Tissue Doppler derived biphasic velocities during the pre and post-ejection phases: patterns, concordance and hemodynamic significance in health and disease.

BACKGROUND: Pre-(PRE) and post-ejection (POE) velocities by mitral annular tissue Doppler (TD) are biphasic and may be related to myocardial deformations. We investigated the predominance and concordance of TD-PRE and POE velocities and their effect on myocardial functions in controls and in heart failure (HF) patients. METHODS: Retrospectively, 84 HF patients [57.6 years, 28(33%) females, NYHA: 2.3 ± 0.6, EF: 55 ± 15%, 52(62%) preserved EF, and 32(38%) reduced EF], 42 normal young controls, and 26 asymptomatic age matched controls were included. Echocardiography was done and from mitral annular tissue Doppler recordings, the biphasic PRE and POE velocity signals were identified and compared between groups. RESULTS: While controls had almost always predominantly positive PRE and negative POE, HF had more negative PRE and positive POE. Moreover, almost all controls exhibited normal concordance (positive PRE and negative POE). HF exhibited more abnormal concordance which was significantly associated with worse NYHA, and parameters of diastolic and systolic functions. Opposite PRE and POE velocities correlated significantly in all groups (PREp vs POEn: young:r = 0.52, p < 0.001, age controls:r = 0.79, p < 0.001, HFpEF: r = 0.56, p < 0.001, HFrEF: r = 0.42, p = 0.018; PREn vs POEp: young: r = 0.25,p = 0.1, age controls: r = 0.42, p = 0.04, HFpEF: r = 0.43, p = 0.004, HFrEF: r = 0.61, p < 0.001) and the ratios PRE-P/N and POE-N/P correlated significantly with E/e' in HF only. CONCLUSIONS: In physiological state, TD signals are predominantly positive during PRE and negative during POE. Opposite PRE and POE velocities corelate, representing the PRE-generation and POE-reversal of shortening-stretch relationships, the attenuation of which in HF may be related to elevated LV filling pressures. In HF, partially or completely reversed concordance of PRE and POE is associated with progressive worsening of clinical and hemodynamic profiles.

Short-term impact of COVID-19 infection on right ventricular functions: single center observational study.

BACKGROUND: COVID-19 pandemic is associated with high morbidity and mortality. Cardiovascular insult is a leading cause of in-hospital mortality in COVID-19 patients, especially right ventricular (RV) dysfunction and massive pulmonary embolism. This study aims to assess short-term impact of COVID 19 infection on (RV) functions among hospitalized patients with moderate or severe illness using bed side trans-thoracic echocardiogram. This study was conducted in 3 isolation hospitals in Cairo, spanning over 3 months during the expected pandemic peak in Egypt in 2020. The study recruited 100 consecutive patients with moderate or severe COVID-19 infection. Four patients refused to participate in the study. Patients with pre-existing structural heart diseases were excluded. All patients underwent full history taking and clinical examination. Bed side echocardiography was done emphasizing on (RV), and (RA) dimensions, (LV) functions and pulmonary artery systolic pressure (PSAS). Cardiac biomarkers were withdrawn and CT angiography was ordered when clinically warranted. RESULTS: The mean age of the studied cohort was 59.5 ± 8.6 years with males comprising 71.9% of the studied group. (RV) and (RA) dilatation was noted in 8 cases (8.3%). (LV) dysfunction was noted in 11 cases (11.4%). (PASP) showed a statistically significant negative correlation with (LV) function. However, (PSAP) was positively correlated to (RA) and (RV) dimensions, tricuspid regurgitation (TR) jet severity, previous COVID infection and elevated cardiac biomarkers. Mortality was noted in 3 cases (3.1%), all had LV dysfunction with elevated troponin level. Six patients (6.2%) had combined (LV) and (RV) dysfunction. CONCLUSIONS: COVID-19 illness had a negative impact on (RV) and (LV) functions, that could be assessed accurately by trans-thoracic 2 D echocardiogram. The degree of ventricular dysfunction correlated with the rise in cardiac biomarkers as well as the degree of (PASP).

