Increased central body fat deposition precedes a significant rise in resting blood pressure in male offspring of essential hypertensive parents: a 5 year follow-up study.

OBJECTIVES: As long as offspring of essential hypertensive parents (OHyp) are lean, their blood pressure usually remains within normal limits. The mechanism(s) transforming this 'genetically dysregulated normotension' into hypertension are unclear. We hypothesized that OHyp are not only genetically prone to develop hypertension, but may also have a particular propensity to accumulate central body fat. DESIGN: A 5-year follow-up cohort study. SETTING: University Hospital in Switzerland. PARTICIPANTS: Seventeen young (25 +/- 1 years, mean +/- SD), lean healthy normotensive male OHyp and 17 age- and sex-matched offspring of normotensive parents (ONorm) paired for baseline blood pressure with the OHyp. MAIN OUTCOME MEASURES: Resting and exercise blood pressure, body weight, body mass index (BMI) and waist-to-hip ratio were assessed at baseline and after 5 years. RESULTS: At baseline, body weight, BMI, waist-to-hip ratio and blood pressure did not differ significantly between OHyp and ONorm. At follow-up, body weight was increased in both groups (from 73.9 +/- 6.0 to 77.7 +/- 8.1 kg in OHyp, P = 0.008, and from 71.5 +/- 6.9 to 73.5 +/- 6.6 kg in ONorm, P = 0.03). BMI followed a similar pattern. In contrast, waist-to-hip ratio increased in OHyp (from 0.84 +/- 0.03 to 0.87 +/- 0.03, P = 0.012), but not in ONorm (from 0.84 +/- 0.03 to 0.84 +/- 0.04, P = 0.79) and was therefore higher in OHyp at follow-up (P = 0.011, OHyp versus ONorm). Peak systolic blood pressure during dynamic exercise also rose at 5 years in the OHyp (from 182 +/- 10 to 214 +/- 17 mmHg, P = 0.0001) while resting systolic blood pressure only tended to do so (from 121 +/- 7 to 128 +/- 12 mmHg, P = 0.07). In ONorm, resting and peak dynamic exercise systolic blood pressure remained unchanged (119 +/- 11 versus 121 +/- 9 mmHg, baseline versus follow-up, P = 0.40, and 186 +/- 12 versus 196 +/- 22 mmHg, P = 0.10, respectively). Thus, systolic peak exercise blood pressure was significantly (P = 0.014) elevated at follow-up in OHyp compared to ONorm, while resting systolic blood pressure only tended (P = 0.06) to do so. CONCLUSIONS: Initially lean normotensive OHyp have a disparate long-term course of central body fat as compared to ONorm. Thus, OHyp are not only genetically prone to develop hypertension, but they also have a particular propensity to accumulate central body fat, even before a distinct rise in resting blood pressure occurs. The exaggerated blood pressure response to exercise observed at follow-up in the OHyp represents another marker that confers them a greater risk of developing future hypertension.

Serial evaluation of perfusion defects in patients with a first acute myocardial infarction referred for primary PTCA using intravenous myocardial contrast echocardiography.

AIMS: To investigate whether myocardial contrast echocardiography using Sonazoid could be used for the serial evaluation of the presence and extent of myocardial perfusion defects in patients with a first acute myocardial infarction treated with primary PTCA, and specifically, (1) to evaluate safety and efficacy of myocardial contrast echocardiography to detect TIMI flow grade 0--2, (2) to evaluate the success of reperfusion and (3) to predict left ventricular recovery after 4 weeks follow-up. METHODS AND RESULTS: Fifty-nine patients underwent serial myocardial contrast echocardiography, immediately before primary PTCA (MCE1), 1 h (MCE2) and 12--24 h after PTCA (MCE3). A perfusion defect was observed in 21 of 24 patients (88%) with anterior acute myocardial infarction. All but one had TIMI flow grade 0--2 prior to PTCA. Nine of 31 patients (29%) with inferior acute myocardial infarction showed a perfusion defect and all had TIMI flow grade 0-2 prior to PTCA. Restoration of TIMI flow grade 3 was achieved in 73% of the patients by primary PTCA. A reduction in size of the initial perfusion defect of at least one segment (16 segment model) or no defect vs persistent defect in patients with anterior acute myocardial infarction was associated with improved global left ventricular function at 4 weeks; mean global wall motion score index 1.29+/-0.21 vs 1.66+/-0.31 (P=0.009). Multiple regression analysis in patients with an anterior acute myocardial infarction revealed that the extent of the perfusion defect at MCE3 was a significant (P=0.0005) independent predictor for left ventricular recovery at 4 weeks follow-up. The only other independent predictor was TIMI flow grade 3 post PTCA (P=0.007). CONCLUSION: Intravenous myocardial contrast echocardiography immediately prior to primary PTCA seems safe and is capable of detecting the presence of a perfusion defect and its subsequent dynamic changes, particularly in patients with a first anterior acute myocardial infarction. A significant reduction in size of the initial perfusion defect using serial myocardial contrast echocardiography predicts functional recovery after 4 weeks and these findings underscore the potential diagnostic value of intravenous myocardial contrast echocardiography.

