Effects of Paclitaxel and Carboplatin combination on mechanical myocardial and microvascular functions: a transthoracic Doppler echocardiography and two-dimensional strain imaging study.

AIM: Paclitaxel and carboplatin are frequently used chemotherapy drugs in the treatment of gynecologic malignancies. Little is known about their effects on left ventricular mechanical and coronary microvascular functions. METHODS: Thirty consecutive patients were prospectively enrolled. Patients underwent transthoracic echocardiography (TTE) before and after chemotherapy, to evaluate left ventricular mechanical functions and coronary flow reserve (CFR). A comprehensive TTE, tissue Doppler and two-dimensional (2D) strain imaging were performed and coronary flow velocity was measured at baseline and after dipyridamole infusion. CFR was calculated as the ratio of hyperemic to baseline diastolic peak flow velocities. Mitral annular velocities by tissue Doppler, peak strain, and systolic strain rate by velocity vector imaging (VVI) were measured. Baseline measurements were compared with healthy controls (n = 26). RESULTS: No patient developed heart failure (HF) symptoms, no significant change occurred in left ventricular ejection fraction or cardiac output and no significant difference was observed in CFR after chemotherapy. Baseline mean longitudinal peak strain and systolic stain rate were similar between patients and controls: -17.5 ± 2.6% versus -17.6 ± 2.2% (P = NS) and -1.04 ± 0.14/sec versus -1.05 ± 0.12/sec (P = NS). Peak strain and systolic strain rate decreased significantly after chemotherapy (from -17.5 ± 2.6% to -16.2 ± 2.5%, P < 0.02; and from -1.05 ± 0.12/sec to -0.96 ± 0.11/sec, P = 0.01, respectively). However, mean longitudinal velocity did not change significantly. CONCLUSION: Paclitaxel and carboplatin combination did not impair CFR; however, this chemotherapy combination could induce subtle impairment in myocardial mechanical function which can be detected by advanced deformation imaging techniques rather than by tissue Doppler imaging or conventional 2D and Doppler echocardiography.

The association between hematological parameters and coronary flow reserve and coronary haemorheology in healthy subjects.

UNLABELLED: Studies carried out on sheep's have suggested possible effects of hematological parameters on coronary flow reserve (CFR). However, there is no study published investigating possible effects of hematological parameters and blood viscosity on coronary haemorheology and CFR in humans. We investigated the possible effects of hematological parameters on CFR using transthoracic echocardiography. METHODS: This study was conducted on 142 healthy subjects free of known cardiovascular risk factors between ages of 18-50 years. Hematological parameters were measured using an automated blood analyzer. Transthoracic echocardiographic examination including CFR measurement was performed on each subject using an Acuson Sequoia C256 Echocardiography System. RESULTS: The study group (142 subject) was divided into two according to the mean CFR values as the group with lower than mean CFR value and the group with upper than mean CFR value. Hematocrit (42.21+/-3.86 vs 40.27+/-3.97, P=0.004), LDL cholesterol, hsCRP values differed between the lower CFR and higher CFR groups. The other hematological parameters including hemoglobin value were similar between the two groups. hsCRP (beta=-0.334, P=0.001), mitral E/A ratio (beta=0.119, P=0.024), and haematocrit (beta=-0.161, P=0.064) values were the independent predictors of CFR. In women's subgroup, age, hemoglobin, hematocrit, and hsCRP values tended to differ between the lower CFR and the higher CFR subgroups. In men's subgroup systolic blood pressure, hsCRP, and mitral E velocity were different between the two groups. CONCLUSION: In addition to the coronary endothelial and coronary microvascular functions, hematocrit and blood viscosity might have some effect on coronary haemorheology and CFR.

Left ventricular twist was decreased in isolated left bundle branch block with preserved ejection fraction.

