Section on Cardiology. (Abstracts of Scientific Posters).

CA1-A (MP). HISTAMINEMIA, REDUCED ASCORBATE, AND OXIDATIVE STRESS PREDISPOSE TO ACUTE CORONARY SYNDROME. Sanjeev S. Hasabnis, DO, Sanda Clejan, PhD, Shankar Japa, PhD, and James Talano, MD. Departments of Cardiology and Pathology, Tulane University Health Sciences Center, New Orleans, LA.

Mast cells are prevalent in the shoulder of unstable atheromas; cardiac mast cells secrete proteases capable of activating matrix metalloproteinases. Histamine is essential in the inflammatory cascade of the unstable plaque. Ascorbate depletion has been correlated with histaminemia, which has been shown to impair endothelial-dependent vasodilation. This study evaluates whether oxidative stress, as measured by levels of isoprostanes (PGF2-a), coupled with an inflammatory state characterized by histaminemia predisposes patients to acute coronary syndrome (ACS). Whole blood histamine, serum vitamin C, and serum PGF2-a levels were obtained on 48 patients with ACS as determined by standard diagnostic criteria, 46 patients with stable coronary artery disease (CAD), and 50 age- and sex-matched normals (NML). Samples were taken at 8:00 a.m. fasting in the CAD and NML groups and within 24 hours of presentation to the emergency department in the ACS group. Data were analyzed by stepwise discriminant and Spearman rank c orrelation coefficient. A significant relationship exists between histamine and PGF2-a levels. As PGF2-a level rises above 60 pg/mL, an increase in histamine level occurs in both the ACS and CAD groups. A significant inverse relationship exists between ascorbate and histamine levels in the ACS versus NML groups (P < .05) and the CAD versus NML groups (P < .05). Histamine and isoprostane levels increase in CAD and ACS patients. Mast cell activation and lipid oxidation generated during atherosclerosis manifest this inflammatory response. Accelerated isoprostane formation and depleted ascorbate paired with histaminemia may be active in CAD and predispose patients to acute coronary syndrome.

CA2-A(MP). INCIDENCE OF QUADRICUSPID AORTIC VALVE AND THE DEVELOPMENT OF AORTIC REGURGITATION. Shewit Weldetensae, MD, Paulette Wehner, MD, George Linsenmeyer, MD, and Silvestre Cansino, MD. Huntington, WV.

Aortic valve anomalies include unicuspid aortic valve, which is inherently stenotic; bicuspid aortic valve, which invariably progresses to aortic stenosis; and the rare quadricuspid aortic valve usually associated with aortic regurgitation, which we propose is related to advancing age. Other associated conditions include atrial septal defect, displacement of the left coronary orifice, pulmonic stenosis, and, rarely, aortic stenosis. Our literature review suggests an autopsy incidence of quadricuspid aortic valve between 0.008% and 0.033%. Olson et al reviewed surgical pathology of 225 patients with pure aortic insufficiency scheduled for valve replacement, and found an incidence of 1%. We identified four patients in our echocardiography laboratory between January 1996 and December 2001. Approximately 19,925 patients underwent echocardiography during this time, establishing an incidence in our institution of 0.02%. We present the clinical features of the four identified patients (3 female, 1 male) with quadric uspid aortic valve, including ages, presentation, degree of aortic insufficiency, and clinical outcomes. The abnormality of quadricuspid aortic valve can be easily overlooked when evaluating a patient for aortic insufficiency. With current echo-Doppler techniques, aortic regurgitation can be detected much earlier than any clinical manifestations. Most of the reported cases we reviewed were found at valve operation or aortic root angiography and were quite incidental. The incidental finding of quadricuspid aortic valve appears to be much more common in younger patients, also true in our small case series, with older patients manifesting more severe aortic insufficiency. The development of aortic insufficiency is related to the area of transvalvular forces. When the four cusps are of equal size, these forces are equally distributed. In contrast, with a small accessory cusp, there is unequal distribution of stress and abnormal leaflet coaptation that results in possible progressive aortic regurgitation with loca lized trauma and deterioration which eventually requires valve replacement in approximately 50% of cases. Hypertension also seems to play an important role in the occurrence of regurgitation and, again, the regurgitation seems to be much more common in the fifth decade of life and later. Quadricuspid aortic valve is a malformation that leads to severe valvular failure in later life, specifically, and should be included in the differential diagnosis when patients present with any degree of aortic insufficiency. Review of a 6-month period in our echocardiography laboratory did confirm the rare nature of this congenital abnormality, suggesting a "real world" incidence of 0.02%.

CA3-A (MP). MULTIPLE CORONARY ARTERY FISTULAE DRAINING INTO LEFT VENTRICULAR CAVITY. Ray K. Bobba, MD, and Barbara Moran-Faile, MD, FACC. Department of Internal Medicine and Division of Cardiology, Greenville Hospital System, Greenville, SC.

We report a case of a 55-year-old woman with no prior cardiac history who was having atypical chest pain. A stress nuclear scan showed questionable infero-apical ischemia. Her medical history was significant for COPD, hypertension, dyslipidemia, and 30-pack-year history of smoking. Cardiac catheterization showed multiple coronary artery fistulae originating from all of the coronary arteries, draining into the left ventricular cavity. The patient was sent home taking a beta-blocker, a calcium channel blocker, aspirin, and a statin. Fistulae terminating into the left heart, particularly into the left ventricle, are the most unusual form. Interference with developmental changes of embryonic myocardial sinusoids might produce an abnormally prominent thebesian system with the morphologic appearance of multiple coronary microfistulae. Most patients with coronary artery fistulae remain asymptomatic, but some may have angina pectoris and, rarely, myocardial ischemia, which is related to coronary steal phenomenon. Mul tiple fistulous communications to the left ventricle involving all three major coronary arteries is a rare anomaly. Of all the reported cases in the English literature, multiple coronary artery fistulae are predominantly seen in females (22/26) compared with males.

