Assessment of left atrial function after percutaneous closure of patent foramen ovale.

BACKGROUND: The influence of atrial septal occluders in left atrial (LA) function after percutaneous closure of patent foramen ovale (PFO) has not been thoroughly studied. METHODS: Twenty-five patients (mean age 40.7 ± 12 years) undergoing percutaneous PFO closure were enrolled in this study. Transthoracic echocardiogram (TTE) was performed 3 and 6 months before the procedure. Volumetric indices (active emptying fraction: LA AEF, expansion index: LA EI, and passive emptying fraction: LA PEF), strain and strain rate (SR), were calculated during the contractile, reservoir, and conduit LA phases for the lateral, anterior, and inferior LA walls with TTE. RESULTS: After 3 months, a decrease in the SR of the LA anterior wall was observed (from 2.12 ± 0.22 to 1.66 ± 0.26, P < 0.045), while the LA lateral wall strain was found to be increased (from 0.708 ± 0.15 to 0.783 ± 0.159, P < 0.001). Moreover, simultaneously LA AEF was greater compared with baseline (from 31.0 ± 1.6 to 34.0 ± 1.6, P < 0.004). However, all these alterations reversed at 6 months. CONCLUSIONS: Segmental LA function is altered transiently after percutaneous PFO closure with a septal occlude. The LA anterior wall SR decreases, while the lateral wall strain increases. The impact of these alterations needs further clarification.

Quantitative analysis of carotid plaque vasa vasorum by CEUS and correlation with histology after endarterectomy.

BACKGROUND: Intraplaque neovascularization and vasa vasorum (VV) proliferation contribute in the progression and rupture of atherosclerotic lesions. Contrast enhanced ultrasonography (CEUS) has been reported to attain data regarding intraplaque neovessels and VV. However, whether the detection of microbubbles by CEUS within atherosclerotic plaques truly represents microvessels is a point of concern. We aimed to evaluate stable and unstable carotid artery plaque (CAP) VV pattern by CEUS and its correlation with histology and immunochemistry. PATIENTS AND METHODS: Patients with CAP scheduled for plaque endarterectomy were enrolled. CAP was initially identified by conventional ultrasonography and subsequently CEUS (harmonic ultrasound imaging with simultaneous intravenous contrast agent injection) was performed. The recorded image loops were evaluated by a semi-automated method. Plaque specimens were excised and underwent histological and immunochemical (for CD34, Vascular Endothelial Growth Factor, CD68 and CD3 antibodies) analysis. RESULTS: Fourteen patients (67.6 ± 10.2 years, 10 males) with a 86.9 ± 11.5 % degree of carotid artery stenosis were evaluated. Histology showed that half of the plaques were unstable. Enhancement of plaque brightness on CEUS was significant for both stable and unstable plaque subgroups (p = 0.018 for both). Immunochemistry showed that microvessels, as assessed by CD34 antibody, were more dense in unstable vs. stable plaques (36.6 ± 17.4 vs. 13.0 ± 7.2 respectively, p = 0.002). However, correlation between plaque brigthness enhancement on CEUS and microvessel density was significant only for stable (r = 0.800, p = 0.031) plaques. CONCLUSIONS: The identification of brightness enhacement during CEUS in carotid atherosclerotic plaques may not always reflect the presence of VV.

Left ventricular diastolic dysfunction is accompanied by increased aortic stiffness in the early stages of essential hypertension: a TDI approach.

