Outcome of patients with right heart thrombi: the Right Heart Thrombi European Registry.

Our aim was the assessment of the prognostic significance of right heart thrombi (RiHT) and their characteristics in pulmonary embolism in relation to established prognostic factors.138 patients (69 females) aged (mean±sd) 62±19 years with RiHT were included into a multicenter registry. A control group of 276 patients without RiHT was created by propensity scoring from a cohort of 963 contemporary patients. The primary end-point was 30-day pulmonary embolism-related mortality; the secondary end-point included 30-day all-cause mortality. In RiHT patients, pulmonary embolism mortality was higher in 31 patients with systolic blood pressure <90 mmHg than in 107 normotensives (42% versus 12%, p=0.0002) and was higher in the 83 normotensives with right ventricular dysfunction (RVD) than in the 24 normotensives without RVD (16% versus 0%, p=0.038). In multivariable analysis the simplified Pulmonary Embolism Severity Index predicted mortality (hazard ratio 2.43, 95% CI 1.58-3.73; p<0.0001), while RiHT characteristics did not. Patients with RiHT had higher pulmonary embolism mortality than controls (19% versus 8%, p=0.003), especially normotensive patients with RVD (16% versus 7%, p=0.02).30-day mortality in patients with RiHT is related to haemodynamic consequences of pulmonary embolism and not to RiHT characteristics. However, patients with RiHT and pulmonary embolism resulting in RVD seem to have worse prognosis than propensity score-matched controls.

Echocardiographic evaluation of external iliac artery Doppler waveform in patients with coronary artery disease.

Visual interpretation of the Doppler waveform in the common femoral or distal external iliac artery (EIA) was reported to be useful in screening for proximal peripheral artery occlusive disease (PAOD) in patients with lower limb ischemia. Commonly patients with coronary artery disease (CAD) referred for echocardiography have coexistent arterial pathology. Therefore, we decided to study whether echocardiographic evaluation of the distal EIA flow can be useful for detection of PAOD in patients with CAD. We studied 150 consecutive patients (pts) with CAD referred for echocardiography. At the end of an echocardiographic examination, evaluation of the flow in the distal EIA with an echocardiographic probe was performed. The Doppler waveform was classified as normal-with early diastolic flow reversal or abnormal-without early diastolic flow reversal. Echocardiographic findings were compared in a blinded fashion with the results of the ankle brachial index measurements (ABI). Based on the ABI ≤ 0.9, peripheral artery disease was diagnosed in 54 pts (36%) and abnormal external iliac Doppler waveform was found in 27 pts (18%). Sensitivity of abnormal external iliac Doppler waveform in predicting PAOD was 48%, specificity 99%, positive predictive value (PPV) 96%, and negative predictive value 77%. Peripheral arterial occlusive disease is common in patients with CAD referred for echocardiographic study. Echocardiographic assessment of distal EIA Doppler waveform has low sensitivity, but high specificity and high PPV in the diagnosis of peripheral arterial occlusive disease.

Echocardiographic Correlates of Abnormal Liver Tests in Patients with Exacerbation of Chronic Heart Failure.

BACKGROUND: Elevated total bilirubin (TB) and transaminases are frequently reported in patients with heart failure and are related to their worse prognosis. On the basis of hemodynamic data from previous studies, the investigators hypothesized that elevated bilirubin and transaminases are associated with different patterns of cardiac remodeling and dysfunction in patients with heart failure (i.e., elevated bilirubin with predominantly right-heart dysfunction and elevated transaminases with predominantly left-heart dysfunction). Therefore, the aim of this study was to evaluate prospectively echocardiographic correlates of elevated TB and transaminases on admission in patients with exacerbation of chronic heart failure. METHODS: The following echocardiographic parameters were prospectively analyzed in 150 patients (mean age, 75 years; 59% men): right ventricular end-diastolic diameter, right atrial area, tricuspid regurgitation, right ventricular systolic pressure, tricuspid annular plane systolic excursion, tricuspid lateral annulus systolic velocity, estimated right atrial pressure, portal vein pulsatility index (PVPI), left ventricular end-diastolic diameter (LVEDD), left ventricular ejection fraction, and cardiac index. RESULTS: Elevated TB was found in 61 patients (41%) and elevated transaminases in 46 patients (31%). In univariate logistic regression analysis, right ventricular end-diastolic diameter, right atrial area, tricuspid regurgitation, estimated right atrial pressure, tricuspid annular plane systolic excursion, tricuspid lateral annulus systolic velocity, PVPI, left ventricular ejection fraction, and cardiac index were significant predictors of elevated TB (P < .05 for all). LVEDD indexed to body surface area, right ventricular end-diastolic diameter, and systolic blood pressure on admission were significant predictors of elevated transaminases (P < .05 for all). In a multivariate regression model, only PVPI remained a significant predictor of elevated TB and LVEDD indexed to body surface area of elevated transaminases. Sensitivity, specificity, and positive and negative predictive values of PVPI > 0.5 in the prediction of elevated TB were 81%, 87%, 82%, and 87%, respectively. CONCLUSION: Several echocardiographic indices of right-heart dysfunction and low cardiac index are related to elevated TB, with an increased PVPI having the best predictive value. A weak statistically significant association was found between elevated transaminase levels and left ventricular end-diastolic diameter indexed to body surface area.

