Associations Between Echocardiographic Right Heart Measurements With Short-Term Prognosis in Heart Failure: A Prospective Study.

BACKGROUND: Echocardiographic right ventricular (RV) dysfunction is a strong risk determinant for prognosis in patients with heart failure (HF). Although parameters of RV systolic function are widely used to define RV dysfunction, there is scarce data to suggest these parameters are best suited to predict HF-related outcomes. AIMS: We aimed to understand which morphologic or functional parameters are most closely associated with short-term mortality and HF-related hospitalization in patients with HF. METHODS: A total of 191 patients from eight study centers were included to this study. A detailed echocardiographic examination was done at enrollment, and patients were followed up for 6 months via direct interviews or phone calls. RESULTS: All right-sided echocardiographic parameters other than tricuspid annular plane systolic excursion were associated with outcomes. In a proportional hazards model that included right-heart parameters, RV longitudinal diameter (HR: 1.07, 95%CI: 1.04-1.10, p < 0.001), wall thickness (HR: 1.3, 95%CI: 1.13-1.50, p < 0.001), and tricuspid annular systolic velocity (HR: 0.90, 95%CI: 0.82-0.96, p = 0.02) were found as the independent predictors. However, only RV longitudinal dimension (HR: 1.04, 95%CI: 1.01-1.08, p = 0.01) and RV wall thickness (HR: 1.32, 95%CI: 1.10-1.60, p = 0.004) were associated with short-term outcomes after adjusting for other clinical and left-sided echocardiographic variables. On a Bayesian logistic regression model that included right-sided echocardiography variables, there was strong evidence for including either RV longitudinal diameter (BF10: 190.4) or wall thickness (BF10: 30.7) to the final model. CONCLUSION: Parameters of RV morphology were better predictors of short-term outcomes in HF patients.

Gut microbiota-derived metabolite trimethylamine N-oxide and biomarkers of inflammation are linked to endothelial and coronary microvascular function in patients with inflammatory bowel disease.

BACKGROUND: Inflammatory bowel disease (IBD), which is an umbrella term used for ulcerative colitis (UC) and Crohn's disease (CD), is associated with an increased risk for atherosclerotic cardiovascular disease (CVD). We aimed to investigate the association of local and systemic biomarkers of inflammation and gut microbiota-derived metabolite trimethylamine N-oxide (TMAO) with endothelial and coronary microvascular dysfunction in IBD. METHODS: A total of 56 patients with IBD (20 with UC and 36 with CD) and 34 age and gender matched controls were included. For all participants, samples were collected to analyze faecal calprotectin, and TMAO concentrations. Ultrasound-based examinations were done to measure flow-mediated vasodilatation (FMD) and coronary flow velocity reserve (CFVR). RESULTS: Patients with IBD had lower CFVR (2.07 (1.82-2.40)) and FMD (8.7 ± 3.7) as compared to controls (2.30 (2.07-2.74), p = 0.005 and 11.9 ± 6.8, p = 0.03). In patients with IBD, TMAO concentration (r = -0.30, p = 0.03), C-reactive protein (r = -0.29, p = 0.03) and WBC count (r = -0.37, p = 0.006) had a significant negative correlation with CFVR, and TMAO (ß = -0.27, 95 % CI: -0.23 to -0.02) and WBC count (ß = -0.31, 95 % CI: -0.56 to -0.06) were significant predictors of CFVR after multivariate adjustment. None of the biomarkers of inflammation or TMAO showed significant correlations with FMD. In patients with UC, TMAO showed a significant correlation with both CFVR (r = -0.55, p = 0.01) and FMD (r = -0.60, p = 0.005) while only WBC count had a statistically significant correlation with CFVR (r = -0.49, p = 0.004) in patients with CD. CONCLUSIONS: Gut microbiota-derived metabolite TMAO and biomarkers of systemic inflammation are associated with measures of endothelial/coronary microvascular dysfunction in patients with IBD.

Coronary microvascular dysfunction is common in patients hospitalized with COVID-19 infection.

