Detection of elevated pulmonary pressures by the ECG-derived ventricular gradient: A comparison of conversion matrices in patients with suspected pulmonary hypertension.

BACKGROUND: The aim was to assess the diagnostic value of the Inverse Dower (INVD)-derived vectorcardiogram (VCG) and the Kors-derived VCG to detect elevated systolic pulmonary artery pressure (SPAP) in suspected pulmonary hypertension (PH). METHODS: In 132 patients, morphologic variables were evaluated by comparing the VCG parameters synthesized by INVD and Kors matrix. Comparison of the diagnostic accuracy of detecting SPAP ≥50mmHg between the matrices was performed by ROC curve analysis and logistic regression analysis. RESULTS: Most VCG parameters differed significantly between INVD and Kors. ROC analysis for detection of SPAP ≥50mmHg by VG projected on the X-axis demonstrated no difference (p=0.99) between INVD (AUC=0.80) and Kors (AUC=0.80). Both the INVD- and Kors-derived VCG provided significant diagnostic information on the presence of SPAP ≥50mmHg (INVD, OR 1.05, 95%CI 1.03-1.07; P<0.001; Kors, OR 1.05, 95%CI 1.03-1.08; P<0.001). CONCLUSION: Although there were significant differences in measures of vector morphology, both INVD- and Kors-derived VCG demonstrated equal clinical performance in case of elevated SPAP.

Prognostic implications of left ventricular regional function heterogeneity assessed with two-dimensional speckle tracking in patients with ST-segment elevation myocardial infarction and depressed left ventricular ejection fraction.

The aim of the current study was to evaluate the prognostic implications of myocardial tissue heterogeneity assessed with two-dimensional speckle-tracking echocardiography in patients three months after first ST-segment elevation myocardial infarction (STEMI) with left ventricular ejection fraction (LVEF) ≤35 %. For this purpose, a total of 79 patients with first STEMI and LVEF ≤35 % at three months postinfarction were evaluated. Based on left ventricular (LV) speckle-tracking longitudinal strain echocardiography, the infarct core, border zone, and remote zone at baseline and three months' follow-up were defined. Patients were followed for the occurrence of the composite end point of appropriate implantable cardioverter-defibrillator (ICD) therapy and/or cardiac mortality. During a median follow-up of 46 months, 13 patients (17 %) reached the composite end point. At baseline, patients with and without events showed comparable values of LV longitudinal strain at the infarct, border, and remote zones. However, at three months' follow-up, patients with events showed significantly more impaired longitudinal strain at the border zone (-6.8 ± 3.1 % vs. -10.5 ± 4.9 %, P = 0.002), whereas LVEF was comparable (28 ± 6 % vs. 31 ± 4 %, P = 0.09). The median three-month LV longitudinal strain at the border zone was -9.4 %. Multivariate Cox regression analysis demonstrated that three-month longitudinal strain >-9.4 % at the border zone was independently associated with the composite end point (hazard ratio 3.94, 95 % confidence interval 1.05-14.70; P = 0.04). In conclusion, regional longitudinal strain at the border zone three months post-STEMI is associated with appropriate ICD therapy and cardiac mortality.

Electrocardiographic detection of right ventricular pressure overload in patients with suspected pulmonary hypertension.

BACKGROUND AND PURPOSE: Early, preferably noninvasive, detection of pulmonary hypertension improves prognosis. Our study evaluated the diagnostic accuracy of the electrocardiographically derived Butler-Leggett (BL) score and ventricular gradient (VG) to estimate mean pulmonary artery pressure (PAP). METHODS: In 63 patients with suspected pulmonary hypertension, BL score and VG were calculated. The VG was projected on a direction optimized for detection of right ventricular pressure overload (VG-RVPO). BL score and VG-RVPO were entered in multiple linear regression analysis and the diagnostic performance to detect PH (invasively measured mean PAP ≥ 25 mmHg) was assessed with receiver operating characteristic analysis. RESULTS: Both BL score and VG-RVPO correlated significantly with mean PAP (r=0.45 and r=0.61, respectively; P<0.001). Combining BL score and VG-RVPO increased the correlation to 0.67 (P<0.001). The diagnostic performance of this combination for the detection of PH was good with an area under the curve of 0.79 (P<0.001). CONCLUSION: Combination of the BL score and VG-RVPO allows for accurate detection of increased PAP.