CA4-A(MP). SCARED TO DEATH (LV APICAL BALLOONING WITHOUT CAD AFTER A STRESSFUL EVENT). George Hennawi, MD, and Vaishali Popat, MD, MPH. Union Memorial Hospital, Baltimore, MD.

A 41-year-old white woman presented with the chief complaint of chest pain and shortness of breath following a robbery during which a gun was pointed to her face. On addmission, the patient was found to have acute pulmonary edema. EKG showed nonspecific T wave changes in the inferolateral leads. Echocardiogram showed EF of 20% and multiple wall motion abnormalities. CPK level was 170 U/L and CK-MB level was 8.7 ng/mL. Emergency cardiac catheterization revealed no evidence of CAD and balooning of left ventricle apex. Patient was admitted to the ICU, and treatment with diuretics and pressors was begun, with immediate improvement. EF on the second day was 25%; on the third day EF was 35% to 40%. Work-up for myocarditis, including viral titers, was negative. She was discharged home taking Lasix, digoxin, and Toprol. Follow-up over 3 years showed normalization of her EF and functional capacity. There are several reports of sudden cardiac death in the literature that were believed to be secondary to underlying CAD. Recently, a group of Japanese researchers reported a new heart syndrome, transient LV apical ballooning without CAD documented by angiogram. The study population included 88 patients (12 men and 76 women) with a mean age of 67 years that presented with this syndrome between 1991-2000. The incidence was 6.3-fold higher in women compared with men. There are only 2 similar cases reported outside Japan. Although the exact mechanism is unknown, it is believed to be stress-induced cardiomyopathy (cathecolamine exposure), dynamic midventricular obstruction due to basal hypercontraction and or secondary myocardial ischemia caused by apical ballooning (increased wall tension). Since there is no need for acute thrombolytic therapy, it is important to differentiate transient LV apical balooning from stenotic acute MI. It requires a high index of clinical suspicion since the signs and symptoms mimic stenotic acute MI.

CA5-A(MP). THERE ARE BOTH SHARED AND INDEPENDENT PATHWAYS INVOLVED IN THE VAGAL PREGANGLIONIC CONTROL OF CARDIAC RATE. Alrich L. Gray, Stephen Newton, Tannis Johnson, Jean-Marie Lauenstein, Jeffrey Ardell, and V. J. Massari, Departments of Pharmacology, Howard University, Washington, DC, and East Tennessee State University, Johnson City, TN.

Previous data indicate that a right atrial intracardiac ganglion (SA ganglion) modulates cardiac rate. The purposes of the experiments outlined were 2-fold: (1) to test the hypothesis that another intracardiac ganglion, the posterior atrial (PA) ganglion also modulates cardiac rate, and (2) to test the hypothesis that separate populations of vagal preganglionic neurons project to the SA and PA ganglia. In the first set of experiments, the right vagus nerve was stimulated in 5 cats and the effects on heart rate were recorded: 1) before and after blockade of the PA ganglion with hexamethonium; and 2) after allowing time for the effects of hexamethonium to wear off. In the second set of experiments, a dual fluorescent retrograde labeling protocol was used. Using a counterbalanced design, one tracer was injected into the SA ganglion, and the other tracer was injected into the PA ganglion (n = 6). Ten days later, the brainstems from these animals were analyzed. Blockade of the PA ganglion resulted in a 38% decreas e in vagal effects on heart rate (P = .006). By fluorescence microscopy, vagal preganglionic neurons were found distributed throughout the ventrolateral nucleus ambiguus (NA-VL). Three populations of neurons were found; one projected to the SA ganglion, a second projected to the PA ganglion, and the third projected to both ganglia. We conclude that: (1) neurons in the PA ganglion mediate, in part, the vagal postganglionic control of cardiac rate, and (2) in the medulla, there are both shared and independent pathways involved in mediating the vagal preganglionic control of cardiac rate. These experiments explain, in part, the function and neuroanatomic organization of the autonomic innervation of the heart. Funding was provided by NIH grants HL-51917, HL58140, The American Heart Association, and the Gustavus and Louise Pfeiffer Research Foundation.

CA6-A(MP). DOXORUBICIN CARDIOTOXICITY IN AFRICAN AMERICANS. Kimberly Dinh, PharmD, Fred Lombardo, PharmD, MS, and William E. Matory, MD. Howard University, Washington, DC.