Atrial Fibrillation in Heart Failure with Preserved Left Ventricular Systolic Function: Distinct Elevated Risk for Cardiovascular Outcomes in Women Compared to Men.

Background: Heart failure with preserved ejection fraction (HFpEF) is prevalent in women and is associated with atrial fibrillation (AF). However, sex associations in AF-related HFpEF are not well explored. Aim: We studied differences between men and women with and without AF-related HFpEF symptoms on left ventricular (LV) geometry and diastolic dysfunction (DD) and their effect on cardiovascular events. Methods: Retrospectively, HFpEF patients with and without a history of AF referred for echocardiography were studied. Echocardiographic assessments were focused on LV geometry and diastolic functions. Patients were followed for the occurrence of cardiac events defined as death and cardiac hospitalization. Results: We studied 556 patients [age: 66.7 ± 17 years, 320 (58%) women, 91 (16%) AF]. Compared to HFpEF without AF (HFpEF-AF), HFpEF with AF patients (HFpEF+AF) were older (76 ± 13.8 vs. 64.9 ± 17.3 years, p < 0.001), had more risk factors, comorbidities, left ventricular hypertrophy (32 vs. 13%, p < 0.001), higher relative wall thickness (0.50 ± 0.14 vs. 0.44 ± 0.15, p < 0.001), and DD (56 vs. 30%, all p < 0.001). HFpEF+AF women had the worst clinical, LV geometric, and diastolic functional profiles and highest rates of cardiovascular outcomes compared to HFpEF+AF men and were the only group to predict outcomes (HR: 2.7, 95%CI: 1.4−5.1), while HFpEF-AF women were a low-risk group; HFpEF+AF and HFpEF-AF men had intermediate cardiovascular outcomes which were confirmed after propensity score matching. Conclusions: Among patients with HFpEF, women with AF had more abnormal LV geometry and diastolic function and had an increased risk of adverse cardiovascular outcomes independent of traditional risk factors, comorbidities, and baseline diastolic function.

Coronary air embolism during mitral valvuloplasty.

A 30-year-old male with a history of rheumatic mitral valve disease presented with progressive exertional dyspnoea. Echocardiography revealed a mitral valve area of 1 cm2, a mitral valve score of 6/16, and absence of mitral regurgitation. Percutaneous mitral valvuloplasty was performed using the multitrack technique. Unexpectedly, one balloon suddenly ruptured during a second inflation. The patient experienced severe chest pain and shock. The electrocardiogram showed ST-segment elevation in leads II, III, and aFV. Prompt resuscitation was performed and right coronary angiography showed a bubble of air trapped at the crux of the right coronary artery, with loss of myocardial blush.The operator injected 100 mcg of nitroglycerin inside the right coronary, followed by intracoronary infusion of normal saline. Ultimately, right coronary angiography revealed that the air was successfully cleared off the artery, with TIMI grade 3 flow and, return of myocardial blush. Eventually, chest pain disappeared, with a favourable haemodynamic condition.

Study of the relation between serum levels of long-acting penicillin and the inflammatory markers: C-reactive protein and interleukin-6 in patients with chronic rheumatic heart disease.