Circulating endothelial progenitor cells are not affected by acute systemic inflammation.

Vascular injury causes acute systemic inflammation and mobilizes endothelial progenitor cells (EPCs) and endothelial cell (EC) colony-forming units (EC-CFUs). Whether such mobilization occurs as part of a nonspecific acute phase response or is a phenomenon specific to vascular injury remains unclear. We aimed to determine the effect of acute systemic inflammation on EPCs and EC-CFU mobilization in the absence of vascular injury. Salmonella typhus vaccination was used as a model of acute systemic inflammation. In a double-blind randomized crossover study, 12 healthy volunteers received S. typhus vaccination or placebo. Phenotypic EPC populations enumerated by flow cytometry [CD34(+)VEGF receptor (VEGF)R-2(+)CD133(+), CD14(+)VEGFR-2(+)Tie2(+), CD45(-)CD34(+), as a surrogate for late outgrowth EPCs, and CD34(+)CXCR-4(+)], EC-CFUs, and serum cytokine concentrations (high sensitivity C-reactive protein, IL-6, and stromal-derived factor-1) were quantified during the first 7 days. Vaccination increased circulating leukocyte (9.8 + or - 0.6 vs. 5.1 + or - 0.2 x 10(9) cells/l, P < 0.0001), serum IL-6 [0.95 (0-1.7) vs. 0 (0-0) ng/l, P = 0.016], and VEGF-A [60 (45-94) vs. 43 (21-64) pg/l, P = 0.006] concentrations at 6 h and serum high sensitivity C-reactive protein at 24 h [2.7 (1.4-3.6) vs. 0.4 (0.2-0.8) mg/l, P = 0.037]. Vaccination caused a 56.7 + or - 7.6% increase in CD14(+) cells at 6 h (P < 0.001) and a 22.4 + or - 6.9% increase in CD34(+) cells at 7 days (P = 0.04). EC-CFUs, putative vascular progenitors, and the serum stromal-derived factor-1 concentration were unaffected throughout the study period (P > 0.05 for all). In conclusion, acute systemic inflammation causes nonspecific mobilization of hematopoietic progenitor cells, although it does not selectively mobilize putative vascular progenitors. We suggest that systemic inflammation is not the primary stimulus for EPC mobilization after acute vascular injury.

Prognostic Implications of Elevated Pulmonary Artery Pressure After ST-Segment Elevation Myocardial Infarction.

Elevated systolic pulmonary artery pressure (SPAP) after ST-segment elevation myocardial infarction (STEMI) has been associated with adverse outcome. However, little is known about the development of increased SPAP after STEMI treated with primary percutaneous coronary intervention. The aims of this study were to investigate the incidence and determinants of elevated SPAP (SPAP ≥36 mm Hg at 12 months) after first STEMI and to analyze its prognostic implications. A total of 705 patients (60 ± 12 years; 75% men; left ventricular ejection fraction [LVEF] 47 ± 9%) with first STEMI treated with primary percutaneous coronary intervention were evaluated. Two-dimensional echocardiography was available at baseline and 12-month follow-up. Data on all-cause mortality were collected at long-term follow-up. Incident elevated SPAP was present in 5% (n = 38) of patients. Patients with incident elevated SPAP were older (66 ± 12 vs 60 ± 11 years, p = 0.001), had more systemic hypertension (58% vs 30%, p <0.001) and lower LVEF (43 ± 9% vs 48 ± 8%, p <0.001) than their counterparts. Left atrial volume was larger (23 ± 11 vs 18 ± 6 ml/m(2), p = 0.006), and moderate to severe mitral regurgitation was more prevalent in patients with incident elevated SPAP (16% vs 7%, p = 0.05). Independent correlates of incident elevated SPAP at 12-month follow-up were age (odds ratio [OR] 1.04, 95% CI 1.01 to 1.08, p = 0.01), hypertension (OR 2.52, 95% CI 1.23 to 5.14, p = 0.01), baseline LVEF (OR 0.94, 95% CI 0.90 to 0.98, p = 0.003), and baseline left atrial volume (OR 1.08, 95% CI 1.03 to 1.12, p = 0.001). Incident elevated SPAP was independently associated with all-cause mortality (hazard ratio 3.84, 95% CI 1.76 to 8.39, p = 0.001). In conclusion, although the incidence of elevated SPAP after STEMI is low, its presence is independently associated with increased risk of all-cause mortality at follow-up.