Does saddle embolism influence short-term prognosis in patients with acute pulmonary embolism?

BACKGROUND: In some patients with acute pulmonary embolism (APE) thrombi may lodge at the levels of the bifurcation of pulmonary trunk and extend into both main pulmonary arteries, forming so-called saddle embolism (SE). AIM: To assess the incidence of SE and whether it is associated with an increased risk of complicated clinical course. METHODS: We studied 150 consecutive patients (94 females, 56 males) aged 63.6+/-16.7 years with APE confirmed with contrast enhanced spiral computed tomography or transesophageal echocardiography. RESULTS: SE was detected in 22 (14.7%) patients. Mean age (SE vs N-SE) was 64.3+/-17.4 vs 63.5+/-16.6 years, heart rate 100.8+/-14.1 beats/min vs 97.8+/-21.1 beats/min, systolic blood pressure 126.2+/-20.1 vs 127.1+/-23.3 mmHg and blood pulsoximetry 92 (68-98) vs 91 (30-98) % (all differences NS). In patients with SE, echocardiographic signs of the right ventricular overload, defined as right to left ventricular end - diastolic ratio >0.6 with right ventricular hypokinesia and/or maximal tricuspid peak systolic gradient >30 mmHg with shortened acceleration time of pulmonary ejection <80 ms, were more frequent (77.3% vs 51.6%, p=0.04), as was the mid-systolic deceleration of pulmonary ejection velocity (77.3% vs 49.2%, p=0.04). Mortality and complicated clinical course rates were similar in patients with SE or N-SE (mortality: 4.5% vs 13.3%, NS, and complicated clinical course: 34.4% vs 25.0%, NS). CONCLUSIONS: Saddle pulmonary embolism is frequent, especially in patients with echocardiographic signs of impaired pulmonary ejection pattern. Saddle embolism does not indicate unfavourable clinical outcome and probably should not influence treatment selection.

Cardiac troponin T monitoring identifies high-risk group of normotensive patients with acute pulmonary embolism.

STUDY OBJECTIVES: Indications for thrombolysis in normotensive patients with pulmonary embolism (PE), based on the presence of right ventricular (RV) overload during transthoracic echocardiography (TTE), are controversial. We checked whether the monitoring of cardiac troponin T (cTnT) might help in risk stratification by detecting patients with RV myocardial injury. PATIENTS AND DESIGN: We studied 64 normotensive patients (30 women and 34 men) with a mean (+/- SD) age of 61.3 +/- 17 years and PE, who had undergone TTE for the assessment of RV overload. Plasma cTnT levels were measured quantitatively (detection limit, > 0.01 ng/mL) at hospital admission, and subsequently three times at 6-h intervals. Heparin therapy alone was used in 87.5% of patients, while 12.5% of patients received thrombolysis. RESULTS: cTnT was detected in 50% of patients. All eight in-hospital deaths occurred in the troponin-positive group, however, in one case the results of the first three assays had been negative. Elevated plasma cTnT increased the risk of PE-related death (odds ratio [OR], 21; 95% confidence interval [CI], 1.2 to 389). Increased age and elevated tricuspid regurgitant jet velocity, but not RV diameter/left ventricle diameter ratio, influenced the hospital mortality rate. Increased cTnT level was the only parameter predicting 15 in-hospital clinical adverse events (ie, death, thrombolysis, cardiopulmonary resuscitation, and IV use of catecholamine agents) [OR, 24.1; 95% CI, 2.9 to 200]. CONCLUSIONS: Patients with PE and elevated cTnT levels detected during repetitive assays are at a significant risk of a complicated clinical course and fatal outcome.