BACKGROUND: There is an evidence of a chronic inflammatory state in patients with chronic rheumatic valvular heart disease (RHD) as shown by high serum levels of high-sensitivity C-reactive protein (hs-CRP) and interleukin-6 (IL6). Despite the efficacy of long-acting penicillin (LAP) in secondary prevention of rheumatic fever, its effect on this inflammatory state is still unknown. So, we sought to study the effect of LAP on the inflammatory markers, CRP and IL-6, in patients with chronic rheumatic heart disease. RESULTS: Eighty RHD patients coming to our hospital's outpatient clinic for rheumatic fever secondary prophylaxis by regular administration of LAP were enrolled in the study. Patients were divided into 3 groups: group A, 70 patients with RHD already on prophylactic LAP, group B, 10 patients with RHD who have not yet started prophylactic LAP, and group C, control group of 10 healthy individuals not known to have RHD. Serum levels of LAP, IL-6, and CRP were measured for the three groups. Group A had significantly lower IL-6 levels than group B (25.22 ± 33.50 vs. 126.1 ± 33.76nng/ml, respectively, p < 0.0001). IL-6 levels were significantly lower in control subjects compared to patients in group B (3.600 ± 2.319, 25.22 ± 33.50 ng/ml, respectively, p < 0.0001). However, IL-6 levels in the control group were lower but non-significantly different compared to group A. CRP level was lower in group A than group B (8419 ± 4935 vs. 14400 ± 3375 mg/dl, respectively, p = 0.0002). CRP levels were significantly lower in control subjects compared to patients in group A and group B. IL-6 values were positively correlated with CRP values (r = 0.6387, p < 0.0001). CRP values were negatively correlated with LAP values (r = -0.5277, p < 0.0001). IL-6 values were negatively correlated with LAP values (r = - 0.4401, p < 0.0001). There was a highly significant difference between LAP level in compliant and non-compliant patients (1.045 ± 1.270 vs. 0.0785 ± 0.1057 ng/ml, respectively, p value < 0.0001). There was also a highly significant difference between CRP level in compliant and non-compliant patients (7640 ± 4558 vs. 13090 ± 4717 mg/dl, respectively, p = 0.005). Moreover, there was a significant difference between IL-6 levels in compliant and non-compliant patients (21.53 ± 32.70 vs. 47.40 ± 30.91 ng/ml, respectively, p value 0.03). CONCLUSION: Serum LAP has a strong negative correlation with IL-6 and CRP levels. Regular administration of LAP strongly ameliorates the inflammatory state seen in patients with RHD.

Combined atrioventricular longitudinal strain rate during isovolumic contraction predicts pulmonary capillary wedge pressure in patients with systolic dysfunction.

BACKGROUND: Reportedly, mitral annular velocities derived by tissue Doppler imaging (TDI)-during isovolumic contraction (IVV) can predict pulmonary capillary wedge pressure (PCWP) in heart failure patients with depressed ejection fraction (EF). We investigated the use of color TDI-derived left atrial (LA) and left ventricular (LV) longitudinal strain rate (SR) during isovolumic contraction (IC) to predict the invasively measured PCWP. METHODS AND RESULTS: Forty patients referred with symptoms of heart failure were prospectively studied [age: 56±8 years, 12 (30%) females, and mean LVEF: 51±14%]. PCWP was measured invasively immediately after echocardiography. Mitral annular IVV was measured for all patients and SR during the IC and ejection were measured for the LV (LVSR-IC, LVSR-Ej) as well as the LA (LASR-IC, and LASR-Ej). Atrioventricular SR during IC and Ej (AVSR-IC, AVSR-Ej) was calculated as the sum of the LV and LA values. Patients were classified and compared based on their EF into 19 (49%) with EF≥55%, and 21 (51%) with EF<55%. No significant differences were noted for age, sex, risk factors, and medications between both patients with EF≥55% and EF<55%. Compared to EF≥55%, patients with EF<55% had lower IVV (4.63±1.2 vs. 7.01±1.9 cm/s, P<0.001), LVSR-Ej (1±0.3 vs. 1.2±0.2, P=0.03), LASR-IC (1.3±0.6 vs. 1.9±1, P=0.03), LASR-Ej (1.5±0.5 vs. 2.6±1.3 s-1, P=0.001), AVSR-IC (2±0.8 vs. 2.7±1.06 s-1, P=0.023), and AVSR-Ej (2.5±0.6 vs. 3.9±1.1 s-1, <0.001). LVSR-IC, LVSR-Ej, LASR-IC, AVSR-IC, and IVV correlated with PCWP in only in EF<55%, with the strongest correlation noted for AVSR-IC (r=-0.72, <0.001). Other correlates with PCWP in EF<55% were E/e' and left atrial volume (r=0.47, 0.7, P=0.04, 0.001; respectively). Multivariate regression revealed that in patients with EF<55% AVSR-IC was the only independent predictor of PCWP. Finally, IVV correlated with LVSR-IC and LASR-IC and this correlation became strongest with AVSR-IC (r=0.77, 0.001). CONCLUSION: The combined LV and LA longitudinal SR during IC as represented by AVSR-IC showed a strong correlation with PCWP in patients with depressed EF. The correlation between mitral annular IVV and PCWP in those patients can be a product of this combination and may a function of atrioventricular mechanical coupling.