OBJECTIVE: Left ventricular (LV) rotation and twist play an important role in LV contraction and relaxation. Left bundle branch block (LBBB) deteriorates both diastolic and systolic functions. We evaluated the LV twist in patients with LBBB and preserved ejection fraction (EF) (>50%) to determine twist as a potential marker for subtle myocardial dysfunction. METHODS: This observational cross-sectional study included 34 LBBB patients with preserved EF who were free from ischemic and valvular disease (Group 1) and 36 healthy controls (Group 2). All patients underwent 2-D Doppler and 2-D speckle tracking echocardiography. LV apical, basal rotation, and twist were evaluated in both groups and compared accordingly. In addition, subjects were dichotomized considering the median twist value of the study population. Binary logistic regression analysis was performed to determine the independent variables associated with inframedian twist. RESULTS: Baseline clinical characteristics were similar in LBBB patients and controls. Mean apical rotation (2.5°±1.9° vs. 4.4°±2.9°; p=0.002), basal rotation (-2.9°±2.3° vs. -4.1°±2.7°; p=0.05), and twist (5.4°±3° vs. 8.6°±3.3°; p<0.001) were decreased in group 1. Parameters related to intra- and interventricular mechanical dyssynchrony, such as longitudinal left ventricular dyssynchrony index (LVdys) and preejection interval of LV, interventricular mechanical delay (IVMD), and left posterior wall contractions (SPMWD) were significantly higher in the LBBB group. The median twist value of the studied population was 6.65°. Binary logistic regression analysis showed that only presence of LBBB was independently associated with inframedian twist (OR=6.250; 95% CI: 2.215-17.632; p<0.001). CONCLUSION: The LBBB might have induced the reduction of LV twist by diminishing the LV rotation before inducing a prominent effect on the left ventricular ejection fraction (LVEF). Therefore, twist may be considered as a marker for subtle LV dysfunction in LBBB with substantially normal EF.

Relationship between CHA2DS2-VASc score and atrial electromechanical function in patients with paroxysmal atrial fibrillation: A pilot study.

BACKGROUND: CHA2DS2-VASc score is the most widely preferred method for prediction of stroke risk in patients with atrial fibrillation. We hypothesized that CHA2DS2-VASc score may represent atrial remodeling status, and therefore echocardiographic evaluation of left atrial electromechanical remodeling can be used to identify patients with high risk. METHODS: A total of 65 patients who had documented diagnosis of paroxysmal atrial fibrillation (PAF) were divided into three risk groups according to the CHA2DS2-VASc score: patients with low risk (score=0, group 1), with moderate risk (score=1, group 2), and with high risk score (score ≥2, group 3). We compared groups according to atrial electromechanical intervals and left atrium mechanical functions. RESULTS: Atrial electromechanical intervals including inter-atrial and intra-atrial electromechanical delay were not different between groups. However, parameters reflecting atrial mechanical functions including LA phasic volumes (Vmax, Vmin and Vp) were significantly higher in groups 2 and 3 compared with group 1. Likewise, LA passive emptying volume (LATEV) in the groups 2 and 3 was significantly higher than low-risk group (14.12±8.13ml/m(2), 22.36±8.78ml/m(2), 22.89±7.23ml/m(2), p: 0.031). Univariate analysis demonstrated that Vmax, Vmin and Vp were significantly correlated with CHA2DS2-VASc score (r=0.428, r=0.456, r=0.451 and p<0.001). Also, LATEV (r=0.397, p=0.016) and LA active emptying volume (LAAEV) (r=0.281, p=0.023) were positively correlated with CHA2DS2-VASc score. In the ROC analysis, Vmin≥11ml/m(2) has the highest predictive value for CHA2DS2-VASc score ≥2 (88% sensitivity and 89% specificity; ROC area 0.88, p<0.001, CI [0.76-0.99]). CONCLUSION: Echocardiographic evaluation of left atrial electromechanical function might represent a useful method to identify patients with high risk.

Right ventricular function is a determinant of long-term survival after cardiac resynchronization therapy.