BACKGROUND AND AIMS: Microvascular disease is considered as one of the main drivers of morbidity and mortality in severe COVID-19, and microvascular dysfunction has been demonstrated in the subcutaneous and sublingual tissues in COVID-19 patients. The presence of coronary microvascular dysfunction (CMD) has also been hypothesized, but direct evidence demonstrating CMD in COVID-19 patients is missing. In the present study, we aimed to investigate CMD in patients hospitalized with COVID-19, and to understand whether there is a relationship between biomarkers of myocardial injury, myocardial strain and inflammation and CMD. METHODS: 39 patients that were hospitalized with COVID-19 and 40 control subjects were included to the present study. Biomarkers for myocardial injury, myocardial strain, inflammation, and fibrin turnover were obtained at admission. A comprehensive echocardiographic examination, including measurement of coronary flow velocity reserve (CFVR), was done after the patient was stabilized. RESULTS: Patients with COVID-19 infection had a significantly lower hyperemic coronary flow velocity, resulting in a significantly lower CFVR (2.0 ± 0.3 vs. 2.4 ± 0.5, p < .001). Patients with severe COVID-19 had a lower CFVR compared to those with moderate COVID-19 (1.8 ± 0.2 vs. 2.2 ± 0.2, p < .001) driven by a trend toward higher basal flow velocity. CFVR correlated with troponin (p = .003, r: -.470), B-type natriuretic peptide (p < .001, r: -.580), C-reactive protein (p < .001, r: -.369), interleukin-6 (p < .001, r: -.597), and d-dimer (p < .001, r: -.561), with the three latter biomarkers having the highest areas-under-curve for predicting CMD. CONCLUSIONS: Coronary microvascular dysfunction is common in patients with COVID-19 and is related to the severity of the infection. CMD may also explain the "cryptic" myocardial injury seen in patients with severe COVID-19 infection.

Lack of right ventricular hypertrophy is associated with right heart failure in patients with left ventricular failure.

Presence of right heart failure (RHF) is associated with a worse prognosis in patients with left ventricular failure (LVF). While the cause of RHF secondary to LVF is multifactorial, an increased right ventricular (RV) afterload is believed as the major cause of RHF. However, data are scarce on the adaptive responses of the RV in patients with LVF. Our aim was to understand the relationship of right ventricular hypertrophy (RVH) with RHF and RV systolic and diastolic properties in patients with LVF. 55 patients with a left ventricular ejection fraction of 40% or less were included in the present study. A comprehensive two-dimensional transthoracic echocardiographic examination was done to all participants. 12 patients (21.8%) had RHF, and patients with RHF had a significantly lower right ventricular free wall thickness (RVFWT) as compared to patients without RHF (5.3 ± 1.7 mm vs. 6.6 ± 0.9 mm, p = 0.02) and the difference remained statistically significant after adjusting for confounders (Δx̅:1.34 mm, p = 0.002). RVFWT had a statistically significant correlation with tricuspid annular plane systolic excursion (r = 0.479, p < 0.001) and tricuspid annular lateral systolic velocity (r = 0.360, p = 0.007), but not with the indices of the RV diastolic function. None of the patients with concentric RVH had RHF, while 22.2% of patients with eccentric RVH and 66.7% of patients without RVH had RHF (p < 0.01 as compared to patients with concentric RVH). In patients with left ventricular systolic dysfunction, absence of RVH was associated with worse RV systolic performance and a significantly higher incidence of RHF.

Thrombolysis in Myocardial Infarction Risk Index Predicts 1-Year Mortality in Patients with Heart Failure: An Analysis of the SELFIE-TR Study.

