Congestive heart failure is the most common cause of mortality in patients with end-stage renal disease (ESRD). Ultrasonic tissue characterization with integrated backscatter offers a promising method for the noninvasive assessment of regional myocardial contractile performance and fibrosis. The aim of this study was to investigate the effect of hemodialysis (HD) on myocardial tissue characterization and left ventricular function in ESRD patients. We examined 26 patients with ESRD undergoing routine HD (age 63 +/- 12 years, duration of HD 9.2 +/- 3.2 years) and 30 patients with essential hypertension (HT; 60 +/- 10 years). Routine echocardiographic parameters and the cyclic variation of ultrasonic integrated backscatter of the ventricular septum (CV-IBS) were measured. Left ventricular mass index was significantly larger in patients with ESRD than in those with HT (217 +/- 56 vs 146 +/- 45 g/m(2), P < 0.05). The indices for left ventricular diastolic function (E/A, the ratio of left ventricular peak early to late diastolic filling velocity; DT, the deceleration time of the early diastolic filling) and CV-IBS had deteriorated significantly in patients with ESRD before HD compared with those with HT (E/A, 0.6 +/- 0.2 vs 0.9 +/- 0.3, P < 0.05; DT, 228 +/- 23 vs 184 +/- 19 ms, P < 0.05; CV-IBS, 9.0 +/- 1.3 vs 12.4 +/- 0.9 dB, P < 0.05), possibly reflecting interstitial fibrosis. In patients with ESRD, HD reduced calculated left ventricular mass index by 19% (before HD, 217 +/- 56 vs immediately after HD, 176 +/- 45 g/m(2), P < 0.05) and CV-IBS by 19% (9.0 +/- 1.3 vs 7.3 +/- 1.1 dB, P < 0.05), that possibly reflected improvement of interstitial edema. HD also significantly improved indices for left ventricular diastolic function (E/A, 0.6 +/- 0.2 vs 0.9 +/- 0.2, P < 0.05; DT, 228 +/- 23 vs 188 +/- 21 ms, P < 0.05). HD improves myocardial interstitial edema and left ventricular diastolic function in patients with ESRD. Noninvasive assessment of ultrasonic tissue characterization is useful in defining the pathophysiological changes of ventricular myocardium in patients with ESRD.

Objective The goal of this study was to investigate transesophageal echocardiographic (TEE) findings after the termination of atrial fibrillation to clarify the direct evidence for occurrence of acute cardiogenic brain embolism (CBE) in patients with paroxysmal atrial fibrillation (PAF).Patients and Methods Among98 consecutive patients with CBE, we investigated TEE in 16 patients with PAF (Group CBE, 72±10 years) within 7 days of the onset and 2 weeks after the first study, in comparison with 15 agematched PAF patients without CBE(Group N). The duration from reversal to normal sinus rhythm to first TEE was 6±1 days in both groups. Results There were no significant differences in left atrial dimension and emptying flow velocity of the left atrial appendage (LAA-eV) between groups. Group CBE had significantly larger LAA area (4.3±1.3 cm2 vs. 3.1±1.0 cm2, p<0.05), smaller LAAfractional area change (LAA-FAC) (43±25% vs. 80±22%, p<0.001), and a higher incidence of left atrial spontaneous echo contrast (LAA-SEC) (25% vs. 7%, p<0.05) than group N, and those abnormalities in group CBEwere significantly improved at the second TEE (LAA area: to 3.2±0.9 cm2, p<0.05; LAA-FAC: to 84±26%, p<0.001; LAA-SEC: to 0%, p<0.05),respectively. Conclusion LAA-FAC is a more sensitive marker for LAAdysfunction than the widely used index, LAA-eV, and a sustained deterioration of LAA-FACmay be direct evidence for thrombus formation and occurrence of acute CBE in patients with PAF.

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A 78-year-old man who had been treated with maintenance hemodialysis for chronic renal failure was admitted with severe edema in left arm for 1 month. Venous angiography showed a severe stenosis in left innominate vein, then, he underwent percutaneous balloon angioplasty and venous stenting (Wall Stent RP). His arm edema soon improved after angioplasty, however, he complained of general fatigue and bradycardia 2 days after the venous angioplasty. Electrocardiogram showed complete atrioventricular block with 35 wide QRS complexes per minute. His echocardiogram showed a pipe-shaped structure with multiple slit and acoustic shadow in right ventricle. His radiographical right ventriculogram revealed the migrated venous stent from innominate vein to right ventricle. We tried to perform percutaneous transvenous stent extraction using Goose-Neck snare catheter, however, the wall stent stuck in the right external iliac vein, and contrast media leaked to the outside of the vascular wall. Therefore, we implanted this stent in the iliac vein with optimal-sized balloon inflation, and succeeded in stopping bleeding. Complete atrioventricular block was recovered to sinus rhythm with left bundle branch block just after the removal of the venous stent from right ventricle, and no cardiovascular events occurred after the treatment.

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