African American race was examined as a risk factor for cardiotoxicity from doxorubicin-based therapy for cancer. Retrospective survey of the Howard University Hospital cancer registry during 1997-2001 identified 100 evaluable patients out of 120 African Americans who underwent doxorubicin-based combination chemotherapy (65% women, 35% men, median age 46 years). The fraction of patients, who developed post-treatment cardiotoxicity, defined as congestive heart failure or left ventricular ejection fractions less than 45%, was compared with that from a retrospective study of 399 patients (predominantly Caucasian) (Singal, NEngl J Med; 339:900-905, 1998). Cases were stratified by cumulative dose of doxorubicin. Statistical significance of the difference in incidence of cardiotoxicity was tested by chi-square analysis. Patients received multiple doses of doxorubicin (range, 264-580 mg/m2; median, 374 mg/m2), with the final echocardiographic assessment at a median of 1.3 years. Howard oncologists frequently used a 48-hour infusion rather than the conventional rapid bolus to reduce the cardiotoxicity of doxorubicin. The fraction with cardiotoxicity in our study versus Singal's review at four ranges of doxorubicin was 25% versus 18% at 551 to 600 mg/m2; 10% versus 4% at 501 to 550 mg/m2, 4% versus 1% at 451 to 500 mg/m2; and 0% versus < 1% at < 450 mg/m2. Eighty-five percent of the patients having depressed ejection fraction and/or heart failure were women. African Americans had a higher rate of cardiotoxicity after doxorubicin (7/100 cases) than Caucasians (10/399), statistically significant at P < .027 with an odds ratio of 2.93. We have shown for the first time that African Americans at our institution appear to suffer cardiotoxicity from doxorubicin three times more frequently than Caucasians, with an even higher risk among females.

CA7-A(MP). RIGHT-SIDED ELECTROCARDIOGRAPHY IN PULMONARY EMBOLISM. Mohammed Alhassen, MD, Ernest Amegashie, MD, and William E. Matory, MD. Department of Medicine/Cardiology, Howard University, Washington, DC.

The purpose of this study was to identify right-sided chest-lead electrocardiographic abnormalities in acute pulmonary embolism. Analysis of electrocardiographic changes in 100 African American patients suspected of having pulmonary embolism was made at Howard University Hospital between 2001 and 2002 (60% women, 40% men, median age 50 years). Twelve-lead EKGs were obtained within one hour of arrival to emergency department. Right-sided EKGs were obtained within 24 hours of onset of symptoms of pulmonary embolism. Parameters of both right- and left-sided EKGs available were measured and compared. Only 20% of these patients were diagnosed with pulmonary embolism. EKG changes (3 of 7) suggestive of acute right ventricular strain were found in both right- and left-sided leads in 16 (80%) patients diagnosed with pulmonary embolism. These EKG changes disappeared within 24 hours of admission in 14 (87.5%) patients. Four patients with a diagnosis of pulmonary embolism had normal left-sided EKG, but the right-sided E KGs showed ST-segment elevation and a qr or qs pattern (prominent q waves) in one to three of the leads V4R, V5R and V6R These patterns were also seen in 10 of the 16 patients showing right ventricular strain pattern in their EKGs. Nonspecific ST-T wave changes were seen in 20 (25%) patients not considered to have pulmonary embolism. V3R leads showed rS configuration in 90% of the patients. EKG changes in right-sided chest leads occur very frequently in pulmonary embolism. The diagnostic potential of routinely recording right-sided EKG appears to be greatest in patients with acute pulmonary embolism not manifesting typical changes in their 12-lead EKGs. This study, also confirms previous case reports observing similar changes in the right-sided leads.

CA8-A(MP). ELECTROCARDIOGRAPHIC CHANGES IN OBSTRUCTIVE SLEEP APNEA SYNDROME. Jehanara Ahmed, MD, James Diggs, MD, and William E. Matory, MD. Department of Medicine/Cardiology, Washington, DC.

The purpose of this study was to examine the electrocardiographic changes in patients with obstructive sleep apnea syndrome. Ninety-eight African American patients with obstructive sleep apnea syndrome as suggested by history and proved by full overnight polysomnogram (in 90 patients) were included in the study. There were 50 women and 48 men. Age ranged between 14-77 years. Medical records were reviewed for demographics, comorbid conditions, and all available electrocardiograms. Patients with history or clinical evidence of cardiopulmonary disease other than systemic hypertension were excluded. Institutional review board approval was obtained. Forty three percent of the patients were morbidly obese, 33% had diabetes, 64% had hypertension, and 17 % had anemia. The following EKG changes were observed: 24% had left atrial enlargement, 18% had sinus tachycardia, 15% had left ventricular hypertrophy, 11% had left axis deviation, 9% had first-degree atrioventricular block, 8% had left bundle branch block and hemib lock, 7% had right bundle branch block, premature atrial contractions, and prolonged QT interval, 4% had right axis deviation, 3% had sinus bradycardia, 2% had right atrial enlargement, and 1% had ectopic atrial rhythm. Eleven percent had normal electrocardiograms. Sleep apnea affects both the right and left sides of the heart. A significant percentage of our patients had abnormal EKGs. Our study is consistent with previous studies proving that complex electrocardiographic changes are associated with obstructive sleep apnea. The EKG changes could be diagnostic if other disease entities are excluded.

CA9-A(MP). EGG CHANGES IN BLACK PATIENTS WITH ACUTE MYOCARDIAL INFARCTION: EFFECT ON THE USE OF THROMBOLYTIC THERAPY Kadisha Rapp, MD, Michael Washington, MD, and William E. Matory, MD. Department. Of Emergency Medicine, Howard University Hospital, Washington, DC.