OBJECTIVE: Predicting outcomes is an essential part of evaluation of patients with heart failure (HF). While there are multiple individual laboratory and imaging variables as well as risk scores available for this purpose, they are seldom useful during the initial evaluation. In this analysis, we aimed to elucidate the predictive usefulness of Thrombolysis in Myocardial Infarction Risk Index (TIMI-RI), a simple index calculated at the bedside with three commonly available variables, using data from a multicenter HF registry. SUBJECTS AND METHODS: A total of 728 patients from 23 centers were included in this analysis. Data on hospitalizations and mortality were collected by direct interviews, phone calls, and electronic databases. TIMI-RI was calculated as heart rate × (age/10)2/systolic pressure. Patients were divided into three equal tertiles to perform analyses. RESULTS: Rehospitalization for HF was significantly higher in patients within the 3rd tertile, and 33.5% of patients within the 3rd tertile had died within 1-year follow-up as compared to 14.5% of patients within the 1st tertile and 15.6% of patients within the 2nd tertile (p < 0.001, log-rank p < 0.001 for pairwise comparisons). The association between TIMI-RI and mortality remained significant (OR: 1.74, 95% CI: 1.05-2.86, p = 0.036) after adjustment for other variables. A TIMI-RI higher than 33 had a negative predictive value of 84.8% and a positive predictive value of 33.8% for prediction of 1-year mortality. CONCLUSION: TIMI-RI is a simple index that predicts 1-year mortality in patients with HF; it could be useful for rapid evaluation and triage of HF patients at the time of initial contact.

Combined past preeclampsia and gestational diabetes is associated with a very high frequency of coronary microvascular dysfunction.

BACKGROUND: A history of preeclampsia (pPE) and gestational diabetes (pGDM) are female-specific risk markers for atherosclerosis and future cardiovascular risk. In addition to increasing the risk of established risk factors for atherosclerosis, such as hypertension or diabetes, evidence suggests that pregnancy-related complications can also directly accelerate atherosclerosis by inducing endothelial dysfunction. A combination of both conditions is seen in a subset of patients with pregnancy, though it is not known whether this combination increases the overall risk for cardiovascular events. AIMS: Present study aimed to find the impact of combined pPE/pGDM on the prevalence of coronary microvascular dysfunction (CMD). METHODS: A total of 24 patients with combined pPE/pGDM, 19 patients with isolated pPE and 63 patients with pGDM were included to the present study and a further 36 healthy women with no previous pregnancy-related complications served as controls. Coronary flow reserve was measured using echocardiography and CMD was defined as a coronary flow reserve ≤2.5. RESULTS: Patients with combined pPE/pGDM had a high prevalence of CMD (91%), which was significantly higher than controls (5.6%, p < 0.001) and patients with pGDM (55%, p = 0.01). A history of pPE on top of pGDM was associated with an increased risk of CMD (HR:6.28, 95%CI:1.69-23.37, p = 0.006) after multivariate adjustment, but pGDM did not increase the odds for CMD in those with pPE. CONCLUSIONS: Combined pPE/pDM is associated with a very high prevalence of CMD, which may indicate an increased risk for future cardiovascular events.

Cardiovascular risk unawareness is common in individuals admitting to cardiology outpatient clinics in Turkey: the CVSCORE-TR study.

OBJECTIVES: Cardiovascular "risk" is an abstract concept that is frequently misunderstood by the general public. However, correct estimation of one's own cardiovascular risk is important as risk unawareness is associated with noncompliance with interventions aimed to reduce risk burden. Knowing the prevalence and factors linked with an increased probability of risk unawareness are therefore important to develop strategies aimed to increase risk awareness. Aims. To study prevalence of risk unawareness and to understand risk markers associated with risk underestimation and overestimation. Design. A total of 1716 participants were enrolled to the study in 33 centers across Turkey. Relevant demographic and clinical data were collected by direct interview. Cardiovascular risk of the participants was calculated using SCORE risk charts. Results. Ten-year risk for a fatal cardiovascular event was calculated as low in 633 (36.8%), intermediate in 513 (29.9%) and high-very high in 570 (33.2%) participants, respectively. According to these findings, 34.6% (n = 593) of the participants estimated their risk correctly, whereas 22.7% (n = 390) of the participants overestimated and 42.7% (n = 733) of the participants underestimated their risk. Male gender was the sole factor that was associated with an increased risk of underestimation, while having hypertension, significant valve disease or atrial fibrillation was associated with increased odds for risk overestimation. Conclusions. Only one-thirds of the sample was aware of their calculated risk for cardiovascular mortality and risk underestimation was the most common mode of risk unawareness, prompting concerns on the possible impact of the latter on adherence to the strategies aimed to reduce cardiovascular risk.