Detection of subtle left ventricular systolic dysfunction in patients with significant aortic regurgitation and preserved left ventricular ejection fraction: speckle tracking echocardiographic analysis.

AIMS: The aim of this study was to characterize left ventricular (LV) mechanics in symptomatic and asymptomatic patients with moderate-to-severe or severe aortic regurgitation (AR) and preserved ejection fraction (left ventricular ejection fraction) using two-dimensional speckle tracking echocardiography (2D-STE). The association between baseline LV strain and development of indications for surgery in asymptomatic patients was also evaluated. METHODS AND RESULTS: A total of 129 patients with moderate-to-severe or severe AR and LVEF >50% (age 55 ± 17 years, 64% male, 53% asymptomatic at baseline) were included. Standard echocardiography and 2D-STE were performed at baseline. Compared with asymptomatic patients, symptomatic patients had significantly impaired LV longitudinal (-14.9 ± 3.0 vs. -16.8 ± 2.5%, P < 0.001), circumferential (-17.5 ± 2.9 vs. -19.3 ± 2.8%, P = 0.001), and radial (35.7 ± 12.2 vs. 43.1 ± 14.7%, P = 0.004) strains. Among 49 asymptomatic patients who were followed up, 26 developed indications for surgery (symptoms onset or LVEF ≤50%). These patients had comparable LV volumes, LVEF, and colour Doppler assessments of AR jet at baseline, but more impaired LV longitudinal (P = 0.009) and circumferential (P = 0.017) strains compared with patients who remained asymptomatic. Impaired baseline LV longitudinal (per 1% decrease, HR = 1.21, P = 0.04) or circumferential (per 1% decrease, HR = 1.22, P = 0.04) strain was independently associated with the need for surgery. CONCLUSION: Multidirectional LV strain was more impaired in symptomatic than in asymptomatic patients with moderate-to-severe or severe AR, despite preserved LVEF. In asymptomatic AR patients, longitudinal and circumferential strains identified patients who would require surgery during follow-up.

Determinants of right ventricular remodeling following ST-segment elevation myocardial infarction.

Right ventricular (RV) function after ST-segment elevation myocardial infarction (STEMI) has important prognostic implications. However, the changes in RV function over time after STEMI and the incidence of RV remodeling remain unknown. The present study evaluated changes in RV dimensions and function in contemporary patients with first STEMI and assessed the independent determinants of RV dysfunction at follow-up. Patients with first STEMI (n = 940, 60 ± 11 years, 77% men) treated with primary percutaneous coronary intervention underwent echocardiography at baseline and 6- and 12-month follow-up. The prevalence of RV dysfunction (tricuspid annular plane systolic excursion [TAPSE] ≤15 mm) decreased significantly at 6 months follow-up (from 15% to 8%, p <0.001) and the incidence of RV remodeling (increase in RV end-diastolic area [RVEDA] ≥20%) was observed in 200 patients (25%). Absolute changes in RVEDA were independently associated with absolute changes in wall motion score index and left ventricular (LV) remodeling (p <0.001 for both parameters), whereas absolute changes in TAPSE were independently related with absolute changes in wall motion score index and mitral regurgitation grade (p <0.001 for both parameters). Independent correlates of RV dysfunction at 6 months follow-up were multivessel coronary disease (odds ratio [OR] 2.13), peak cardiac troponin T (OR 1.05), angiotensin-converting enzyme inhibitors and/or angiotensin receptor blockers use (OR 0.27), baseline LV ejection fraction (OR 0.96) and baseline TAPSE (OR 0.88). In conclusion, despite the non-negligible incidence of RV remodeling in patients with first STEMI, RV function improves early after STEMI. Multivessel coronary disease, infarct size, baseline LV ejection fraction and TAPSE and the nonuse of angiotensin-converting enzyme inhibitors and/or angiotensin receptor blockers are independent determinants of RV dysfunction.