Several studies have demonstrated that black patients with acute myocardial infarction (AMI) are less likely to receive thrombolytic therapy than white patients with AMI. The reason for this difference has not been clearly identified. One possibility mentioned is that blacks may be less likely than white patients to have the necessary ST-segment elevation (STE) on their presenting ECGs to qualify for thrombolytic therapy. The objective of this study is to review the EGG changes of black emergency department patients with AM! diagnosed within 12 to 24 hours of presentation. This was a retrospective one-year study of black ED patients with AMI. The presenting ECGs of ED patients with AMI, diagnosed by abnormal levels of CK-MB and troponins obtained within 12 to 24 hrs of presentation, were reviewed for the presence or absence of STE. Data were also collected on other abnormalities seen in these ECGs. Patient charts from the Medical Records Department of Howard University Hospital were reviewed for all the data used in this study. Forty-four patients thus far have met the entry criteria, all having a confirmed AMI. Only 6 (13%) of these patients were found to have STE on the presenting EGG. The majority of patients (38 patients, 86%) did not have STE. The most common abnormality was ST depression (11 patients, 25%). Other abnormalities noted were nonspecific ST-T changes (20%), left ventricular hypertrophy (18%), T-wave inversion (13%), and left bundle branch block (11%). The majority of black patients with AM! presenting to the ED are ineligible to receive thrombolytic therapy because of the lack of STE on their ECGs. Only 13% of patients in this study were found to have STE on their ECGs, in comparison to other studies that show percentages of up to 66% for all patient groups. The lack of STE in ECGs of black patients with AMI severely limit the number of patients eligible for necessary thrombolytic therapy. In this population group, other modalities must be optimized to treat this important condition.

CA10-A(MP). FATAL AORTIC VALVE STAPHYLOCOCCUS AUREUS ENDOCARDITIS PRESENTING AS STROKE AND MYOCARIMAL INFARCTION AND COMPLICATED BY PERIVALVULAR ABSCESS FORMATION AND FISTULOUS COMMUNICATION BETWEEN THE AORTIC ROOT AND LEFT' ATRIUM. G. Mustafa Awan, MD, and Emesto Umana, MD. University of South Alabama College of Medicine, Mobile, AL.

The incidence of infective endocarditis (IE) in the United States has increased over the last several decades. Its hospital mortality rate remains high, and it is associated with significant intracardiac (perivalvular and myocardial abscesses, myocardial infarction [MI], conduction abnormalities, valve destruction, pericarditis) and extracardiac (systemic embolization, mycotic aneurysms, vasculitis) complications. Left sided Staphylococcus aureus JE is associated to a poor prognosis, and has an estimated mortality rate of 35% to 40%, likely due to its ability to destroy valve tissue and its propensity to embolize. We present an unusual case of aortic valve S aureus endocarditis presenting with almost simultaneous stroke and MI and complicated by a fistula communicating between the aortic root and the left atrium (LA). A 43-year-old man with history of intravenous drug use was brought to the hospital with acute onset of right-sided hemiplegia and expressive aphasia. On physical examination he was also found wi th multiple petechiae distributed over both lower extremities; Janeway lesions were noted in palms and soles; and Osler nodes were palpated. On cardiac examination he was found with a II/VI blowing decrescendo diastolic murmur and a III/VI mid-systolic murmur. Significant laboratory abnormalities were leukocytosis (28,300 white blood cells/mL), thrombocytopenia (87,000 platelets/mL), and azotemia (creatinine level, 3.1mg/dL). Brain computed tomography confirmed a left cerebellar infarct and probable infarcts of the left parietal and temporal regions. Transthoracic echocardiogram revealed a large mobile echodensity in the aortic valve (AV) and mild to moderate aortic insufficiency. Within 12 hours of hospitalization, the patient developed an acute inferior ST-segment elevation MI. Both the stroke and the Ml were considered to be embolic in nature, originating from the large vegetation. Multiple blood cultures confirmed S aureus as the causative organism of IE. Transesophageal echocardiogram confirmed a large A V vegetation complicated by a ruptured perivalvular abscess, with fistulous communication between the aortic root and the LA. The patient underwent aortic and mitral valve replacement, but died a shortly after surgery. Embolic events are common in IE. Approximately 20% to 50% of patients will have embolic complications and the majority (65%) will involve the central nervous system. Microscopic coronary embolism documented in autopsy series is frequent (47%-80%), but clinical MI is extremely rare (1.8%). Simultaneous cardiac and cerebral embolization has not been reported in the literature. To our knowledge this is the first report of a patient with a AV S aureus IE presenting with almost simultaneous stroke and MI and complicated by perivalvular abscess formation and a fistulous communication between the aortic root and the LA, and it exemplifies the highly virulent behavior S aureus left-sided endocarditis. CA11-A(MP). A COMPARISON OF REFRACTORY ANGINA PATIENTS TREATED WITH ENHANCED EXTERNAL COUNTERPULSATION (EECP) FROM TURKEY AND THE UNITED STATES: A REPORT FROM THE INTERNATIONAL EECP PATIENT REGISTRY. Ozlem Soran, MD, FACC, Atilla Sengul, MD, Coskun Ikizler, MD, Tolga Yener, MD, and Elizabeth D. Kennard. Cardiovascular Institute and the Department of Epidemiology, University of Pittsburgh, Pittsburgh, PA, and the Medkar Heart Center, Ankara, Turkey.