Usefulness of novel Martin/Hopkins and Sampson equations over Friedewald equation in cardiology outpatients: A CVSCORE-TR substudy.

BACKGROUND AND AIMS: The Friedewald equation (LDL-Cf) is known to produce inaccurate estimations of low-density lipoprotein cholesterol (LDL-C) when triglycerides are high (>400 mg/dL) or LDL-C is low (<70 mg/dL). The Martin/Hopkins (LDL-Cmh) and Sampson (LDL-Cs) equations were developed to overcome these limitations, but few data are available to assess whether these equations offer incremental usefulness over LDL-Cf. Our aim was to understand whether there was any incremental usefulness of novel equations on decisions regarding patient management. METHODS: Four thousand one hundred and ninety-six cardiology patients who were included in a multicentre registry database were analysed. Each patient was assigned to a cardiovascular risk class using the SCORE (Systematic COronary Risk Evaluation) algorithm, and relevant European guidelines were used to assess LDL-C targets. RESULTS: Compared with LDL-Cmh and LDL-Cs, LDL-Cf was able to correctly identify 96.9%-98.08% of patients as within or outside the LDL-C target, respectively, and 1.95%-2.8% of patients were falsely identified as being within the LDL-C target. Kappa coefficients for agreement between LDL-Cf vs LDL-Cmh and LDL-Cf vs LDL-Cs were 0.868 and 0.918 (P < .001). For patients not on cholesterol-lowering drugs, the decision to initiate treatment would be different in 1.2%-1.8% of cases if LDL-Cs or LDL-Cmh were used, respectively. For those already on cholesterol-lowering drugs, decisions regarding treatment intensification would be different in 1.5%-2.4% of cases if LDL-Cs or LDL-Cmh were used. CONCLUSIONS: In most cardiology outpatients, the Friedewald equation has excellent agreement with the novel Martin/Hopkins and Sampson equations, and treatment decisions should not change in most patients.

Pressure-dimension index: A novel "morphologic-functional" index of right ventricle that predicts short-term survival after left ventricular assist device implantation.

BACKGROUND: Right ventricular failure (RVF) after left ventricular assist device (LVAD) implantation is a major cause of postoperative morbidity and mortality. Despite the availability of multiple imaging parameters, none of these parameters had adequate predictive accuracy for post-LVAD RVF. AIM: To study whether right ventricular pressure-dimension index (PDI), which is a novel echocardiographic index that combines both morphologic and functional aspects of the right ventricle, is predictive of post-LVAD RVF and survival. METHODS: 49 cases that underwent elective LVAD implantation were retrospectively analyzed using data from an institutional registry. PDI was calculated by dividing systolic pulmonary artery pressure to the square of the right ventricular minor diameter. Cases were categorized according to tertiles. RESULTS: Patients within the highest PDI tertile (PDI>3.62 mmHg/cm2 ) had significantly higher short-term mortality (42.8%) and combined short-term mortality and severe RVF (50%) compared to other tertiles (P < .05 for both, log-rank p for survival to 15th day 0.014), but mortality was similar across tertiles in the long-term follow-up. PDI was an independent predictor of short-term mortality (HR:1.05-26.49, P = .031) and short-term composite of mortality and severe RVF (HR:1.37-38.87, P = .027). CONCLUSIONS: Increased PDI is a marker of an overburdened right ventricle. Heart failure patients with a high PDI are at risk for short-term mortality following LVAD implantation.