OBJECTIVE: To investigate the inter-relationship between aortic stiffness and left ventricular (LV) diastolic function in subjects with newly diagnosed uncomplicated essential hypertension. METHODS: We studied 106 consecutive newly diagnosed subjects (aged 51 years, 80 males) with stage I-II essential hypertension, and 50 normotensives matched for age, sex and body mass index. LV diastolic function was estimated by pulsed tissue Doppler imaging (TDI) echocardiography, averaging diastolic mitral annular velocity measurements (Emav, Amav, Emav/Amav ratio) from four separate sites (basal septal, lateral, anterior, and inferior LV wall). Moreover, aortic stiffness was evaluated by non-invasive carotid-femoral pulse wave velocity (c-f PWV) measurement. RESULTS: Hypertensives compared with normotensives exhibited greater LV mass index and Amav (110 versus 95 g/m and 10 versus 8.8 cm/s, respectively, P < 0.001 for both cases), and greater c-f PWV (8.47 versus 7.48 m/s, P < 0.03), as well as lower Emav and Emav/Amav values, (8.4 versus 10 cm/s and 0.82 versus 1.15, respectively, P < 0.001 for both cases). In the group of hypertensives, a univariate analysis revealed that c-f PWV was negatively associated with Emav (r = -0.305, P = 0.005), as well as with Emav/Amav ratio (r = -0.437, P < 0.001). Moreover, a multivariate analysis showed that the TDI-derived Emav/Amav ratio was significantly associated with age (P = 0.001), relative wall thickness (P = 0.006) and c-f PWV (P = 0.03), while the conventional Doppler-derived E/A ratio was significantly associated only with age (P = 0.001). CONCLUSIONS: TDI-detected LV diastolic dysfunction is accompanied by increased aortic stiffness in newly diagnosed essential hypertension, suggesting that there may be a common pathophysiological pathway linking these two entities.

Relation of left ventricular concentric remodeling to levels of C-reactive protein and serum amyloid A in patients with essential hypertension.

In this study, we investigated possible relations between left ventricular (LV) concentric remodeling and plasma levels of high-sensitivity C-reactive protein (hs-CRP) and serum amyloid-A (SAA) in subjects who had essential hypertension; 65 consecutive subjects who had hypertension, did not have diabetes, and had normal LV mass were categorized as those whose LV relative wall thickness was <0.44 (n = 41) and those whose relative wall thickness was > or =0.44. Venous blood samples were collected for determination of metabolic profile and plasma levels of hs-CRP and SAA. Subjects whose relative LV wall thickness was > or =0.44 compared with those whose relative LV wall thickness was <0.44 had significantly increased systolic blood pressure by 4.5 mm Hg (p = 0.015) and higher levels of plasma hs-CRP (1.80 vs 1.39 mg/L, p = 0.001) and SAA (10.22 vs 4.86 mg/dl, p = 0.000), although the 2 groups did not differ with regard to age, gender, waist-to-hip ratio, and diastolic blood pressure (p = NS for all). In the entire study population, log hs-CRP and SAA exhibited positive relations with systolic blood pressure (r = 0.21 and r = 0.29, respectively; p <0.05 for the 2 markers) and relative wall thickness (r = 0.26 and r = 0.81, respectively; p <0.05 for the 2 markers). Multiple linear regression analysis showed that age, gender, and diastolic blood pressure were significantly associated with LV mass index (p <0.05), whereas gender, body mass index, log hs-CRP, and SAA were significantly associated with relative wall thickness (p <0.003). By analysis of covariance, log hs-CRP and SAA were significantly different between subjects whose relative LV wall thickness was > or =0.44 and those whose relative LV wall thickness was <0.44 after the adjustment for age, gender, body mass index, and systolic/diastolic blood pressure (p <0.005 for the 2 markers). In conclusion, alterations in LV geometry are associated with increased serum CRP and SAA levels in patients who are newly diagnosed with essential hypertension.

Cardiac echo-lab productivity in times of economic austerity.

The present study attempts to offer insight into the volume, cost, and productivity of the operation of a cardiac echocardiographic laboratory (echo-lab) in a major public hospital of Greece and thus to contribute, on a practical level, to the widening of knowledge in the strategic field of secondary and tertiary healthcare management. The conducted research includes the basic step of the deployment of a primary data registry in the echo-lab and unfolds in three levels, i.e. the variability measurement of the quantity and cost of medical services provided to different patient populations, the assessment of operating costs and the development of productivity indexes. The results show that the mean costs of provision do change among distinct patient populations. The most important, from a financial standpoint, population cluster appears to be the one corresponding to outpatients. Productivity indices presented in this analysis constitute an essential piece of information which the public healthcare system is currently largely lacking, and which, combined with the pricing and the diagnosis-related group coding system of hospitals, can be used to improve efficiency in the management of secondary and tertiary care.