Immediate and long-term outcome of redo percutaneous mitral valvuloplasty: comparison with initial procedure in patients with rheumatic mitral restenosis.

AIMS: We explored the immediate and long-term outcome of redo percutaneous mitral valvuloplasty (PMV) in a series of patients with mitral restenosis in comparison with initial PMV in the same series. METHODS: We enrolled 40 consecutive patients presenting with mitral restenosis after successful initial PMV. Redo PMV was performed by the antegrade transseptal approach using either the Inoue technique or the multitrack technique. Reassessment by transthoracic echocardiography was repeated 48 hours later, and annually thereafter. Procedural success was defined as 50% or more increase of mitral valve area (MVA) with a final MVA >or=1.5 cm(2), without major complications. Restenosis was defined as loss of >50% of the initial gain of MVA by the preceding PMV with a final MVA <1.5 cm(2). RESULTS: Procedural success was achieved in 37 (92.5%) patients. Both the initial and redo procedures were similar concerning the final MVA and mean transmitral pressure gradient (P > 0.05 for all). The gain of MVA was higher in the initial as compared to the redo procedure (P < 0.001). The initial mitral valve score correlated negatively with the final MVA in both the initial and redo procedures, and was the only independent predictor of the time to redo procedure, by multivariate regression analysis. At long-term follow-up (61 +/- 2.8 months), the mean MVA was 1.6 +/- 0.3 cm(2). Three patients--out of 12 available for follow-up--developed restenosis. CONCLUSION: Redo PMV for mitral restenosis is feasible, safe, and achieves immediate and long-term outcome comparable to initial PMV.

Cardiac tamponade after mitral valvuloplasty in a pregnant woman.

Mitral stenosis during pregnancy poses a substantial risk, both to the mother and foetus. Percutaneous mitral valvuloplasty performed during pregnancy has been associated with an excellent short-term outcome, with reduction of both maternal and foetal complications. We report a case of percutaneous mitral valvuloplasty in a pregnant woman with severe rheumatic mitral stenosis and impending pulmonary oedema. The procedure was performed through a right femoral vein approach, employing the multitrack technique, using 2 balloons (20 and 18 mm). Inadvertently, the procedure was complicated by cardiac tamponade. Despite a stable haemodynamic condition, and absence of echocardiographic signs of chamber collapse, haemodynamic monitoring revealed an equal value for right atrial, left atrial and left ventricular end-diastolic pressure. Immediately, adequate pericardiocentesis was performed and post-procedural echocardiography revealed a mitral valve area of 2.0 cm2, with no mitral regurgitation. Eventually, the pregnancy was continued and ultimately, the patient gave birth to a healthy full-term baby.

Head-to-head comparison between redo percutaneous mitral valvuloplasty for mitral restenosis and percutaneous mitral valvuloplasty for de novo mitral stenosis.

AIMS: In a retrospective study design, we explored the immediate results of redo-percutaneous mitral valvuloplasty in comparison with initial percutaneous mitral valvuloplasty. METHODS AND RESULTS: We included 30 consecutive patients with de-novo mitral stenosis (group A) and 40 consecutive patients with mitral restenosis after successful initial percutaneous mitral valvuloplasty (group B). Echocardiographic assessment of the mitral valve was performed in all patients by trans-thoracic echocardiography and transesophageal echocardiography excluded left atrial thrombosis. Percutaneous mitral valvuloplasty was performed by the antegrade trans-septal approach using either the standard Inoue technique or the multi-track technique. Patient assessment by trans-thoracic echocardiography was repeated 48 hours following the procedure. Procedural success was defined as a 50% or more increase of mitral valve area with a final mitral valve area > or = 1.5 cm2, without major complications. Procedural success was achieved in 28 (93.3%) patients in group A and in 37 (92.5%) patients in group B (p > 0.05). The two groups were similar concerning the final mitral valve area, gain of mitral valve area, mean pressure gradient across the mitral valve and complication rate (p > 0.05 for all). The final mitral valve area correlated negatively with the initial mitral valve score in both group A and B. CONCLUSION: Redo-percutaneous mitral valvuloplasty for mitral restenosis achieves comparable immediate results to initial percutaneous mitral valvuloplasty.