Relationship between malnutrition and coronary microvascular dysfunction in patients with nonischemic dilated cardiomyopathy

Background/ aim: Malnutrition is common in patients with nonischemic dilated cardiomyopathy (DCM), especially in the end stages of the disease where heart failure symptoms predominate. Malnutrition has been associated with atherosclerosis in patients with chronic kidney disease, but it is unknown whether a similar relationship exists between malnutrition and coronary microvascular dysfunction (CMD). In the present study, we aimed to analyse whether indices of malnutrition were associated with coronary flow reserve (CFR) in patients with DCM. Materials and methods: A total of 33 cases who were prospectively followed up with by institutional DCM registry were found eligible for inclusion. Coronary flow reserve was measured with transthoracic echocardiography from the left anterior descending artery. The study sample was divided into 2 groups using a CFR cut-off value of 2.0. Geriatric nutritional index (GNI), prognostic nutritional index (PNI), and C-reactive protein/albumin ratio (CAR) were calculated. Results: A total of 17 out of 33 cases (51.5%) had a low (<2.0) CFR. Both GNI and PNI were similar between the 2 groups, but the inflammatory­nutritional parameter CAR was significantly higher in those with a low CFR (1.18 ± 0.64 vs. 0.54 ± 0.28, P < 0.001). CAR remained an independent predictor of CFR on multivariate regression (ß = 0.65, P < 0.001) after adjustment for demographic (age, sex, body mass index), nutritional (GNI, PNI, albumin), and inflammatory (C-reactive protein) parameters. For a cut-off value of 0.80, CAR had a sensitivity of 85.7% and specificity of 73.6% to predict a CFR <2.0 (AUC: 0.835, 95%CI: 0.693­0.976, P = 0.001). Conclusions: Our findings indicate that not malnutrition per se but a combination of inflammation activation and malnutrition is predictive of CMD in patients with DCM.

Correlation and agreement between 2D and 3D speckle-tracking echocardiography for left ventricular volumetric, strain, and rotational parameters in healthy volunteers and in patients with mild mitral stenosis.

BACKGROUND: Recent advances had allowed measurement of myocardial deformation parameters using 3D speckle-tracking echocardiography (STE). Agreement between these two modalities and interchangeability of findings remain as an issue since 2DSTE is more widely available than 3DSTE. The aim of this study was to investigate the correlation and agreement between 2DSTE and 3DSTE in healthy volunteers and in patients with mild mitral stenosis (MS). METHODS: Data from 31 patients with mild MS and 27 healthy volunteers were included in this study. Data were analyzed for the correlation and agreement between 2DSTE and 3DSTE for volumetric, strain, and rotational parameters. RESULTS: There were no significant differences between 2DSTE and 3DSTE in both control and MS groups for left ventricular volumetric and rotational parameters. 3D global longitudinal strain (GLS) and global circumferential strain (GCS) were significantly higher in healthy volunteers (P < 0.001 for both), while only 3DGCS was significantly higher than 2DGCS in MS group (P < 0.001). The correlation between 3DSTE and 2DSTE was weak-to-moderate in both groups for strain and rotational parameters, and overall, correlation coefficients were higher in MS group. An exception was GLS in MS group, where coefficient of correlation was excellent (r = 0.907). Agreement between two modalities was poor for strain and rotational parameters, and the average bias was high. CONCLUSIONS: Overall, the agreement between 2DSTE and 3DSTE for strain and rotational measures was poor with a high average bias. The agreement between 2DSTE and 3DSTE is affected by the presence of underlying MS and the direction of strain.

The predictive role of modified TIMI risk index in patients with ST-segment elevation myocardial infarction.