Impact of right ventricular dyssynchrony on left ventricular performance in patients with pulmonary hypertension.

Pulmonary hypertension has been associated with right ventricular (RV) dyssynchrony which may induce left ventricular (LV) dysfunction and dyssynchrony through ventricular interdependence. The present study evaluated the influence of RV dyssynchrony on LV performance in patients with pulmonary hypertension. One hundred and seven patients with pulmonary hypertension (age 63 ± 14 years, systolic pulmonary arterial pressure 60 ± 19 mmHg) and LV ejection fraction (EF) >35% were evaluated. Ventricular dyssynchrony was assessed with speckle tracking echocardiography and defined as the standard deviation of the time to peak longitudinal strain of six segments of the RV (RV-SD) and the LV (LV-SD) in the apical 4-chamber view. Mean RV-SD and LV-SD assessed with longitudinal strain speckle tracking echocardiography were 51 ± 28 and 47 ± 21 ms, respectively. The patient population was divided according to the median RV-SD value of 49 ms. Patients with RV-SD ≥49 ms had significantly worse NYHA functional class (2.7 ± 0.7 vs. 2.3 ± 0.7, p = 0.004), RV function (tricuspid annular plane systolic excursion: 16 ± 4 vs. 19 ± 4 mm, p < 0.001), LVEF (50 ± 10 vs. 55 ± 8%, p = 0.001), and larger LV-SD (57 ± 18 vs. 36 ± 18 ms, p < 0.001). RV-SD significantly correlated with LV-SD (r = 0.55, p < 0.001) and LVEF (r = -0.23, p = 0.02). Multiple linear regression analysis showed an independent association between RV-SD and LV-SD (ß = 0.35, 95%CI 0.21-0.49, p < 0.001). RV dyssynchrony is significantly associated with LV dyssynchrony and reduced LVEF in patients with pulmonary hypertension.

Accuracy of three-dimensional versus two-dimensional echocardiography for quantification of aortic regurgitation and validation by three-dimensional three-directional velocity-encoded magnetic resonance imaging.

Quantitative assessment of aortic regurgitation (AR) remains challenging. The present study evaluated the accuracy of 2-dimensional (2D) and 3-dimensional (3D) transthoracic echocardiography (TTE) for AR quantification, using 3D 3-directional velocity-encoded magnetic resonance imaging (VE-MRI) as the reference method. Thirty-two AR patients were included. With color Doppler TTE, 2D effective regurgitant orifice area (EROA) was calculated using the proximal isovelocity surface area method. From the 3D TTE multiplanar reformation data, 3D-EROA was calculated by planimetry of the vena contracta. Regurgitant volumes (RVol) were obtained by multiplying the 2D-EROA and 3D-EROA by the velocity-time integral of AR jet and compared with that obtained using VE-MRI. For the entire population, 3D TTE RVol demonstrated a strong correlation and good agreement with VE-MRI RVol (r = 0.94 and -13.6 to 15.6 ml/beat, respectively), whereas 2D TTE RVol showed a modest correlation and large limits of agreement with VE-MRI (r = 0.70 and -22.2 to 32.8 ml/beat, respectively). Eccentric jets were noted in 16 patients (50%). In these patients, 3D TTE demonstrated an excellent correlation (r = 0.95) with VE-MRI, a small bias (0.1 ml/beat) and narrow limits of agreement (-18.7 to 18.8 ml/beat). Finally, the kappa agreement between 3D TTE and VE-MRI for grading of AR severity was good (k = 0.96), whereas the kappa agreement between 2D TTE and VE-MRI was suboptimal (k = 0.53). In conclusion, AR RVol quantification using 3D TTE is accurate, and its advantage over 2D TTE is particularly evident in patients with eccentric jets.