Prevalence and predictors of pulmonary hypertension in elderly patients with isolated diastolic heart failure.

BACKGROUND: Despite the growing recognition that pulmonary hypertension can develop in diastolic heart failure; its clinical significance remains poorly defined. AIM: We sought to explore the prevalence and predictors of pulmonary hypertension in elderly patients with isolated diastolic heart failure. METHODS: We enrolled 100 consecutive elderly patients with isolated diastolic heart failure. All patients underwent transthoracic echocardiography to measure the pulmonary artery systolic pressure, diastolic function indices (mitral E peak deceleration time, isovolumetric relaxation time, early mitral annular diastolic velocity), left atrial diameter and left ventricular mass index. Pulmonary hypertension was defined as pulmonary artery systolic pressure > or = 37 mm Hg. We classified patients into two groups: one with diastolic heart failure and concomitant pulmonary hypertension, and one with diastolic heart failure but without concomitant pulmonary hypertension. RESULTS: The mean age of the whole series was 65.4 + or - 5.4 years, 49 (49%) being female. Patients with pulmonary hypertension (20% of the whole series) were more often females, hypertensive, more likely to have atrial fibrillation, pulmonary congestion symptoms, larger left atrial diameter, lower early mitral annular diastolic velocity, lower left ventricular ejection fraction, and more likely to have mitral regurgitation (p < 0.05 for all). Multivariate logistic regression analysis identified female gender, atrial fibrillation, and early mitral annular diastolic velocity (e') as the independent predictors of the presence of pulmonary hypertension. CONCLUSIONS: Pulmonary hypertension is fairly prevalent in elderly patients with diastolic heart failure. Female gender, atrial fibrillation, and early mitral annular diastolic velocity (e') were the independent predictors of the presence of pulmonary hypertension in this patient group.

Impact of Ramadan Fasting on Biochemical and Exercise Parameters Among Patients Undergoing Exercise-Based Cardiac Rehabilitation.

BACKGROUND: Ramadan fasting is an important worship activity for Muslims. It is not known if fasting could have deleterious effect on cardiac patients joining cardiac rehabilitation (CR) program, especially during summer season. AIM: To assess the effect of Ramadan fasting on biochemical and exercise parameters among patients undergoing 12-week exercise-based CR program. PATIENTS AND METHODS: 53 patients joining CR program in university hospital were included in the study. The patients were divided into two groups according to their Ramadan fasting status. Fasting group included 32 patients, while non-fasting group included 21 patients. All patients underwent supervised exercise-based CR during the month of Ramadan. Plasma osmolality, blood urea and serum creatinine were assessed before CR and during the last week of Ramadan. Lipid profile, echocardiography and exercise parameters were assessed before and after CR program. RESULTS: The two groups were similar in baseline characteristics including: risk factors, osmolality, urea, creatinine, lipid profile and hemoglobin values, as well as ejection fraction and exercise parameters. After the program, both groups showed significant improvement in ejection fraction, total cholesterol, LDL and HDL levels. There was also improvement in duration of exercise reached and achieved METs before and after CR program in both groups. An important notice was that fasting did not significantly influence plasma osmolality in either group. CONCLUSION: Ramadan fasting did not change serum osmolality or negatively affect the results of CR among cardiac patients. It appears to be safe to undergo exercise-based CR during Ramadan even in summer season.

Colchicine ameliorates the chronic inflammatory state in patients with chronic rheumatic valvular heart disease: a pilot study.