EECP is a novel, noninvasive analogue of the intra-aortic balloon pump recently approved for use for the treatment of refractory angina. Although primarily used in the United States, the treatment is now being used in other parts of the world. This study examines the safety and efficacy of EECP for the first cohort of Turkish patients and compares them with patients treated in the United States (US). Prior to 1998, the majority of the EECP studies took place at academic centers. The International EECP Patient Registry was designed to document the safety and efficacy of EECP in a variety of clinical settings. The unique aspect of this study is to enroll consecutive angina patients from academic and nonacademic, hospital-based, free-standing treatment centers with no exclusions due to demographics, clinical status, or outcome. To date, 4,345 patients have been enrolled from US sites and 158 in other countries. Of these, 39 were treated in Turkey (TR). The TR patients were younger (57.8 vs 67 years; P < .001) wi th a similar proportion of men( 82% vs 75%, P = NS). Duration of coronary artery disease was less at 9 years for TR pateints and 11 years for US patients. Previous revascularization was less at 54% for TR patients vs 86% for US patients (P < .001). 55% of TR patients and 81% of US patients were no longer candidates for further revascularization. TR patients had less incidence of diabetes (25% vs 42%; P < .05), hypertension (38% vs 71%, P < .001), noncardiac vascular disease (5% vs 32%, P< .001). History of hyperlipidemia was similar in both groups (72% vs 80%; P = NS). TR patients had less severe angina (Class III+IV+Unstable; 67% vs 84%; P < .001), similar multivessel disease (69% vs 76%; P = NS) and less nitroglycerin use (59% vs 70%; P < .01). However, TR patients were more likely to have a history of congestive heart failure (56% vs 32%; P < .01). More than half of the patients in both groups reported their health status and quality of life as very poor with unsatisfactory lifestyles. The rate of completi on of the treatment course was higher in TR patients (92% vs 83% P = NS). TR patients had higher diastolic augmentation ratios (1.21 vs 0.79; P < .001). After a mean treatment course of 35 hours, both groups showed a significant reduction in the severity of angina (P < .001), with 89% of TR patients and 74% of US patients reporting no angina or class I/II angina. Nitroglycerin use was discontinued in 43% of TR patients and 53% of US patients. Major adverse cardiovascular events during the treatment period (death/CABG/PCI/MI) were low in both groups (2.4% vs 2.7%, P = NS). Post-EECP evaluation of QoL, health status improvement, and lifestyle satisfaction showed significant increase in both groups (P < .001). In conclusion, Turkish patients presenting for EECP treatment show very different baseline profiles with respect to risk factors, medical history, comorbidities, and anginal symptoms. However both cohorts achieved substantial reduction in angina and improvement in QoL with EECP, despite an unfavorable base line profile.

CA12-A(MP). IMPACT OF CORONARY ARTERY DISEASE AND ROLE OF CORONARY ARTERY STENTING IN LUNG TRANSPLANTATION RECIPIENTS. Lee Arcement, MD, Leo Seoane, MD, Hector O. Ventura, MD, and Vincent Valentine, MD. Metairie, LA.

Coronary artery disease (CAD) is a relative contraindication to lung transplantation (LT). Other solid organ transplantation recipients have worsened outcomes in the setting of preoperative CAD. This may be due to accelerated atherosclerosis, a consequence of the metabolic complications of immunosuppressive regimens (eg, hypertension, diabetes, hyperlipidemia). We sought to determine the impact of pre-LT CAD and the impact of percutaneous revascularization (ie, stenting) of significant CAD (SCAD) on outcome following LT. Seventy-five of 141 recipients from December 1990 to September 2001 met criteria for preoperative left heart cathterization (LHC). Criteria for LHC included age > 45 years, or < 45 years with 1 or more CAD risk factors. A normal LHC was defined as no angiographic lesions seen. SCAD was defined as a left main stenosis > 50% or other epicardial artery stenosis > 70%. All other lesions were termed insignificant CAD (ISCAD). Patients with SCAD required stenting prior to LT. There were no differen ces between groups (normal vs ISCAD and/or SCAD) with regard to sex, race, single vs bilateral LT, or underlying diagnosis. Mean age in the normal cohort was 51.6 +/- 1.2 years vs 58.8 +/- 1.9 years in the CAD (ISCAD) + SCAD) group. There was a nonsignificant trend for worsened survival in the ISCAD cohort at 3 years. Patients with ISCAD or SCAD amendable to stenting had no worsened survival compared with those without CAD. CAD may not be a relative contraindication to LT. Also, coronary artery stenting appears to be a safe method of revascularization in this small series of LT recipients.

CA13-A(MP). TISSUE DOPPLER IMAGING: A NEW ECHOCARDIOGRAPHIC MODALITY WITH PREDICTIVE VALUE IN REJECTION SURVEILLANCE. G. J. Putzer, R. Boucek, Jr., A. Asante-Korang, and M. Boucek. Harvard University Health Services, Cambridge, MA, Harvard University, School of Public Health; Boston, MA, All Children's Hospital, St. Petersburg, FL, and Denver Children's Hospital, Denver, CO.

ECHO-A is a multiparametric echocardiographic analysis algorithm with high predictive value for pediatric recipients. One of the diastolic parameters of ECHO-A is left-ventricle posterior-wall maximum thinning velocity (LVPWmax) calculated by computer-assisted analysis of digitized M-mode tracings. LVPWmax can be derived by tissue Doppler imaging (TDI) without stringent endocardial definition required for off-line digitized M-mode analysis. The purpose of this study was to compare LVPWmax by M-mode with LVPWmax derived directly from TDI in pediatric heart recipients. LVPWmax was determined by pulse-wave Doppler using TDI filtering (Toshiba 7000) in 177 echocardiograms performed on 33 recipients (age range, 3 months to 16 years). Mean LVPWmax by M-mode (130 mm/sec) and TDI (122 mm/sec) were related (r = 0.478; regression analysis) but were not identical (mean difference = 3.4 mm/sec with + 2 SD= 90 mm/sec and - 2SD = 83 mm/sec; Bland-Altman analysis). However, the predictive value of ECHO-A was comparable usin g wall-thickness normalized LVPWmax derived by either TDI or M-mode. With 9 treated rejection episodes, the negative predictive value for ECHO-A using TDI was 97.8% compared to 96.7% by M-mode. In conclusion, TDI-derived LVPWmax, when incorporated into a multiparametric analysis, is a new modality for noninvasive rejection surveillance.