BACKGROUND: Right ventricular (RV) dysfunction is a marker of poor prognosis in patients with heart failure. The aim of this study was to investigate the impact of RV function on the long-term outcomes of patients undergoing cardiac resynchronization therapy (CRT). METHODS: A total of 120 consecutive patients treated with CRT according to guideline criteria were followed over 5 years. Comprehensive echocardiographic analyses of RV function and radial and longitudinal mechanical left ventricular dyssynchrony were performed at baseline and 6 months after implantation. RV function was evaluated by two-dimensional longitudinal strain of the free wall, fractional area change, tricuspid annular plane systolic excursion, and tricuspid annular systolic velocity. Long-term follow-up events were defined as all-cause mortality, heart transplantation, or assist device implantation. RESULTS: Long-term events occurred in 38 patients. Among the studied variables for RV function, RV strain < 18% had the highest sensitivity (79%) and specificity (84%) to predict a poor outcome after CRT (area under curve, 0.821; P < .0001). When adjusted for confounding baseline variables of ischemic etiology, mechanical dyssynchrony, left ventricular end-systolic volume, mitral regurgitation, and medical therapy, RV dysfunction remained independently associated with outcomes, indicating a 5.7-fold increased risk for hard events (P < .0001). CONCLUSIONS: Preserved RV function as assessed by speckle-tracking strain imaging appears to be an independent predictor of long-term event-free survival after CRT.

Two cases of multivessel coronary artery ectasias resulting in acute inferior myocardial infarction.

The incidence of multivessel coronary artery ectasias (CAEs) among patients undergoing coronary artery angiography is very rare. All three coronary vessels can be affected by CAE, but most patients have an isolated arterial ectasia, commonly the right coronary artery. In this report we present two cases with inferior myocardial infarction that was likely caused by thrombotic occlusion of CAEs.

Asymptomatic aortic dissection late after aortic valve replacement.

Aortic dissection (AD) in patient with prostetic aortic valve is a rare but potentially fatal complication. Predictors of the occurrence of AD after aortic valve replacement (AVR) include fragility and thinning of the ascending aorta, aortic dilatation, aortic regurgitation (AR) and high blood pressure before AVR operation. AD is usually symptomatic, but rarely asymptomatic.We presented a case of asymptomatic AD seen in routine echocardiographic examination at 15 years after the AVR surgery.

An Unusual Type of Localized Hypertrophic Cardiomyopathy With Wolf Parkinson White Syndrome Presenting With Pulmonary Edema.

Hypertrophic cardiomyopathy (HCM) is an autosomal dominant heart disease that is the most common genetic cardiac disorder. The disease is characterized by excessive thickening of the left ventricular myocardium. The anterior portion of the interventricular ventricular septum is often involved. Asymmetric hypertrophy of apical site, left ventricular free wall, and right ventricle are less common in hypertrophic cardiomyopathy that occur in 1% cases. We report a case of a patient with an unusual type of hypertrophic cardiomyopathy and Wolf Parkinson White (WPW) presenting with pulmonary edema.

Body composition monitor measurement technique for the detection of volume status in peritoneal dialysis patients: the effect of abdominal fullness.

BACKGROUND: Bioimpedance spectroscopy (BIS) is used to assess volume status in peritoneal dialysis (PD) patients. However, it is proposed that it may be troubling in patients with abnormal fluid distribution and body geometry. It is not clear whether having an empty abdomen or not interferes with the BIS results and its relation with echocardiographic findings in PD patients. METHODS: Twenty-five prevalent PD patients were enrolled. Echocardiography and body composition analysis using BIS technique (50 frequencies, the Body Composition Monitor, BCM) were performed. Overhydration (OH), extracellular water (ECW) in liters and OH/ECW ratio were used as volume status indices. Differences in volume and echocardiographic findings, in patients with empty and with full abdomen, and their correlations with echocardiographic parameters were investigated. RESULTS: Mean age and PD duration were 61 ± 2.5 years and 42 ± 33 months, respectively. Sixty-four percent were male and 24% were diabetic. Mean left ventricular mass index (LVMi) was 131 ± 43 g/m (,) (2) mean left atrium diameter (LA) was 4.1 ± 0.1 cm, mean left ventricular ejection fraction (EF) was 64 ± 10%. Mean OH in patients with full abdomen were 1.67 ± 1.51 L and 1.68 ± 1.48 L, depending on the inclusion or exclusion of the dialysate volume, respectively. In patients with an empty abdomen, mean OHs were 2.12 ± 1.76 L and 1.91 ± 1.56 L, depending on the inclusion or exclusion of the dialysate volume. BIS measurements with an empty, but not with a full abdomen, was related to the echocardiographic parameters. CONCLUSION: BIS is a reliable method to evaluate volume status in PD patients. BIS performed after peritoneal equilibration test with an empty abdomen, better reflects overhydration and is related to echocardiographic parameters.