BACKGROUND: The prognostic value of thrombolysis in myocardial infarction (TIMI) risk index (TRI) has been reported in patients with coronary artery disease. In this study, we evaluated the additional prognostic value of blood urea nitrogen (BUN) level to the TRI in patients with ST-segment elevation myocardial infarction (STEMI). METHODS: We evaluated the in-hospital and long-term (3-year) prognostic value of modified TRI (mTRI) in patients with STEMI. The mTRI is calculated using the following equation; mTRI = (TRI × BUN)/10. Patients were stratified into 5 groups according to 20-point increments of mTRI. RESULTS: The patients with higher mTRI had significantly higher in-hospital and long-term mortality. The risk for in-hospital and long-term mortality was highest for those within the Q5 (36.8 and 42.3%, respectively) and it was significantly higher than all the other groups (p < .001 for both). CONCLUSIONS: In this study, the prognostic value of TRI has been augmented by multiplication of TRI with BUN/10. Therefore, we present a pilot study of association of mTRI with overall STEMI patients.

Right Ventricular Hypertrophy and Dilation in Patients With Human Immunodeficiency Virus in the Absence of Clinical or Echocardiographic Pulmonary Hypertension.

BACKGROUND: Involvement of right-sided heart chambers (RSHCs) in patients infected with human immunodeficiency virus (HIV) is common and is usually attributed to pulmonary arterial or venous hypertension (PH). However, myocardial involvement in patients with HIV is also common and might affect RSHCs even in the absence of overt PH. Our aim was to define morphologic and functional alterations in RSHC in patients with HIV and without PH. METHODS AND RESULTS: A total of 50 asymptomatic patients with HIV and 25 control subjects without clinical or echocardiographic signs for PH were included in the study. Transthoracic echocardiography was used to obtain measurements. Patients with HIV had significantly increased right ventricular end-diastolic diameter (RVEDD) and right ventricular free wall thickness (RVFWT), as well as increased right atrial area and pulmonary arterial diameter, compared with control subjects. After adjustment for age, sex, and body surface area, RVFWT (average 1.81 mm, 95% confidence interval [CI] 0.35-3.26 mm) and RVEDD (average 6.82 mm, 95% CI 2.40-11.24 mm) were significantly higher in subjects infected with HIV. More patients with right ventricular hypertrophy were on antiretroviral treatment, and RVFWT was on average 1.3 mm higher (95% CI 0.24-2.37 mm) in patients on antiretroviral treatment after adjustment for confounders. CONCLUSIONS: These findings suggest that alterations in RSHCs were present in patients with HIV without PH.

Morphologic and Functional Changes in Right-Sided Cardiac Chambers in Patients With Chronic Liver Disease and Normal Pulmonary Artery Pressure.

OBJECTIVES: To investigate the effects of chronic liver disease (CLD) on the structural and functional characteristics of right-sided heart chambers in patients with normal pulmonary artery pressure. METHODS: Fifty-one patients with known CLD but without pulmonary hypertension or other cardiovascular conditions were consecutively enrolled, along with 25 age- and sex-matched participants. Patients with CLD were classified according to the Model of End-Stage Liver Disease score and Child-Pugh classification. Right ventricular (RV) and right atrial (RA) dimensions, indices of RV systolic/diastolic function, and myocardial strain were measured by standard echocardiographic methods. RESULTS: Patients in the study group had similar RV end-diastolic, end-systolic, and RA dimensions compared to controls. Similarly, neither the conventional indices of RV systolic/diastolic function nor the strain imaging findings were different between groups (P > .05). Only RV free wall thickness was significantly higher in the study group (mean ± SD, 4.15 ± 0.64 versus 3.75 ± 0.37 mm; P < .001). Right ventricular end-diastolic diameter (P = .018; r = 0.334) and RA area (P = .017; r = 0.335) had a significant correlation with RV free wall thickness in patients with CLD. Patients treated with beta blockers were found to have a significant reduction in mean RV free wall strain compared to patients who did not receive beta blocker treatment (-20.37 ± 6.6 versus -24.07 ± 6.52; P = .04). CONCLUSIONS: Patients with CLD had increased RV free wall thickness despite normal systolic pulmonary pressure, presumably secondary to cirrhotic cardiomyopathy. In the absence of pulmonary hypertension, however, cirrhotic cardiomyopathy did not cause impaired RV systolic or diastolic function.

Inadvertent Left Ventricle Endocardial or Uncomplicated Right Ventricular Pacing: How to Differentiate in the Emergency Department.