CA14-A(MP). ANKLE BRACHIAL INDEX: AN UNDERUTILIZED COST-EFFECTIVE SCREENING TOOL. Lee Arcement, MD, Kathy Hebert, MD, and Hector O. Ventura. Ochsner Clinic Foundation, New Orleans, LA, and Chabert Medical Center, Houma, LA.

Peripheral vascular disease (PVD) is a marker for increased cardiovascular morbidity and mortality. Also, the symptoms of PVD are often not reported by patients. A method to identify such patients is desirable. The ankle brachial index (ABI) is an objective, simple screening tool used for the detection of PVD, and can be performed in the outpatient setting at no additional cost. ABIs were obtained on all patients (n = 438) referred for stress testing over a 4-month period and were performed prior to either exercise or pharmacologic stress testing. An abnormal ABI was defined as < 0.8. Median age was 54 +/- 12 years (range, 25-82 years). Of the entire population, 86% were asymptomatic regarding claudication. Females outnumbered males (62% vs 38%). One-hundred thirty-five patients (31% of entire cohort) had an abnormal ABI. Of these, 51(38%) had a positive stress test. An abnormal ABI was common in all groups with cardiovascular risk factors referred for stress testing, especially diabetics and those known to h ave PVD. Patients with cardiovascular risk factors have a higher prevalence of abnormal ABI and, thus, PVD. PVD can be identified by the routine, cost-effective use of the ABI. With the early detection of PVD, management to prevent debilitating claudication, ulcers, or amputation must first begin with patient identification, education, and treatment of modifiable risk factors.

CA15-A. ATRIAL FIBRILLATION AS A PRESENTING SYMPTOM FOR NON-HODGKIN'S LYMPHOMA. Cindy A. Codispoti, DO, and Sheri Y N. Boyd, MD. Fort Sam Houston, TX.

Malignant lymphoma rarely involves the heart, especially at initial diagnosis. Diffuse large B-cell lymphoma constitutes approximately 30% of all non-Hodgkin's lymphomas (NHLs) and is the most common histologic subtype. Forty percent of cases may present with extranodal disease, most commonly affecting the gastrointestinal tract, testis, bone, thyroid, salivary glands, skin, liver, breast, nasal cavity, and central nervous system. We report a case of a 77-year-old woman who initially presented with newly diagnosed paroxysmal atrial fibrillation manifested by intermittent episodes of palpitations and shortness of breath. Treatment was begun with warfarin and digoxin at that time. Upon second presentation two weeks later, she was admitted with intermittent palpitations, fevers, night sweats, and weight loss. She was febrile and tachycardic. Physical examination was significant for a new holosystolic murmur at the left lower sternal border. Initial laboratory results demonstrated a mild hyperkalemia, mild normoc ytic/normochromic anemia, therapeutic INR, and negative urine and blood cultures x2. ECG revealed sinus tachycardia. CXR was unrevealing. The patient then underwent a transthoracic echocardiogram the day after admission, which demonstrated a large mass in the right atrium, a possible mass in the region of the atrioventricular groove, and a new pericardial effusion. The patient subsequently received a cardiac MM, which confirmed two separate right atrial masses, a pericardial effusion, and bilateral pleural effusions. A CT scan of the chest and abdomen additionally revealed diffuse lymphadenopathy, a large liver mass, renal hypodensities, a T12 lytic lesion, and a sacral mass. The patient then underwent CT-guided liver biopsy, which lead to the diagnosis of Stage IVB diffuse B-cell lymphoma. Bone marrow aspirate revealed numerous medium-large atypical cells with pleomorphic nuclei and multiple nucleoli with maturation and differentiation markers of lymphoid cells. Flow cytometry was positive for CD-19, CD-20, and CD-22. Subsequent lumbar puncture and CT of the head/brain were negative for malignancy, and the patient underwent chemotherapy with CHOP-R. To date, there has been only one reported case of a patient presenting with atrial fibrillation who was eventually diagnosed with primary cardiac diffuse large cell lymphoma. There are 5 additional reported cases of atrial fibrillation associated with non-Hodgkin's lymphoma. Those that demonstrated atrial fibrillation as the presenting symptom were eventually diagnosed with primary cardiac lymphoma. This case demonstrates diffuse large B-cell lymphoma presenting as atrial fibrillation secondary to intracardiac tumor. It emphasizes the important diagnostic utility of echocardiography in the face of a new murmur and dysrhythmia. While 20% of cases of non-Hodgkin's lymphoma demonstrate intracardiac involvement at autopsy, it is rare for NHL to present with initial cardiac symptoms. To our knowledge, this is the first case of diffuse NHL presenting as cardiac dysrhythmia .

CA16-A(MP). INADVERTENT IMPLANTATION OF AN IMPLANTABLE CARDIOVERTER DEFIBRILLATOR (ICD) LEAD INTO THE LEFT VENTRICLE VIA A PATENT FORAMEN OVALE: CLINICAL AND ECHOCARDIOGRAPHIC RECOGNITION OF A RARE COMPLICATION OF ICD IMPLANTATION. Imran Arif MD, Aldino Cellini, MD, and Silvestre Cansino, MD. Department of Cardiovascular Medicine, Joan C. Edwards School of Medicine, Marshall University, Huntington, WV.