Diastolic dysfunction precedes myocardial hypertrophy in the development of hypertension.

BACKGROUND: Left ventricular (LV) hypertrophy and impaired diastolic function may occur early in systemic hypertension, but longitudinal studies are missing. METHODS: We performed an echocardiographic follow-up study in young initially normotensive male offspring of hypertensive (OHyp) (n = 25) and normotensive (ONorm) (n = 17) parents. Blood pressure (BP), LV mass, and mitral inflow were determined at baseline and after 5 years. Pulmonary vein flow pattern assessment and septal myocardial Doppler imaging were additionally performed at follow-up. RESULTS: At follow-up, BP was not significantly different between the two groups (128 +/- 11/84 +/- 10 v 123 +/- 11/81 +/- 5 mm Hg, OHyp v ONorm) but five OHyp had developed mild hypertension. LV mass index remained unchanged and was not different between the two groups at follow-up (92 +/- 17 v 92 +/- 14 g/m2). Diastolic echocardiographic properties were similar at baseline, but, at follow-up, the following differences were found: mitral E deceleration time (209 +/- 32 v 185 +/- 36 msec, P < .05) and pulmonary vein reverse A wave duration (121 +/- 15 v 107 +/- 12 msec, P < .05) were prolonged in the OHyp as compared to the ONorm. Compared to the normotensive subjects, the five OHyp who developed hypertension had more pronounced alterations of LV diastolic function, that is, significantly higher mitral A (54 +/- 7 v 44 +/- 9 cm/sec, hypertensives v normotensives, P < .05), lower E/A ratio (1.31 +/- 0.14 v 1.82 +/- 0.48, P < .05), increased systolic-to-diastolic pulmonary vein flow ratio (1.11 +/- 0.3 v 0.81 +/- 0.16, P < .005), longer myocardial isovolumic relaxation time (57 +/- 7 v 46 +/- 12 msec, P < .05) as well as smaller myocardial E (10 +/- 1 v 13 +/- 2 cm/sec, P < .05) and E/A ratio (1.29 +/- 0.25 v 1.78 +/- 0.43, P < .05), despite similar LV mass (91 +/- 16 v 93 +/- 18 g/m2). CONCLUSIONS: Over a 5-year follow-up, initially lean, normotensive, young men with a moderate genetic risk for hypertension, developed Doppler echocardiographic alterations of LV diastolic function compared to matched offspring of normotensive parents. These alterations were more pronounced in the OHyp who developed mild hypertension and occurred without a distinct rise in LV mass.

Transesophageal echocardiography to evaluate success of transcatheter closure of large secundum atrial septal defects in adults using the buttoned device.

