The increased incidence of adverse cardiovascular events in patients with aortic sclerosis is associated with coronary artery disease and inflammation, not a result of the effects of valvular heart disease per se.

The direct manipulation of coronary blood flow to induce regional myocardial ischemia has been almost entirely limited to experimental animal models. Thus, the detection of ischemia-induced left ventricular dysfunction in human subjects has been generally limited to observations made under conditions of diagnostic loading or during spontaneous clinical events. Percutaneous coronary angioplasty requires repeated interruptions of coronary blood flow for periods as long as 1 minute. The resulting appearance of or increase in ischemia-produced changes in myocardial function were detected by two-dimensional echocardiography in 18 patients undergoing angioplasty of 22 coronary stenoses. Accordingly, left ventricular contraction was studied during 52 episodes of regional coronary blood flow interruption and reperfusion in the process of inflating and deflating the angioplasty balloon. Before angioplasty, left ventricular wall motion was normal in 14 patients. There was mild anteroapical hypokinesia in two patients, anteroapical akinesia in one and mild inferior hypokinesia in one. Balloon inflations repeatedly produced new or increased wall motion abnormalities in the distribution of the instrumented coronary artery in 19 (86.4%) of the 22 procedures, but did not alter wall motion during angioplasty of one left circumflex artery lesion, one highly collateralized left anterior descending artery stenosis and one left anterior descending stenosis that had already caused severe anteroapical dyssynergy. Hypokinesia, usually rapidly progressing to dyskinesia, began 19 +/- 8 seconds (mean +/- SD) after coronary occlusion. Wall motion began to normalize 17 +/- 8 seconds after reperfusion.(ABSTRACT TRUNCATED AT 250 WORDS)

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Cor triatriatum dexter is a rare congenital anomaly in which an obstructive membrane is located in the right atrium. The detection usually occurs after the sequelae of systemic congestion, coagulopathy, and hepatic dysfunction have set in, leading up to a high surgical risk. A percutaneous balloon correction of cor triatriatum dexter in a patient with advanced right-sided congestive symptoms and hepatic dysfunction is presented. This efficacious method is an alternative to surgical correction and could be extended to the more common cor triatriatum sinistra.

Abstract. Objective: To prospectively examine the diagnostic accuracy of two-dimensional transthoracic echocardiography (2-D echo) in emergency department (ED) patients being evaluated for acute pulmonary embolism (PE). Methods: This was a 14-month prospective observational trial of a convenience sample of ED patients undergoing evaluation for suspected PE at a suburban teaching hospital. The 2-D echo was defined as positive if any two of the following were noted: right ventricular dilation, abnormal septal motion, loss of right ventricular contractility, elevated pulmonary artery or right ventricular pressures, moderate to severe tricuspid regurgitation, or visualization of a clot seen in the right ventricle or pulmonary artery. The patient was considered to have a PE if one of the following was positive: a pulmonary angiogram, contrast helical computed tomography, a magnetic resonance angiogram, a high-probability ventilation/perfusion (V/Q) scan without contradictory evidence, or an intermediateprobability V/Q scan with ultrasonic evidence of deep venous thrombosis. Results: Of 225 cases identified, 39 met the defined criteria for PE (17%). A 2-D echo was performed on 124 patients (55%), of whom 27 (22%) had PE. In 20 patients the 2-D echo had at least two indicators of right ventricular strain; however, only 11 of these patients had confirmed pulmonary embolus. The 2-D echo had a sensitivity of 0.41 (95% CI = 0.32 to 0.49) and a specificity of 0.91 (95% CI = 0.86 to 0.96). The likelihood ratio positive was a moderately strong 4.4, with a weak likelihood ratio negative of 0.6. Conclusions: Bedside 2-D echo is not a sensitive test for the diagnosis of PE in ED patients. Positive findings moderately increase the suspicion for PE but are not diagnostic. Key words: two-dimensional echocardiography; transthoracic echocardiography; diagnosis; pulmonary embolism. ACADEMIC EMERGENCY MEDICINE 2000; 7:994-998 D IAGNOSTIC evaluation for acute pulmonary embolism (PE) continues to challenge experienced emergency medicine (EM) clinicians. A number of recent publications have observed that two-dimensional transthoracic echocardiography (2-D echo) may play a diagnostic role and provide important hemodynamic information reflecting the effect of a pulmonary embolus on the function of the right heart. 1-10 We have previously reported the diagnostic utility of 2-D echo for PE when compared with the criterion standard, pulmonary angiography.11 However, concerns regarding these findings include the retrospective nature of the study based on a medical record review, and that the study population was biased by including patients who developed an embolism after admission, and then only those whose diagnosis was uncertain and for whom conditions permitted a pulmonary angiogram. To the best of our knowledge, there have been no prior prospective studies with 2-D echo of emergency department (ED) patients considered by the emergency physician as potentially having a PE. Because of these issues, we prospectively examined the diagnostic...

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