BACKGROUND: Inflammation is an important contributor to the pathogenesis of rheumatic heart disease (RHD). High serum levels of C-reactive protein (CRP) and interleukin-6 (IL-6) are commonly seen in patients with chronic (RHD) and indicate the presence of a chronic inflammatory state. The aim of this study was to assess the effect of colchicine as anti-inflammatory drug on the serum levels of the inflammatory markers (CRP) and (IL-6) in patients with chronic (RHD). RESULTS: This is a prospective controlled study that enrolled thirty-five patients with chronic (RHD) visiting Ain Shams University Hospital's outpatient clinic for receiving regular long acting penicillin as rheumatic fever prophylaxis. Ten matched healthy individuals were taken as control group. Blood samples for serum levels of CRP and IL-6 were collected before and 1 month after receiving colchicine 0.5 mg BID. Mean (CRP) level was 6.09 ± 4.39 IU/ml versus 0 IU/ml in the control group respectively (P = 0.0001). Mean (IL-6) level was 113.57 ± 37.41 ng/l versus 10.50 ± 5.99 ng/l, in the control group (p = 0.0001). Mean (CRP) was 6.09 ± 4.39 IU/ml before and became 3.34 ± 3.07I U/ml 1 month after colchicine therapy. Mean (IL-6) level was 113.57 ± 37.4 ng/l before and became 45.57 ± 20.39 ng/l 1 month after colchicine therapy (P = 0.001). CONCLUSION: In this pilot study, using colchicine as anti-inflammatory drug in patients with chronic (RHD) significantly reduced the serum inflammatory markers (CRP) and (IL-6), thus helping in ameliorating their chronic inflammatory state.

Can a novel echocardiographic score better predict outcome after percutaneous balloon mitral valvuloplasty?

OBJECTIVE: The assessment of patients with mitral stenosis before percutaneous balloon mitral valvuloplasty (PBMV) is crucial to predict outcome after the procedure. We tried to explore the prognostic power of a novel echocardiographic score to predict immediate postprocedural outcome in comparison to the standard score. METHODS: We enrolled 50 consecutive patients with moderate to severe mitral stenosis admitted to undergo PBMV. For all patients, we assessed both the standard Massachusetts General Hospital (MGH) score and a novel score based on calcification (especially commissural) and subvalvular involvement. Patients underwent PBMV with the double balloon technique. Thereafter, patients were classified into two groups: group 1 (poor outcome) defined as no procedural success and/or increase of MR by more than 1 grade and group 2 (optimal outcome) defined as procedural success with increase of MR by 1 grade or less. RESULTS: The total MGH score did not differ significantly between the two groups. However, among the individual parameters of the score, both calcification and subvalvular affection were significantly higher in group 1 versus group 2 (2.8 +/- 0.4 versus 1.7 +/- 0.8, and 2.4 +/- 0.5 versus 1.6 +/- 0.4, respectively, P < 0.01 for both). The total novel score and its two individual parameters (calcification and subvalvular involvement) were all significantly higher in group 1 versus group 2 (6 +/- 1.5 versus 2.9 +/- 1.9, 4.9 +/- 1.2 versus 2.4 +/- 1.5, 1.5 +/- 1.6 versus 0.5 +/- 0.9, respectively, P < 0.01 for all). Multivariate analysis demonstrated the novel score to be the only independent predictor of poor outcome. CONCLUSION: The novel score is more reliable and correlates with outcome better than the standard score.

Precision Phenotyping in Heart Failure and Pattern Clustering of Ultrasound Data for the Assessment of Diastolic Dysfunction.