Aggravation of left ventricular diastolic dysfunction in hypertensives with coronary artery disease.

We investigated the combined effects of hypertension and coronary artery disease (CAD) on left ventricular (LV) diastolic function. We examined 118 consecutive hypertensives who underwent diagnostic coronary angiography. All patients underwent a complete echocardiographic study within 24 h of catheterization by operators blind to their condition. The study participants were divided into two groups according to the presence of CAD: group A, with the disease (n=72); and group B, without (n=46). Patients with CAD exhibited lower LV fractional shortening and ejection fraction (P=0.002 and P=0.001). Hypertensives with CAD had significantly prolonged isovolumic relaxation time (IVRT) compared to those without CAD (P<0.001). Most interestingly, CAD patients had significantly worse Ema/Ama, Vp (flow propagation velocity), E/Vp and Vp/IVRT (all P<0.05). In addition, after adjusting for confounders, univariate and multivariate logistic regression analyses revealed that IVRT increases were associated with greater odds of CAD, whereas decreases in Vp or Vp/IVRT were associated with lower odds of CAD (all P ≤ 0.001). In hypertensives, the early recognition of LV diastolic performance alteration may be associated with the presence of significant CAD, indicating the need for more aggressive approaches both in terms of pharmacological treatment and interventional evaluation.

Tricuspid regurgitation after successful mitral valve surgery.

The tricuspid valve (TV) is inseparably connected with the mitral valve (MV) in terms of function. Any pathophysiological condition concerning the MV is potentially a threat for the normal function of the TV as well. One of the most challenging cases is functional tricuspid regurgitation (TR) after surgical MV correction. In the past, TR was considered to progressively revert with time after left-sided valve restoration. Nevertheless, more recent studies showed that TR could develop and evolve postoperatively over time, as well as being closely associated with a poorer prognosis in terms of morbidity and mortality. Pressure and volume overload are usually the underlying pathophysiological mechanisms; structural alterations, like tricuspid annulus dilatation, increased leaflet tethering and right ventricular remodelling are almost always present when regurgitation develops. The most important risk factors associated with a higher probability of late TR development involve the elderly, female gender, larger left atrial size, atrial fibrillation, right chamber dilatation, higher pulmonary artery systolic pressures, longer times from the onset of MV disease to surgery, history of rheumatic heart disease, ischaemic heart disease and prosthetic valve malfunction. The time of TR manifestation can be up to 10 years or more after an MV surgery. Echocardiography, including the novel 3D Echo techniques, is crucial in the early diagnosis and prognosis of future TV disease development. Appropriate surgical technique and timing still need to be clarified.

Exaggerated exercise blood pressure response is related to tissue Doppler imaging estimated diastolic dysfunction in the early stages of hypertension.

We investigated the plausible interrelationship of exaggerated blood pressure response (EBPR) during exercise with left ventricular (LV) diastolic dysfunction, both associated with adverse cardiovascular outcomes, in the early stages of essential hypertension (EH). Sixty-five consecutive patients (aged 54 years, 56 males) with stage I to II EH underwent 24-hour ambulatory blood pressure (BP) recording and treadmill exercise testing and were classified as subjects with (n = 21) and without EBPR (n = 44) based on the systolic BP elevation at peak exercise (>/=210 mm Hg for men and >/=190 mm Hg for women). LV diastolic function was estimated by pulsed tissue Doppler imaging (TDI), averaging diastolic mitral annular velocities (Em, Am) from four separate sites (LV lateral, septal, anterior, and inferior wall). Hypertensives with EBPR, compared with those without EBPR, exhibited increased 24-hour pulse pressure by 4.8 mm Hg (P < .05) and significantly lower values of Em/Am ratio by 0.07 (P < .05). Univariate logistic regression analysis revealed that only 24-hour pulse pressure (odds ratio [OR] = 1.069; P = .043) and Em/Am (OR = 0.041; P = .049) were independent predictors of EBPR. Hypertensives with EBPR compared to their counterparts without EBPR are characterized by more pronounced LV diastolic dysfunction - assessed by TDI. Moreover, the increased pulsatile load seems to be a common denominator of these hypertension-linked states.