A 28-year-old white man who was diagnosed with idiopathic dilated cardiomyopathy underwent AICD implantation for prevention of sudden cardiac death due to ventricular tachycardia. During routine follow-up in transplant clinic 1 month after AICD placement, echocardiogram was obtained for follow-up of his left ventricular systolic function. Echocardiogram revealed AICD lead (9 French size) going from right atrium into left atrium, traversing the interatrial septum via a patent foramen ovale, and across the mitral valve embedded in the basal lateral wall of the left ventricle. Patient was hospitalized and anticoagulation therapy was begun to reduce the risk of cerebrovascular accident. An EKG showed sinus with paced right bundle branch block morphology. Overpenetrated posteroanterior and lateral chest radiographs showed lead directed posteriorly and downwards. Lead was repositioned into the right ventricle without any complication. To our knowledge, this is the first case report describing inadvertent implantati on of AICD lead in the left ventricle. We review important clinical clues and the role of echocardiography in making the diagnosis of this extremely rare complication of AICD implantation.

CAl7-A. AMINOPHYLLINE-INDUCED CORONARY VASOSPASM. Amy S. Armstrong, MD, and Ernesto Umana, MD. University of South Alabama College of Medicine, Mobile, AL.

Coronary vasopasm (Prinzmet al's or variant angina) is an unusual chest-pain syndrome characterized by angina associated with ECG ST-segment elevation and caused by coronary spasm. It usually occurs at rest, and may be precipitated by cold exposure, cocaine use, exercise, hyperventilation, emotional stress, alcohol withdrawal, hypomagnesemia, and vasoactive drugs. The diagnosis is based on the demonstration of EGG changes during a spontaneous episode of angina or with provocation maneuvers. In most individuals, coronary angiography demonstrates some degree of atherosclerotic disease, varying in severity from minimal to subtotal obstruction of at least one epicardial vessel. During angiography, vasospasm may occur spontaneously or with the administration of pharmacologic agents (eg, ergonovine, acetylcholine). It usually involves a large segment of the vessel, and may involve more than one epicardial artery. We report an unusual case of coronary vasospasm associated to the administration of aminophylline. A 52 -year-old man with history of variant angina underwent dipyridamole stress testing because of frequent recurrent angina. He tolerated well the dipyridamole infusion, and no EGG changes were documented. At the termination of the pharmacologic stress, 125 mg of aminophylline was administered. Two minutes later, the patient developed severe angina associated with diffuse ST-segment elevation (up to 5 mm). Symptoms and EGG changes resolved within 5 minutes following the administration of nitroglycerine. Because of the severity of symptoms and EGG changes, immediate coronary angiography was performed. It revealed only mild to moderate coronary artery disease. Previous angiograms had documented coronary vasospasm involving all three major coronaries and similar degrees of coronary atherosclerosis. Aminophylline is commonly used to counteract the effects of dipyridamole during stress testing. Only one series of possible aminophylline-induced coronary vasospasm has been reported, but without angiographic evidence of spasm. To our knowledge, this is the first case to demonstrate clinical and EGG evidence as well as angiographic evidence of coronary vasospasm associated with aminophylline administration. Our case illustrates an extremely rare but potentially severe complication associated with the administration of aminophylline. Caution should be taken in patients with variant angina if aminophylline use is considered.

CA18-A. FEASIBILITY OF PREHOSPITAL THROMBOLYTIC THERAPY IN A COUNTY WITH SIGNIFICANT RURAL AREAS. Ravi K. Bobba, MD, Martin Crane, PhD, and Gregory W. San, MD. Greenville Hospital System, Greenville, SC.

The purpose of this study was to assess the results of the routine use reteplase for prehospital myocardial infarction in a county with a significant rural population. It was a retrospective cohort study based on medical record review in Greenville County, South Carolina, a county with a large mixed urban and rural population. There were 25 eligible patients with acute ST-segment elevated MI treated with prehospital reteplase. They were compared with 57 patients who were treated with reteplase after arrival to the ED. From the onset of symptoms, prehospital-initiated thrombolytic therapy was given in a mean (SD) of 85.6 (65.2) minutes compared with 174.7 (134.3) minutes in the ED cohort. (P<.001) There was one death in the ED-treated group; complications were similar in the two groups. These results mirror the results from prior reported trials. The routine administration of prehospital reteplase for acute MI is safe and results in a significant reduction in time to treatment when initiated with trained EMS t echnicians in a large county. We recommend that county health systems with similar capabilities consider prehospital thrombolytics for their patients with acute ST-segment elevated myocardial infarction.

CA19-A. GADOLINIUM CORONARY SINUS VENOGRAPHY DURING BIVENTRICULAR PACEMAKER INSERTION IN A PATIENT WITH SEVERE RENAL INSUFFICIENGY. Captain Maria R.J. Kostur, MD, Lt. Col. Michael Ferguson, MD, Major John Musa, MD, and Major E. Michael Purvis, MD. Keesler Medical Center, Keesler AFB, MS.