OBJECTIVES: To determine the success rate of transcatheter closure of secundum atrial septal defects (ASDs) in adults and to characterize anatomical structures predisposing to unsatisfactory results. PATIENTS AND METHODS: Preinterventional and follow-up transesophageal echocardiography of 17 consecutive patients treated with a Sideris buttoned device was reviewed. Residual jet size of 5 mm or smaller was considered an adequate result; jet size larger than 5 mm was inadequate. Maximal ASD diameter, ASD area, and anterior, posterior, superior, and inferior septal rims were measured. RESULTS: The 7 patients with adequate results (41%) had smaller defects before implantation of a buttoned device (mean +/- SD maximal ASD diameter, 12 +/- 4 vs 19 +/- 5 mm; P<.005). Total rim length (mean +/- SD) was longer in patients with an adequate result (71 +/- 8 vs 46 +/- 11 mm; P<.001). The ASD size and length of the superior septal rim were independent predictors for an adequate result. Only 3 patients, all with ASD diameter less than 13 mm, had completely closed defects. All patients with ASD diameter greater than 20 mm had inadequate results and an unsatisfactory device position. The defect size (mean +/- SD) was similarly reduced in patients with adequate and inadequate results (9 +/- 3 vs 8 +/- 4 mm). CONCLUSION: Adults with a small ASD are more likely to have an adequate result after treatment with the buttoned device. A sufficiently large superior septal rim is particularly important for an adequate result. Most patients with a large ASD have inadequate results, although their ASD size is reduced by a similar absolute area as in patients with an adequate result.

Influence of the ultrasound contrast agent Levovist on human nailfold capillary microcirculation.

Little is known about the behavior of ultrasound contrast microbubbles in human capillaries. The evaluation of circulatory effects of echo contrast media may bring valuable information for the interpretation of echo contrast phenomena in the human myocardium. In 12 healthy volunteers (aged 31 +/- 6.7 years; five women), nailfold capillaries were examined by means of TV microscopy. The authors investigated acral microcirculation at rest and after local cold application with and without saccharide-based microbubbles (10 mL Levovist 300 mg/mL IV). The mean blood flow velocity at rest was 1.18 +/- 0.18 mm/s (mean value +/-1 SD) and 1.11 +/- 0.11 mm/s (mean value +/- 1 SD) after the injection of Levovist (ns). One minute after local cold exposure a decrease of the blood flow velocity by 61% before and by 75% after intravenous Levovist was found. In both groups the cold-induced decrease of blood flow velocity was statistically significant (p<0.01), whereas there was no significant difference in flow reaction between the two groups. No wall adhesion of blood cells or extravasation of contrast into the surrounding tissue was detected. After intravenous injection of a regular dose of saccharide-based microbubbles Levovist, no change of blood cell flow velocity and no wall adhesion or extravasation could be found at rest and after cold application in human nailfold capillaries. Since microcirculatory flow characteristics in the finger nailfold capillaries are not influenced by Levovist, it might be assumed also that myocardial blood flow behavior remains unchanged, so that this contrast agent may be used as a flow tracer for cardiac investigation.

Influence of left ventricular relaxation on the pressure half time of aortic regurgitation.

BACKGROUND: The severity of aortic regurgitation can be estimated using pressure half time (PHT) of the aortic regurgitation flow velocity, but the correlation between regurgitant fraction and PHT is weak. AIM: To test the hypothesis that the association between PHT and regurgitant fraction is substantially influenced by left ventricular relaxation. METHODS: In 63 patients with aortic regurgitation, subdivided into a group without (n = 22) and a group with (n = 41) left ventricular hypertrophy, regurgitant fraction was calculated using the difference between right and left ventricular cardiac outputs. Left ventricular relaxation was assessed using the early to late diastolic Doppler tissue velocity ratio of the mitral annulus (E/ADTI), the E/A ratio of mitral inflow (E/AM), and the E deceleration time (E-DT). Left ventricular hypertrophy was assessed using the M mode derived left ventricular mass index. RESULTS: The overall correlation between regurgitant fraction and PHT was weak (r = 0.36, p < 0.005). In patients without left ventricular hypertrophy, there was a significant correlation between regurgitant fraction and PHT (r = 0.62, p < 0.005), but not in patients with left ventricular hypertrophy. In patients with a left ventricular relaxation abnormality (defined as E/ADTI< 1, E/AM< age corrected lower limit, E-DT >/= 220 ms), no associations between regurgitant fraction and PHT were found, whereas in patients without left ventricular relaxation abnormalities, the regurgitant fraction to PHT relations were significant (normal E/AM: r = 0.57, p = 0.02; E-DT< 220 ms: r = 0.50, p < 0.001; E/ADTI < 1: r = 0.57, p = 0.02). CONCLUSIONS: Only normal left ventricular relaxation allows a significant decay of PHT with increasing aortic regurgitation severity. In abnormal relaxation, which is usually present in left ventricular hypertrophy, wide variation in prolonged backward left ventricular filling may cause dissociation between the regurgitant fraction and PHT. Thus the PHT method should only be used in the absence of left ventricular relaxation abnormalities.