Plasma neuropeptide Y immunoreactivity influences left ventricular mass in pheochromocytoma.

UNLABELLED: Left ventricular hypertrophy (LVH) in patients with arterial hypertension is closely related to the levels of blood pressure (BP), catecholamines, angiotensin II and other mitogenic peptides. Pheochromocytoma (pheo) is a type of hypertension caused by excessive production of catecholamines. The aim of this study was to determinate if left ventricular hypertrophy in patients with pheochromocytoma is related to catecholamines and neuropeptide Y (NPY). METHODS: 29 patients with pheochromocytoma (22 F, age 40 +/- 13 years), plasma concentration of neuropeptide Y immunoreactivity, noradrenaline (NA), and adrenaline (A) were determined. Twenty-four hour urine collection for determination of noradrenaline and adrenaline were performed. Every patient had echocardiographic examination and 24 h ambulatory blood pressure monitoring. RESULTS: Left ventricular hypertrophy was diagnosed in 14 patients. No differences in systolic and diastolic blood pressure in patients with and without left ventricular hypertrophy were found. Plasma noradrenaline and adrenaline levels did not differ between both groups, while plasma neuropeptide Y immunoreactivity was higher in patients with left ventricular hypertrophy than in patients without left ventricular hypertrophy (18.46 +/- 13.26 vs. 9.3 +/- 5.9 fmol/ml (p = 0.02)). Left ventricular mass index (LVMI) correlated with plasma neuropeptide Y-immunoreactivity (r = 0.42 p = 0.023), however, no relationship between left ventricular mass index and plasma or urine noradrenaline and adrenaline levels were found. CONCLUSION: Our results indicate that mitogenic effect of neuropeptide Y may play a role in pathogenesis of left ventricular hypertrophy in patients with pheochromocytoma.

Echocardiographic evaluation of aorto-iliac occlusive disease.

Several studies demonstrated feasibility of visual assessment of the common femoral artery Doppler waveform, in an indirect evaluation of aorto-iliac segment stenosis. Patients with cardiac diseases referred for echocardiography often have coexistent arterial pathology. Since many of them are potential candidates for endovascular procedures, we decided to study, whether echocardiography can be useful for detection of aorto-iliac occlusive disease. We evaluated 92 patients with abdominal aortic aneurysm or peripheral artery occlusive disease, referred from the vascular surgery department for cardiac evaluation before surgery. At the end of an echocardiographic examination, evaluation of flow in the distal external iliac arteries with an echocardiographic probe was performed. The Doppler waveform was classified into normal--with early diastolic flow reversal or abnormal--without early diastolic flow reversal. Echocardiographic results were compared in a blinded fashion with reports from computed tomography angiography. Overall there were 58 iliac segments with significant (≥70%) area stenosis or occlusion and 126 iliac segments without significant disease on computed tomography angiography. Abnormal Doppler waveform was found in 56 out of 58 abnormal iliac segments-sensitivity 97%, and normal waveform was found in 106 out of 126 normal iliac segments-specificity 84%. Positive predictive value of abnormal Doppler waveform for significant iliac disease was 74%, and negative predicting value was 98%. Detection of significant stenoses in aorto-iliac segments is feasible with echocardiography. Further studies are necessary to evaluate its potential utility in a population of patients with cardiac disease referred for echocardiographic study.

Descending aortic Doppler flow pattern in patients with proximal peripheral artery disease.

Midsystolic deceleration (notch) in pulmonary pulse-wave (PW) Doppler flow is a common finding in patients with pulmonary embolism. The possible mechanism involves early reflection of pressure wave from proximal embolic sites. The aim of this study was to evaluate with PW Doppler whether occlusion or significant stenosis in the distal aorta or iliac arteries might produce a similar midsystolic notch in descending aortic flow. Echocardiography was performed in 97 consecutive patients with severe peripheral artery disease (PAD) admitted for vascular surgery and in 41 controls. PW Doppler assessment of flow in the proximal descending aorta was recorded from the suprasternal window. After exclusion of 13 patients due to inadequate visualization, atrial fibrillation, or aortic aneurysm, 84 patients were analyzed. Diagnosis of midsystolic notch was made by an experienced echocardiographer blinded to the vascular status of patients. A midsystolic notch in the descending aorta was present in 43 of 49 patients (87.7%) with occlusion or with >70% stenosis in the aortoiliac segment, 6 of 35 (17.1%) patients with occlusion or significant stenosis distal to the external iliac artery, and 0 patient from the control group. Sensitivity of the midsystolic notch in the detection of aortoiliac disease in patients with PAD was 87.7% and specificity was 82.8%. In conclusion, midsystolic deceleration (notch) in the descending aortic Doppler waveform is characteristic for patients with significant proximal PAD. The possible mechanism involves arterial pressure wave reflection from the occlusion or significant stenosis in the aortoiliac segment.