Implantation of a left ventricular assist device in patients with a complex apical anatomy.

Implantation of a left ventricular assist device can be challenging in patients with an altered apical anatomy after cardiac surgery or as the result of the presence of a calcified apical aneurysm. In this paper we present 2 cases with a challenging apical anatomy and introduce a new surgical technique facilitating left ventricular assist device implantation in these patients.

Prognostic value of right ventricular longitudinal peak systolic strain in patients with pulmonary hypertension.

BACKGROUND: Right ventricular (RV) function is an important prognostic marker in patients with pulmonary hypertension. The present evaluation assessed the prognostic value of RV longitudinal peak systolic strain (LPSS) in patients with pulmonary hypertension. METHODS AND RESULTS: A total of 150 patients with pulmonary hypertension of different etiologies (mean age, 59±15 years; 37.3% male) were evaluated. RV fractional area change and tricuspid annular plane systolic excursion index were evaluated with 2-dimensional echocardiography. RV LPSS was assessed with speckle-tracking echocardiography. The patient population was categorized according to a RV LPSS value of -19%. Among several clinical and echocardiographic parameters, the significant determinants of all-cause mortality were evaluated. There were no significant differences in age, sex, pulmonary hypertension cause and left ventricular ejection fraction between patients with RV LPSS <-19% and patients with RV LPSS ≥-19%. However, patients with RV LPSS ≥-19% had significantly worse New York Heart Association functional class (2.7±0.6 versus 2.3±0.8; P=0.003) and lower tricuspid annular plane systolic excursion (16±4 mm versus 18±3 mm; P<0.001) than their counterparts. During a median follow-up of 2.6 years, 37 patients died. RV LPSS was a significant determinant of all-cause mortality (HR, 3.40; 95% CI, 1.19-9.72; P=0.02). CONCLUSIONS: In patients with pulmonary hypertension, RV LPSS is significantly associated with all-cause mortality. RV LPSS may be a valuable parameter for risk stratification of these patients. Future studies are needed to confirm these results in the pulmonary hypertension subgroups.

Right ventricular longitudinal peak systolic strain measurements from the subcostal view in patients with suspected pulmonary hypertension: a feasibility study.

BACKGROUND: The assessment of right ventricular (RV) function with two-dimensional echocardiography can be challenging in patients with pulmonary hypertension, especially in those with chronic pulmonary disease. The aim of the present study was to evaluate the feasibility of measuring RV longitudinal peak systolic strain (LPSS) in the echocardiographic subcostal view in patients with suspected pulmonary hypertension. METHODS: A total of 179 patients evaluated for pulmonary hypertension were included (85 with systemic disorder, 64 with pulmonary disease, and 30 with RV dilatation and dysfunction). Additionally, 30 normal controls were evaluated. The feasibility of RV LPSS speckle-tracking measurements in the apical four-chamber view and in the subcostal view was evaluated. Furthermore, the RV LPSS speckle-tracking measurements performed in these two echocardiographic views were compared. RESULTS: The feasibility of RV LPSS in the subcostal view was 95.3%, 92.2%, 93.3%, and 93.3% in patients with systemic disorder, with pulmonary disease, with RV dilatation and dysfunction, and controls, respectively. In comparison, the feasibility of RV LPSS in the apical four-chamber view was 92.9%, 82.8%, 90%, and 93.3% in each group, respectively. Bland-Altman analysis showed good agreement between measurements in both echocardiographic views (systemic disorder: mean bias, -0.14; pulmonary disease: mean bias, 0.28; RV dilatation and dysfunction: mean bias, 0.3; and normal controls: mean bias, -0.14). CONCLUSIONS: The subcostal view provides a good alternative for RV strain assessment in patients who are evaluated for pulmonary hypertension. This measurement may be a valuable surrogate of RV function in patients with challenging apical windows.