BACKGROUND: Temporary transvenous pacemaker implantation is an important and critical procedure for emergency physicians. Traditionally, temporary pacemakers are inserted by electrocardiography (ECG) guidance in the emergency department because fluoroscopy at the bedside in an unstable patient can be limited by time and equipment availability. However, in the presence of atrial septal defect, ventricular septal defect, and patent foramen ovale, the pacemaker lead can be implanted inadvertently into the left ventricle or directly into the coronary sinus instead of right ventricle. Regular pacemaker rhythm can be achieved despite inadvertent implantation of the pacemaker lead into the left ventricle, leading to ignorance of the possibility of lead malposition. CASE REPORT: A 65-year-old female patient with hemodynamic instability and complete atrioventricular block underwent temporary pacemaker implantation via right jugular vein with ECG guidance at the emergency department. Approximately 12 h after implantation, it was noticed that the ECG revealed right bundle branch block (RBBB)-type paced QRS complexes. Diagnostic workup revealed that the lead was inadvertently located in the left ventricular apex. This case illustrates the importance of careful scrutiny of the 12-lead ECG and imaging clues in identifying lead malposition in the emergency department. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: Because inadvertent left ventricle endocardial pacing carries a high risk for systemic embolization, it is important to determine whether an RBBB pattern induced by ventricular pacing is the result of a malpositioned lead or uncomplicated transvenous right ventricular pacing.

An unexpected complication of acute pancreatitis: Intra-cardiac thrombus.

Left atrial thrombus after acute pancreatitis (AP) is a rare clinical statement. Because of induction of systemic prothrombotic process by AP; some patients with underlying risk factors may develop an intra-cardiac thrombus. We present a 53years-old-woman with moderate mitral stenosis and atrial fibrillation. However the patient was under warfarin treatment, she developed a big left atrial big thrombus which was originated from left atrial appendage after she was suffered from AP.

Easily measurable, noninvasive, and novel finding for pulmonary hypertension: Hypertrophy of the basal segment of septomarginal trabeculation of right ventricle.

BACKGROUND: Effect of pulmonary hypertension (PH) on right ventricular (RV) geometry constitutes an ideal target to assess both pulmonary artery pressure (PAP) and its physiological importance. In this study, we evaluated the diagnostic power of the basal segment of septomarginal trabeculation (SMT) in predicting the PH and RV hypertrophy by cardiovascular magnetic resonance (CMR) in patients with idiopathic pulmonary arterial hypertension (IPAH) and Eisenmenger's syndrome (ES). METHODS: Eleven patients with IPAH, seven patients with ES, and 20 healthy controls were enrolled. CMR was used to measure the area and the thickness of the basal segment of SMT and right ventricular free wall (RVFW). Pulmonary artery systolic pressures (PASPs) were estimated by transthoracic echocardiography (TTE) with continuous-wave Doppler analysis measuring maximal tricuspid regurgitation (TR) velocity. Late gadolinium enhancement (LGE) findings of CMR and brain natriuretic peptide (BNP) levels were also obtained in all patients and control group. RESULTS: The area and the thickness of the basal segment of SMT were higher in patients with IPAH and ES than control group (P<.001). Pulmonary artery dimension, end-diastolic diameter of RV, RVFW thickness, and BNP levels were found to be significantly correlated with PAP (P<.001). LGE was present at the insertion point of RV only in patients group (P<.001). CONCLUSIONS: Increased area and thickness of the basal segment of SMT are easily measurable noninvasive markers of PH in patients with IPAH and ES.

Reverberation and multiple shadow artifacts recorded from patients with intra-pericardial centrifugal continuous-flow left ventricular assist devices.

Artifacts are by-products of ultrasound imaging that may cause confusion or misdiagnosis if not interpreted correctly. There are, however, several disorders where a specific pattern of artifacts can aid in diagnosis, especially when the object in question cannot be visualized directly. In this manuscript, we report two patients with reverberation and shadow artifacts originating from the housing and the propeller of a continuous-flow intra-pericardial left ventricular assist device. Visualization of the artifacts required modified transthoracic views, so these artifacts should not pose a diagnostic challenge during a routine echocardiographic evaluation. However, we consider that shadow artifacts might be used to evaluate pump thrombosis in patients with intra-pericardial assist devices.

