color-Doppler image, detection of venous hypertension by spectral Doppler, performed distal to the bleeding area, strongly supports the presence of venous obstruction where the exact cause may be established by CT.

In antiphospholipid syndrome (APS), there is a high prevalence of valvular heart disease which leads to increased risk of thrombo-embolic events, in particular, cerebrovascular events. We present a patient with cerebral infarction, previous deep-vein thrombosis, and miscarriages with positive lupus anticoagulant and anticardiolipin antibodies. Echocardiographic examination revealed mitral valve leaflet thickening and verrucous vegetations consistent with Libman–Sacks endocarditis, which is commonly associated with APS. In patients with combined Libman–Sacks endocarditis and antiphospholipid antibodies, anticoagulation therapy with warfarin is indicated due to high risk of valvular thrombus formation and subsequent embolization.

A 25-year-old woman presented with Streptococcus milleri brain abscess. Previous cardiac history was unremarkable. In search for a source of embolism echocardiography was performed and revealed a previous undiagnosed Ebstein's anomaly of moderate severity with apical displacement of the septal leaflet of the tricuspid valve and a secundum atrial septal defect (ASD) with left to right shunt. The combination of increased right atrial pressure caused by Ebstein's and an ASD with possibility of transient right to left shunt predispose for paradoxical embolization. The most likely reason for development of a brain abscess in this patient is septic embolization from an infectious focus outside the heart. Ebstein's anomaly can remain undiagnosed until adulthood if the right ventricle, in spite of the smaller size, is haemodynamically well functioning.