Midazolam premedication improves tolerance of transesophageal echocardiography.

Patient premedication for transesophageal echocardiography (TEE) is still under debate, especially the use of sedatives. We performed a double-blind, placebo-controlled study to clarify the efficacy of low-dose intravenous midazolam as premedication for TEE. Placebo or midazolam (< or =50 kg, 2.0 mg intravenously; 50 to 80 kg, 2.5 mg; and > or =80 kg, 3.0 mg intravenously) was given in addition to topical anesthesia to 200 consecutive in- and outpatients. Blood pressure, heart rate, and oxygen saturation were monitored. Patients were interviewed immediately, and 2 to 10 days after TEE. Sixteen patients received an additional dose of midazolam, and in 12 follow-up was incomplete. Patients taking midazolam reported less gag reflex at probe introduction and during TEE, as did the examiners (p < 0.05 to 0.0001). Probe manipulations were found to produce less discomfort after midazolam administration (p < 0.005). Midazolam patients experienced less dyspnea (p < 0.01) despite a minimal decrease in oxygen saturation of 2% (p < 0.0001). The following day patients taking midazolam reported less sore throats, and painful swallowing was less frequent (p < 0.01 to 0.001). Systolic blood pressure decreased slightly in the midazolam group (132 +/- 24 to 121 +/- 20 mm Hg, p < 0.0001). The rate of minor complications showed no difference. Thus, TEE probe introduction and manipulation was tolerated better after low-dose midazolam premedication, and patients experienced less pharyngeal discomfort the day after. Midazolam was well tolerated and the complication rate did not increase. Thus low-dose, short-acting benzodiazepine premedication improves patient comfort during and after TEE and generous use can be recommended.

Successful conservative treatment of nontyphoid salmonella endocarditis involving a bioprosthetic valve.

We report a first case of Salmonella enteritidis endocarditis involving a bioprosthetic aortic valve. Despite additional native tricuspid valve involvement, the clinical course was favorable using an antibiotic regimen of ciprofloxacin and netilmicin. Although Salmonella prosthetic valve endocarditis is considered an indication for surgical replacement of the prosthesis, this case indicates that prolonged treatment with fluoroquinolones may be an alternative provided that the hemodynamic situation is stable.

Quantitation of mitral regurgitation using the systolic/diastolic pulmonary venous flow velocity ratio.

OBJECTIVES: The purpose of this study was to test the hypothesis that pulmonary venous flow velocity ratios during systole and diastole in patients with mitral regurgitation (MR) correctly predict the quantitative degree of MR. BACKGROUND: Pulmonary venous flow velocity measurements have thus far been used only for the qualitative assessment of MR. Recent studies have evaluated this method using transesophageal echocardiography against semiquantitative references. METHODS: In 100 patients without aortic regurgitation or atrial fibrillation and with left ventricular (LV) ejection fraction >45%, MR was assessed by quantitative echocardiographic Doppler and color Doppler, providing forward and total LV stroke volume for the calculation of the mitral regurgitant fraction (RFstandard), the reference parameter, and also supplying mitral regurgitant orifice area (ROA) values and the RF by the flow convergence method (RFPISA [proximal isovelocity surface area]). Measurements of pulmonary venous flow velocity time integral values during systole to diastole (VTIs/VTId) were obtained and tested for their predictibility of ROA, RFstandard and RFPISA. RESULTS: There was an inverse and significant correlation between VTIs/VTId and ROA, RFPISA and RFstandard, respectively: RFstandard=49 - 20 VTIs/VTId, r=0.77, p=0.0001. A principal source of variability in the relation between VTIs/VTId and RFstandard was the presence of mitral valve prolapse as the cause of MR. Pulmonary venous flow reversal (VTIs/VTId <0) correctly identified severe MR with 52% sensitivity, 96% specificity and 80% positive and 87% negative predictive accuracy. CONCLUSIONS: The VTIs/VTId ratio allows a moderately accurate assessment of the severity of MR.

Normotensive offspring of hypertensive parents: no evidence of left ventricular diastolic dysfunction in a cross-sectional study.