OBJECTIVES: The aim of this study was to investigate whether cluster analysis of left atrial and left ventricular (LV) mechanical deformation parameters provide sufficient information for Doppler-independent assessment of LV diastolic function. BACKGROUND: Medical imaging produces substantial phenotyping data, and superior computational analyses could allow automated classification of repetitive patterns into patient groups with similar behavior. METHODS: The authors performed a cluster analysis and developed a model of LV diastolic function from an initial exploratory cohort of 130 patients that was subsequently tested in a prospective cohort of 44 patients undergoing cardiac catheterization. Patients in both study groups had standard echocardiographic examination with Doppler-derived assessment of diastolic function. Both the left ventricle and the left atrium were tracked simultaneously using speckle-tracking echocardiography (STE) for measuring simultaneous changes in left atrial and ventricular volumes, volume rates, longitudinal strains, and strain rates. Patients in the validation group also underwent invasive measurements of pulmonary capillary wedge pressure and LV end diastolic pressure immediately after echocardiography. The similarity between STE and conventional 2-dimensional and Doppler methods of diastolic function was investigated in both the exploratory and validation cohorts. RESULTS: STE demonstrated strong correlations with the conventional indices and independently clustered the patients into 3 groups with conventional measurements verifying increasing severity of diastolic dysfunction and LV filling pressures. A multivariable linear regression model also allowed estimation of E/e' and pulmonary capillary wedge pressure by STE in the validation cohort. CONCLUSIONS: Tracking deformation of the left-sided cardiac chambers from routine cardiac ultrasound images provides accurate information for Doppler-independent phenotypic characterization of LV diastolic function and noninvasive assessment of LV filling pressures.

Radius of proximal isovelocity surface area in the assessment of rheumatic mitral stenosis: Connecting flow to anatomy and hemodynamics.

BACKGROUND: Echocardiographic assessment of left atrial pressure (LAP) in mitral stenosis (MS) is controversial. We sought to examine the role of the radius of the proximal isovelocity surface area (PISA-r) in the assessment of the hemodynamic status of MS after fixing the aliasing velocity (Val). METHODS AND RESULTS: We studied 42 candidates of balloon mitral valvuloplasty (BMV), for whom pre-BMV echocardiography was done and LAP invasively measured before dilatation. PISA-r was calculated after fixing aliasing velocity to 33 cm/s. In addition, the ratio IVRT/Te'-E was also measured, where IVRT was isovolumic relaxation time, and Te'-E was the time difference between the onset of mitral flow E-wave and mitral annular early diastolic velocity. IVRT/Te'-E and PISA-r showed a strong correlation with LAP (r = -0.715 and -0.637, all p < 0.001) and with right-sided pressures. In addition, PISA-r correlated with mitral valve area by planimetry method (MVA) and with left ventricular outflow tract stroke volume (r = 0.66 and 0.71, all p < 0.001). Receiver operator characteristic curve (ROC-curve) showed that PISA-r was not inferior to IVRT/Te'-E in differentiating LAP ⩾25 from <25 mmHg. CONCLUSION: Provided that Val is set to a constant of 33 cm/s, PISA-r can assess the hemodynamic status of MS, and seems a simple alternative to the tedious IVRT/Te'-E for estimation of LAP.

Tissue Doppler-Derived Myocardial Acceleration during Isovolumetric Contraction Predicts Pulmonary Capillary Wedge Pressure in Patients with Significant Mitral Regurgitation.

The aim of this study was to determine whether isovolumic contraction velocity (IVV) and acceleration (IVA) predict pulmonary capillary wedge pressure (PCWP) in mitral regurgitation. Forty-four patients with mitral regurgitation were studied. PCWP was invasively measured. IVV, IVA and the ratio IVRT/Te'-E (where IVRT = isovolumic relaxation time, and Te'-E = time difference between the onset of mitral annular e' and mitral flow E waves) were measured. Mean age was 59.2 ± 13.3 y. Twenty-six patients had an ejection fraction ≥55%, and 18 patients had an ejection fraction <55%. IVRT/Te'-E was impossible in 11 patients because Te'-E = zero. PCWP correlated with IVV, IVA and IVRT/Te'-E; overall (r = -0.714, -0.892 and, -0.752, all p < 0.001), ejection fraction ≥55 (r = -0.467, -0.749, -0.639, p = 0.016, <0.001, 0.003) and ejection fraction <55% (r = -0.761, -0.911 and -0.833, all p < 0.001). Similar correlations were found for sinus and atrial fibrillation. Our study suggests that IVV and IVA correlate with PCWP in patients with mitral regurgitation irrespective of systolic function or rhythms and, thus, can be alternatives to the tedious IVRT/Te'-E, especially when impossible because Te'-E = 0.

Near-fatal cardiac arrest due to cardiac tamponade during percutaneous mitral valvuloplasty.