Gadolinium is a rare earth element commonly utilized for magnetic resonance imaging. The incidence of contrast nephropathy with this agent is exceptionally low, and far less than that seen with iodinated media. We report a novel use of gadolinium to assist with placement of a coronary sinus pacemaker lead in a patient with severe cardiomyopathy and end stage renal insufficiency An 81-year-old male with sick sinus syndrome, complete heart block requiring dual chamber pacing and ischemic cardiomyopathy was referred for biventricular pacing. The patient was experiencing New York Heart Association Class IV symptoms despite maximum tolerable medical therapy. Medical options were limited due to hypotension and polycystic kidney disease with severe chronic renal insufficiency characterized by a blood urea nitrogen (BUN) level of 87 mg/dL and a creatinine (Cr) level of 2.9 mg/dL. His electrocardiogram revealed dual chamber pacing with a QRS duration of 200 msec. His echocardiogram was significant for paradoxical sept al motion and moderate mitral regurgitation with an overall ejection fraction of 10% to 15%. Although complicated by diminished renal function, the patient's prolonged QRS and depressed ejection fraction made him a good candidate for placement of a biventricular pacemaker. The patient's coronary sinus was cannulated via the right subclavian vein, using a guide placed within a guiding sheath and advanced over a wire. The wire and guide were exchanged for a balloon-tipped catheter, and coronary sinus flow was occluded. Contrast venography was performed with two 7 cc hand injections of gadodiamide (Omniscan, 0.5 mmol/mL) in RAO caudal and LAO projections. A coronary sinus lead was placed in a lateral cardiac vein using the gadolinium venogram as a "road map." The coronary sinus lead demonstrated acceptable pacing thresholds. There were no contrast-related complications associated with the implant. Renal function remained stable 48 hours post-procedure (BUN = 87 mg/dL; Cr = 2.9 mg/dL). In a recently published reg istry of 5 million patients who received gadolinium, a severe allergic reaction incidence of 1 per million procedures was found, and there were no reported incidents of worsening renal function. Its utility in vascular interventions is limited by dose toxicity, expense, quantum mottle, and reduced radiopacity. Although the use of gadolinium in peripheral vascular imaging has been previously described, this is the first known report of its use in selective coronary sinus venography. Gadolinium is a promising alternative to iodinated contrast for coronary sinus visualization in patients with severe renal insufficiency or a history of adverse reactions to iodine.

CA20-A. THE VALUE OF WBC-TAGGED STUDY IN DIAGNOSING ASCENDING GRAFT INFECTION. J. Rossman, MS, G. K. Sharma, MD and V. B. Shah, MD. Medical College of Georgia, Augusta, GA.

Infection of an aortic prosthetic graft is a rare complication that is associated with high morbidity and mortality In cases of bacteremia where prosthetic aortic graft infection is suspected, TEE and CT scans usually provide the crucial evidence needed prior to timely surgical intervention. Here we report a case of a 49-year-old man with fever and chills who had an aortic valve conduit implanted 17 years ago. His initial Staphylococcus aureus bacteremia resolved with antibiotic therapy, but he remained febrile with no source of infection. Chest CT scans and TEEs were nondiagnostic. A WBC-tagged study demonstrated minimal iridium uptake in the mediastinum. Intra-operative evaluation revealed a pus pocket surrounding the aortic root, and Gram stains of this area were positive for WBCs and gram-positive cocci. The prosthetic aortic valve conduit was resected, and a homo-graft was implanted. The patient was discharged home on antibiotic therapy. According to the literature, this patient had the longest time betw een implantation and infection of an ascending aortic graft. This case reinforces the need for intensive evaluation to rule out infection of prosthetics. Here we discuss the value of a WBC-tagged study when chest CT and TEE studies are inconclusive.

CA21-A. PAPILLARY FIBROELASTOMA INVOLVING THE LEFT VENTRICULAR WALL. Jeffrey W. Schoondyke, MD, MPH, Baha Shabaneh, MD, Ellie Alevritis, MD, Ryan Stanton; Rebecca Copeland, MD, Matt Parks, MD, Tamar A. Giorgadze, MD, and Patrick N. Costello, MD. East Tennessee State University, Johnson City, TN.

A 71-year-old white woman presented to her primary care physician for a routine visit and was found to have a new, previously undocumented cardiac murmur. A subsequent transthoracic echocardiogram revealed a 1-cm mobile mass arising from the lateral free wall of the left ventricle. Transesophageal echocardiography later confirmed these findings. The patient underwent a left ventnculotomy and excision of a 1.5-cm friable mass, which was later identified as a papillary fibroelastoma (PFE) by routine histopathologic studies. We present this unique case with a review of the literature.

CA22-A. CARDIOTOXICITIES OF TAXOL. Kalpana Prakasa, MD, Fitzroy Dawkins, MD, and William E. Matory, MD. Department of Medicine, Divisions of Oncology/Cardiology, Howard University, Washington, DC.

The purpose of this study was to assess the cardiac disturbances in patients treated with taxol. One hundred nineteen Mrican American patients received Taxol for various cancers at Howard University Hospital during the years 1993 to 2001. Medical records of 102 patients were available for review. Sixty-seven percent were women and 33% were men. Age ranged between 26 and 85 years. Medical records were reviewed for demographics, types of cancer, dosage and frequency of Taxol and other chemotherapeutic agents, events during Taxol infusion, initial and subsequent EKGs, echocardiograms, and hospital admissions. Institutional review board approval was obtained. Ninety-one patients received additional chemotherapy and 11 patients were treated with Taxol as a single agent. Dosage of Taxol ranged from 75 to 420 mg/m2, administered every 1 to 3 weeks. Our study revealed the following cardiac events: 18% sinus tachycardia, 8.5% myocardialinfarction, 4% premature atrial contractions, 3% premature ventricular contractions and atrial flutter, 1% sinus bradycardia and prolonged QT interval. More than 50% of patients had risk factors for coronary artery disease. These cardiac disturbances were observed from 1 day to 1 month after receiving the chemotherapy and were independent of dosage of Taxol. Most of the patients with these arrhythmias had underlying comorbid conditions: dehydration, anemia, sepsis, and hypoxia. Possibly comorbidities and/or the chemotherapies contributed to these cardiac disturbances. Taxol was not associated with significant cardiac disturbances in our study population; however more prospective studies with closer follow-up during Taxol infusion are needed to assess its cardiotoxicities.