Left ventricular filling alterations occur early in the development of systemic hypertension. We tested the hypothesis that alteration of diastolic filling might be present in a normotensive population with increased genetic risk for hypertension in the absence of increased left ventricular mass. In a blinded study we compared 31 lean, normotensive offspring of hypertensive parents having normal left ventricular mass (risk group) with 30 matched individuals without family history of hypertension (control group). Left ventricular diastolic function was assessed using Doppler echocardiography. Transmitral flow velocities showed no significant differences between the two groups. Peak early diastolic flow was 0.79+/-0.12 m/s and 0.79+/-0.13 m/s in the risk group and control group, respectively. Peak late diastolic flow was 0.44+/-0.08 in the risk group and 0.42+/-0.11 m/s in the control group. The ratio of early to late diastolic velocity was 1.85+/-0.32 and 1.94+/-0.37. The deceleration time of the early diastolic flow was identical in both groups: 138+/-24 ms and 138+/-23 ms. There was no significant prolongation of the isovolumic relaxation time in the risk group: 75+/-17 compared to 73+/-17 ms in the control group. Doppler measurements showed no correlation with left ventricular mass. We conclude that, in this cross-sectional study, young normotensive offspring of hypertensive parents do not exhibit Doppler echocardiographic signs of diastolic filling alteration in the absence of increased left ventricular mass.

Destruction of contrast microbubbles during ultrasound imaging at conventional power output.

Inhomogenous opacification of cardiac chambers has been frequently observed after intravenous administration of long-persisting echocardiographic contrast agents. We observed this phenomenon to be most pronounced at high acoustic powers with incomplete opacification of the left ventricular apex and left ventricular outflow tract. Reducing the acoustic energy to which the contrast was exposed by decreasing transmit power or intermittently suspending insonification resulted in homogenous opacification of the entire left ventricular cavity. We systematically examined the effect of varying insonification power on the persistence of three investigational ultrasound contrast agents in both in vitro and in vivo models. We found an inverse relationship between the insonifying power and the persistence of the contrast agents. Contrast intensity decay could be reduced either by decreasing exposure to ultrasound by minimizing the transmit power of the system or by intermittently suspending ultrasound generation (triggering). Minimization of ultrasound contrast exposure to ultrasound energy thus improves echocardiographic contrast duration and homogeneity.

[Atrial septum defect and open foramen ovale. Diagnosis, clinical aspects and therapy using a catheter technique]. / Vorhofseptumdefekt und offenes Foramen ovale. Diagnostik, Klinik und Therapie mittels Kathetertechnik.

The purpose of this report is to describe the pathophysiology and clinical symptoms of atrial septal defects with emphasis on right ventricular failure and the risk of paradoxical embolism in the setting of a patent foramen ovale. The diagnosis of both the atrial septal defects and the patent foramen ovale, usually is made by echocardiography. Percutaneous transcatheter occlusion of an atrial septal defect and a patent foramen ovale has gained interest for some years as a treatment alternative to surgical closure. Preliminary results of different devices have been encouraging and the method appears to be a viable alternative to surgical closure.

[Non-surgical closure of type-II atrial-septal defect and patent foramen ovale]. / Nicht-chirurgischer Verschluss des Vorhofseptumdefekts Typ II und des offenen Foramen ovale.

In the past the standard therapy for significant atrial septal defect was surgical closure. In the presence of a patent foramen ovale with otherwise unexplained (cryptogenic) cerebral embolism, the therapy was oral anticoagulation or antiplatelet therapy. Surgery was considered only in the event of recurrence. Percutaneous transcatheter occlusion of atrial septal defect and patent foramen ovale is a new and valuable alternative to surgical closure. This report presents current knowledge and our own experience of nonsurgical closure of atrial septal defects and patent foramen ovale.

[Transesophageal echocardiography]. / Transösophageale Echokardiographie.

An outstanding image quality and detail resolution are characteristics of the transesophageal echocardiographic approach. Transesophageal echocardiography however, is more expensive than transthoracic echocardiography and semi-invasive. Indeed a restricted use is warranted for situations where the additional information obtained is decisive for further patient management. This is the case in the evaluation of patients with unexplained cerebrovascular events, diseases in the left or right atrium, suspected endocarditis, prior to valvuloplasty or valvular reconstructive surgery, suspected prosthetic valve dysfunction and diseases of the thoracic aorta, especially aortic dissection. In most centers TEE is routinely performed during cardiac surgery. In critically ill patients TEE can be performed safely and provides important information. Future development will include even more detailed image quality, newer imaging methods allowing assessment of myocardial perfusion and especially threedimensional imaging.