The incidence of hemopericardium following percutaneous mitral valvuloplasty is reported at 1-3%, being related to either trans-septal puncture, or left ventricular perforation with guide wires or balloons. We report a case of percutaneous mitral valvuloplasty for a middle-aged man with moderately severe rheumatic mitral stenosis. The procedure was performed through a right femoral vein approach, employing the multitrack technique, utilizing 2 balloons (20 and 18 mm). Inadvertently, the procedure was complicated by cardiac tamponade. Despite immediate diagnosis and prompt pericardiocentesis, hemodynamic stability was not maintained. Echocardiography revealed a mass in the posterior pericardial sac. The patient was arrested in asystole, and rigorously resuscitated during transfer to the operating room. Exploration revealed a tear in the left ventricular apex that was adequately sutured. In a few days, the patient gradually regained adequate consciousness, and was ultimately discharged. Post-procedural echocardiography revealed a mitral valve area of 1.9 cm(2), with no mitral regurgitation.

Simplifying proximal isovelocity surface area as an assessment method of mitral valve area in patients with rheumatic mitral stenosis by fixing aliasing velocity and mitral valve angle.

UNLABELLED: We aimed to test the ability of a simple equation using proximal isovelocity surface area method (PISA), created by fixing the angle to 100° and the aliasing velocity to 33 cm/s, to calculate mitral valve area (MVA) and assess severity in patients with rheumatic mitral stenosis (MS). METHODS AND RESULTS: In a series of 51 consecutive patients with rheumatic MS, MVA was assessed by four methods, conventional PISA equation (PISAconventional), simple PISA equation (PISAsimple), pressure half time (PHT), and planimetry (PLN) which was taken as the reference method. All methods correlated significantly with PLN with the highest correlation found in case of PISAconventional and PISAsimple (r = 0.97, 0.96, p < 0.001), while the correlation in case PHT was relatively weaker (r = 0.69, p < 0.001). Bland-Altman analysis revealed that the level of agreement with PLN was better in case of both PISA methods than PHT and, moreover, were close to each other. The number of cases that showed agreement of severity grade with planinetry was better in case of PISAconventional (42 cases) and PISAsimple (44 cases) than that in case of PHT (34 cases, p = 0.037). Finally, the measure of agreement with Cohen's Kappa test was better in case of PISAconventional and PISAsimple than that in case of PHT. CONCLUSION: Provided that aliasing velocity is fixed at 33 cm/s, PISA can effectively predict mitral valve area and severity of MS by a simple equation, with the advantage of easy and accurate calculation over other methods.

Alternate-day versus daily atorvastatin in coronary artery disease: a randomized study.

OBJECTIVE: We sought to compare the effect of alternate-day versus daily atorvastatin 10 mg, on serum low-density lipoprotein cholesterol (LDL-C) and high-sensitivity C-reactive protein (hs-CRP) in patients with coronary artery disease (CAD) and controlled serum LDL-C by daily atorvastatin. METHODS: The study was prospective, randomized, single-blinded, two-armed. Randomization was performed by a computer-generated randomization list. We randomized 60 patients with CAD and controlled serum LDL-C to receive either atorvastatin in the standard-dose of 10 mg daily (Group A=30 patients), or the same medication every other day (Group B=30 patients). Primary efficacy criterion included changes in serum LDL-C and hs-CRP from the initial to the 6-week follow-up values. RESULTS: The mean age was 54.5±7.7 years, (70% males). LDL-C was significantly lower in Group A as compared with group B at 6-week follow-up (88±21 versus 105±26 mg/dl, respectively, p=0.008). Similarly, the mean percent increase of LDL-C from baseline to final assessment was significantly lower in Group A as compared with Group B (1.5±0.2 versus 32.8±6.2%, respectively, p<0.0001). However, the mean percent change of hs-CRP value was statistically similar between the two groups (p=0.108). Patients reported no side effects attributable to the medication. CONCLUSION: The current pilot study demonstrated that in patients with CAD who have achieved target LDL-C level, maintenance on alternate-day atorvastatin 10 mg was inferior to daily atorvastatin in keeping LDL-C below the target level; however, it produced a similar effect on hs-CRP.