The Effect of Left Ventricular Assist Device Implantation on Serum Albumin, Total Protein and Body Mass: A Short-Term, Longitudinal Follow-Up Study.

BACKGROUND: Cardiac cachexia and low serum albumin levels are poor prognostic signs in advanced heart failure, while overweight patients or patients who gain weight after treatment have more favourable outcomes. Weight gain following LVAD implantation is common, while the dynamic changes in body mass or serum proteins have not been studied adequately. Our aim was to study short-term changes in serum albumin, total protein and body weight following LVAD implantation and to compare these changes with heart failure patients treated medically. MATERIALS AND METHODS: A total of 15 patients scheduled for LVAD implantation and 15 patients receiving medical treatment were prospectively enrolled. Anthropometric and laboratory data for the patients were obtained at baseline and at first and sixth months after LVAD implantation. RESULTS: Anthropometric, demographic and clinical characteristics between two groups were similar at baseline. Both serum albumin (3.59±0.71 vs. 4.17±0.46g/dl, p=0.01) and total protein (6.45±0.80 vs. 7.12±0.35g/dl, p<0.01) levels were significantly lower in LVAD group at baseline. Both total protein and serum albumin levels increased significantly in LVAD group (final total protein 7.60±0.62g/dl and serum albumin 4.20±0.46g/dl; p<0.01 for both), while there was a nonsignificant small decrease in serum albumin in medical group. The change in serum albumin, but not total protein was significantly different between LVAD and medical groups at the sixth month. Body weight initially decreased in LVAD group at first month but was nonsignificantly higher compared to baseline and medical group at the sixth month. There was a moderate correlation between the percentage weight gain and percentage increase in serum albumin in LVAD group at six months (r=0.44). CONCLUSIONS: In suitable patients with advanced heart failure, LVAD treatment can correct hypoalbuminaemia associated with heart failure within six months after implantation.

Right ventricular geometry and mechanics in patients with obstructive sleep apnea living at high altitude.

PURPOSE: Repetitive obstruction of larynx during sleep can lead to daytime pulmonary hypertension and alterations in right ventricular morphology and function in a small fraction of obstructive sleep apnea syndrome (OSAS) patients. Environmental effects, particularly high altitude, can modify the effects of OSAS on pulmonary circulation, since altitude-related hypoxia is related with pulmonary vasoconstriction. This potential interaction, however, was not investigated in previous studies. METHODS: A total of 41 newly diagnosed OSAS patients were included in this study after pre-enrolment screening. Two-dimensional, three-dimensional, and Doppler echocardiographic data were collected after polysomnographic verification of OSAS. Three-dimensional echocardiograms were analyzed to calculate right ventricular volumes, volume indices, and ejection fraction. RESULTS: Systolic pulmonary artery pressure (38.35 ± 8.60 vs. 30.94 ± 6.47 mmHg; p = 0.002), pulmonary acceleration time (118.36 ± 16.36 vs. 103.13 ± 18.42 ms; p = 0.001), right ventricle (RV) end-diastolic volume index (48.15 ± 11.48 vs. 41.48 ± 6.45 ml; p = 0.009), and RV end-systolic volume index (26.50 ± 8.11 vs. 22.15 ± 3.85; p = 0.01) were significantly higher in OSAS patients, with similar RV ejection fraction (EF) between groups. No significant differences were noted in other two-dimensional, Doppler or speckle-tracking strain, measurements. Both RVEF and pulmonary acceleration time were predictors of disease severity. CONCLUSIONS: A greater degree of RV structural remodeling and higher systolic pulmonary pressure were observed in OSAS patients living at high altitude compared to healthy highlanders. The reversibility of these alterations with treatment remains to be studied.