Second harmonic imaging of an intravenously administered echocardiographic contrast agent: Visualization of coronary arteries and measurement of coronary blood flow.

OBJECTIVES: This study sought to evaluate the potential of second harmonic contrast echocardiography to assess coronary vasculature. BACKGROUND: Newer transpulmonary ultrasound contrast agents capable of resonance phenomena detected by harmonic imaging may theoretically be able to demonstrate blood flow in the myocardium. METHODS: Transthoracic B-mode images and Doppler were obtained using a prototype second harmonic ultrasound system after femoral vein injection of AF0145 (10 to 40 mg) in 13 closed chest dogs (mean weight 25.6 kg). Coronary Doppler flow was simultaneously invasively measured using an intracoronary flow wire and visually compared with transthoracic Doppler flow. "Noninvasive" coronary vasodilator reserve was determined by measuring the ratio of the Doppler time velocity integral after adenosine to the baseline value and compared with the "invasive" intracoronary determination. RESULTS: Harmonic imaging showed heterogeneous opacification of the myocardium characterized by linear branching structures consistent with intramyocardial coronary arteries, which were not clearly visible during conventional ultrasound imaging. In nine dogs, transthoracic Doppler was performed, and characteristic coronary Doppler flow was observed, identical to the simultaneously observed intracoronary Doppler flow. Intracoronary adenosine (120 to 150 microgram) equally increased intracoronary and transthoracic Doppler flow velocities. The calculated "noninvasive" and "invasive" coronary vasodilator reserve ratios were similar ([mean +/- SD] 3.3 +/- 1.0 and 3.6 +/- 1.2, p = NS), with excellent correlation (r = 0.95, p = 0.0012). CONCLUSIONS: These findings indicate that noninvasive assessment of intramyocardial coronary vasculature and measurement of coronary blood flow reserve are possible using second harmonic contrast echocardiography.

[Mycotic aneurysm of the external iliac artery as a complication of percutaneous transluminal coronary artery dilatation]. / Mykotisches Aneurysma der Arteria iliaca externa als Komplikation einer perkutanen transluminalen Koronardilatation.

Percutaneous coronary interventional procedures exhibit an increased risk of peripheral vascular complications compared with diagnostic coronary angiography. Septic complications affect typically the puncture site. We describe a septic event (staphylococcus aureus) resulting in a mycotic aneurysm of the iliacal artery with embolic gonarthritis after a prolonged percutaneous transluminal coronary angioplasty performed 13 days after diagnostic coronary angiography using the same vascular access. The presumed culprit was the reintroduced dilatator which must have been contaminated. An emergency resection of the aneurysm and implantation of a Gore-Tex crossover bypass had to be performed. With prolonged parenteral and enteral antibiotic treatment the infection was controlled. We discuss risk factors for septic complications after coronary interventions and possible preventive measures.

[Non-invasive assessment of left ventricular diastolic function disorder using Doppler echocardiography]. / Nichtinvasive Erfassung der linksventrikulären diastolischen Funktionsstörung mittels Doppler-Echokardiographie.

Symptoms of a variety of cardiac diseases may well be caused predominantly by diastolic dysfunction, which appears to be one of the first detectable cardiac alterations. Diastole represents a complex interplay of multiple factors. Doppler echocardiography offers a noninvasive and relative simple method to assess left ventricular volumetric filling rates. The pulsed-wave Doppler method enables us to measure mitral flow velocities. Two distinct mitral flow velocity patterns have been recognized for situations with diastolic dysfunction. The pattern of delayed relaxation was reported in primary and in secondary left ventricular hypertrophy, myocardial ischemia and infarction and in dilated cardiomyopathy. The pattern of increased stiffness was described in constrictive pericarditis, restrictive processes and in heart transplant rejection. Doppler echocardiography has shown to be a helpful diagnostic tool, but a number of factors influencing mitral flow measurements have to be considered in each case, as there are age, heart rate, loading conditions and mitral regurgitation. Further studies are needed with respect to future control of therapeutic interventions and prognostic statements.