Evaluation of coronary microvascular function in patients with end-stage renal disease, and renal allograft recipients.

BACKGROUND: Approximately half of all deaths in patients with end-stage renal disease (ESRD) are due to cardiovascular diseases. Although renal transplant improves survival and quality of life in these patients, cardiovascular events significantly affect survival. We sought to evaluate coronary flow reserve (CFR), an indicator of coronary microvascular function, in patients with ESRD and in patients with a functioning kidney graft. METHODS: Eighty-six patients (30 with ESRD, 30 with a functioning renal allograft, and 26 controls) free of coronary artery disease or diabetes mellitus were included. Transthoracic Doppler echocardiography was used to measure coronary peak flow velocities at baseline and after dipyridamole infusion. CFR was calculated as the ratio of hyperemic to baseline diastolic peak flow velocities and was compared among the groups. RESULTS: The mean age of the study population was 36.1+/-7.3 years. No between-group differences were found regarding age, sex, or prevalences of traditional coronary risk factors other than hypertension. Compared with the renal transplant and control groups, the ESRD group had significantly lower mean CFR values. On multivariate regression analysis, serum levels of creatinine, age, and diastolic dysfunction were independent predictors of CFR. CONCLUSIONS: CFR is impaired in patients with ESRD suggesting that coronary microvascular dysfunction, an early finding of atherosclerosis, is evident in these patients. Although associated with a decreased CFR compared with controls, renal transplant on the other hand seems to have a favorable effect on coronary microvascular function.

Coronary flow reserve is impaired in patients with aortic valve calcification.

BACKGROUND: Calcific aortic valve disease is an active and progressive condition. Data indicate that aortic valve calcification (AVC) is associated with endothelial dysfunction and accepted as a manifestation of atherosclerosis. Coronary flow reserve (CFR) determined by transthoracic echocardiography has been introduced as a reliable indicator for coronary microvascular function. In this study we aimed to evaluate CFR in patients with AVC. METHODS: Eighty patients, aged more than 60 years, without coronary heart disease or diabetes mellitus were included: 40 had AVC without significant stenosis (peak gradient across the valve <25 mm Hg) and 40 had normal aortic valves (controls). Using transthoracic Doppler echocardiography, we measured coronary diastolic peak flow velocities (PFV) at baseline and after dipyridamole infusion. CFR was calculated as the ratio of hyperemic to baseline diastolic PFV and was compared between groups. RESULTS: Mean ages for patients with AVC and controls were 68.9+/-6.2 and 67.6+/-5.9 years (P=.3). There were no significant differences regarding clinical characteristics, laboratory findings, ejection fraction, or peak aortic valve gradients. Mean diastolic PFV at baseline and during hyperemia were 28.4+/-4.2 and 59.2+/-7.8 cm/s for AVC and 27.7+/-3.9 and 68.5+/-10.5 cm/s for controls. Compared with controls, patients with AVC had significantly lower CFR values (2.12+/-0.41 versus 2.51+/-0.51; P<.0001). CONCLUSION: CFR is impaired in patients with AVC before valve stenosis develops, suggesting that microvascular-endothelial dysfunction is present during the early stages of the calcific aortic valve disease.

Serum gamma-glutamyl transferase activity: a new marker for stent restenosis?

Stent restenosis remains the main limitation of percutaneous coronary intervention. Elevated serum gamma-glutamyl transferase (GGT) level is associated with an inflammatory response. We aimed to determine the correlation of stent restenosis with the serums level of GGT. One hundred and twenty patients (age 58.56+/-10.46 years, 66% male) with a history of coronary stent implantation and had undergone control coronary angiography (60 with restenosis and 60 without) were included. All had baseline serum GGT activity and were free of systemic and hepatobiliary disease. Median baseline serum GGT activity was significantly higher in patients with restenosis (34.00 U/L (24.00-47.75)) than in those without restenosis (21.00 U/L (17.25-26.7500)) (P<0.0001). Stent restenosis was identified in 38% of the patients with a serum GGT value >40 U/L and in 5% of patients with a serum GGT value