Biomarker-based risk assessment model in acute pulmonary embolism.

AIMS: Despite growing interest in biomarkers application for risk evaluation in acute pulmonary embolism (APE), no decision-making levels have been defined. METHODS AND RESULTS: We developed a biomarker-based risk stratification in 100 consecutive, normotensive on admission, APE patients (35 males, 65 females, 62+/-18 years). On admission serum NT-proBNP and cardiac troponin T (cTnT) levels were assessed and echocardiography was performed. All-cause 40-day mortality was 15% and APE mortality was 8%. In univariable analysis, cTnT>0.07 microg/L predicted all-cause mortality, hazard ratio (HR) 9.2 (95% CI: 3.3-26.1, P<0.0001), and APE mortality, HR 18.1 (95% CI: 3.6-90.2, P=0.0004); similarly, NT-proBNP>7600 ng/L predicted all-cause and APE mortalities [HR 6.7 (95% CI: 2.4-19.0, P=0.0003) and 7.3 (95% CI: 1.7-30.6, P=0.007)]. NT-proBNP<600 ng/L indicated uncomplicated outcome. Multivariable analysis revealed that cTnT>0.07 microg/L was the most significant independent predictor, whereas NT-proBNP and systemic systolic blood pressure measured on admission and echocardiographic parameters were non-significant. APE mortality in patients with NT-proBNP> or =600 ng/L and cTnT> or =0.07 microg/L reached 33%. NT-proBNP<600 ng/L indicated group without deaths. APE mortality for patients with NT-proBNP> or =600 ng/L and cTnT<0.07 microg/L was 3.7%. Incorporation of echocardiographic data did not improve group selection. CONCLUSION: Simultaneous measurement of serum cTnT and NT-proBNP allows for precise APE prognosis. Normotensive patients on admission with cTnT> or =0.07 microg/L and NT-proBNP> or =600 ng/L are at high risk of APE mortality, whereas NTproBNP<600 ng/L indicates excellent prognosis.

Homocysteine, adrenergic activity and left ventricular mass in patients with essential hypertension.

OBJECTIVE: Assessment of relationship between homocysteine (Hcy) and noradrenaline (NA), adrenaline (A) concentration and left ventricular mass index (LVMI) in patients with essential hypertension (EH). DESIGN AND METHODS: Samples obtained from 37 patients (14 female, 23 male) with mild EH (according to WHO criteria) (mean age 43.6 +/- 13.2 years) and 37 healthy volunteers (18 female, 19 male; mean age 38.2 +/- 10.6 years) were evaluated for Hcy (ELISA), NA and A (HPLC). Each patient underwent echocardiographic investigation with LVMI measurement (Penn convention). The examinations were performed in the outpatient clinic. RESULTS: Hcy was significantly higher in patients with EH (8.7 +/- 2.4 vs 6.6 +/- 1.3 micromol/l; p < 0.01). NA and A levels were significantly elevated in the EH group (A: 43.9 +/- 26.4 vs 36.9 +/- 29.4 pg/ml; NA: 428.5 +/- 148.8 pg/ml vs 314.6 +/- 103.4 pg/ml; both p < 0.05). LVMI was also significantly higher in EH group (96.6 +/- 19.5 vs 83.4 +/- 16.0 g/m2; p < 0.01). There was no significant correlation between Hcy and other analysed parameters in the studied groups. CONCLUSION: High levels of Hcy appear together with increased left ventricular mass and augmented adrenergic activity in patients with EH. Coexistence of high Hcy concentration, left ventricular hypertrophy and increased adrenergic activity increases the risk of atherosclerosis and cardiovascular disease in patients with EH.