In 105 patients with active infective endocarditis, disease-associated complications defined as severe heart failure (New York Heart Association class IV), embolic events and in-hospital death were correlated to the vegetation size determined by both transthoracic and transesophageal echocardiography. A detailed comparison between anatomic and echocardiographic findings, performed in a subgroup of 80 patients undergoing surgery or necropsy, revealed that true valvular vegetations can be reliably identified by echocardiography in the vast majority of patients; the detection rate was significantly higher for the transesophageal (90%) than for the transthoracic (58%) approach, particularly when infected prosthetic valves were evaluated. However, an accurate echocardiographic differentiation between true vegetations and other endocarditis-induced valve destruction (ruptured leaflets or chordae) is impossible. The correlation of vegetation size with endocarditis-associated complications showed that patients with a vegetation diameter greater than 10 mm had a significantly higher incidence of embolic events than did those with a vegetation diameter less than or equal to 10 mm (22 of 47 versus 11 of 58; p less than 0.01). Particularly for patients with mitral valve endocarditis, a vegetation diameter greater than 10 mm was highly sensitive in identifying patients at risk for embolic events. Vegetation size, however, was not significantly different in patients with and without severe heart failure or in patients surviving or dying during acute endocarditis. In addition, no significant correlation was found between vegetation size and location of endocarditis or type of infective organism.(ABSTRACT TRUNCATED AT 250 WORDS)

The data indicate that transesophageal echocardiography leads to a significant improvement in the diagnosis of abscesses associated with endocarditis. The technique facilitates the identification of patients with endocarditis who have an increased risk of death and permits earlier treatment.

T wave concordance in the normal human electrocardiogram (ECG) generally is explained by assuming opposite directions of ventricular depolarization and repolarization; however, direct experimental evidence for this hypothesis is lacking. We used a contact electrode catheter to record monophasic action potentials (MAPs) from 54 left ventricular endocardial sites during cardiac catheterization (seven patients) and a new contact electrode probe to record MAPs from 23 epicardial sites during cardiac surgery (three patients). All patients had normal left ventricular funtion and ECGs with concordant T waves. MAP recordings during constant sinus rhythm or right atrial pacing were analyzed for (1) activation time (AT) = earliest QRS deflection to MAP upstroke, (2) action potential duration (APD) = MAP upstroke to 90% repolarization, and (3) repolarization time (RT) = AT plus APD. AT and APD varied by 32 and 64 msec, respectively, over the left ventricular endocardium and by 55 and 73 msec, respectively, over the left ventricular epicardium. On a regional basis, the diaphragmatic and apicoseptal endocardium had the shortest AT and the longest APD, and the anteroapical and posterolateral endocardium had the longest AT and the shortest APD (p < .05 to < .0001). RT was less heterogeneous than APD, and no significant transventricular gradients of RT were found. In percent of the simultaneously recorded QT interval,-epicardial RT ranged from 70.8 to 87.4 (mean 80.7 + 3.9) and endocardial RT ranged from 80 to 97.8 (mean 87.1 4.4) (p < .001). Plotting of APD as a function of AT, independent of the recording site, revealed a close inverse relationship, such that progressively later activation was associated with progressively earlier repolarization The linear regression slope of this relationship averaged from all 10 hearts was -1.32 + 0.45 (r = -.78 + . 10). These data suggest a transmural gradient of repolarization,with earlier repolarization occurring at the epicardium. The negative correlation between AT and APD, which was found at both the endocardial and epicardial surface and had an average slope of greater than unity, may further contribute to a positive ventricular gradient and T wave concordance.

17 beta-Oestradiol produced an endothelium independent relaxation of precontracted human coronary arteries in vitro, and this effect was associated with an increase in both cyclic AMP and the cyclic GMP content. This direct relaxant effect of oestrogens on coronary arteries may contribute to the beneficial effects of oestrogen replacement therapy in postmenopausal women.

The incidence of left atrial spontaneous echo contrast was evaluated in 52 patients with isolated or predominant mitral valve stenosis (Group 1) and 70 other patients who had undergone mitral valve replacement (Group 2). All patients were studied by conventional transthoracic and transesophageal two-dimensional echocardiography. Spontaneous echo contrast could be visualized within the left atrium in 35 Group 1 patients (67.3%) (including 7 patients with sinus rhythm) and 26 Group 2 patients (37.1%) (all with atrial fibrillation). Patients with spontaneous echo contrast had a significantly larger left atrial diameter and a greater incidence of both left atrial thrombi and a history of arterial embolic episodes than did patients without spontaneous echo contrast. Association between spontaneous echo contrast and left atrial thrombi and a history of arterial embolization (considered individually or in combination) showed a high sensitivity and negative predictive value. It is concluded that spontaneous echo contrast is a helpful finding for identification of an increased thromboembolic risk in patients with mitral stenosis and after mitral valve replacement.