Is There a Typical Doppler Pattern in Patients With Apical Hypertrophic Cardiomyopathy With Aneurysm?

Nineteen consecutive patients with apical hypertrophic cardiomyopathy and apical aneurysm underwent a comprehensive echo-Doppler including continuous wave Doppler at midventricular level. Three different flow patterns, pattern A (more frequent), pattern B, and pattern C, and expression of different intracavitary pressure gradients were defined. (Level of Difficulty: Intermediate.).

Efficacy of cardiometabolic drugs in reduction of epicardial adipose tissue: a systematic review and meta-analysis.

BACKGROUND: Epicardial adipose tissue (EAT) plays an important role in cardiometabolic risk. EAT is a modifiable risk factor and could be a potential therapeutic target for drugs that already show cardiovascular benefits. The aim of this study is to evaluate the effect of cardiometabolic drugs on EAT reduction. METHODS: A detailed search related to the effect on EAT reduction due to cardiometabolic drugs, such as glucagon-like peptide-1 receptor agonist (GLP-1 RA), sodium-glucose cotransporter-2 inhibitors (SGLT2-i), and statins was conducted according to PRISMA guidelines. Eighteen studies enrolling 1064 patients were included in the qualitative and quantitative analyses. RESULTS: All three analyzed drug classes, in particular GLP-1 RA, show a significant effect on EAT reduction (GLP-1 RA standardize mean difference (SMD) = - 1.005; p < 0.001; SGLT2-i SMD = - 0.552; p < 0.001, and statin SMD = - 0.195; p < 0.001). The sensitivity analysis showed that cardiometabolic drugs strongly benefit EAT thickness reduction, measured by ultrasound (overall SMD of - 0.663; 95%CI - 0.79, - 0.52; p < 0.001). Meta-regression analysis revealed younger age and higher BMI as significant effect modifiers of the association between cardiometabolic drugs and EAT reduction for both composite effect and effect on EAT thickness, (age Z: 3.99; p < 0.001 and Z: 1.97; p = 0.001, respectively; BMI Z: - 4.40; p < 0.001 and Z: - 2.85; p = 0.004, respectively). CONCLUSIONS: Cardiometabolic drugs show a significant beneficial effect on EAT reduction. GLP-1 RA was more effective than SGLT2-i, while statins had a rather mild effect. We believe that the most effective treatment with these drugs should target younger patients with high BMI.

Approach to the Patient with Acute Aortic Syndromes in Light of the New Consensus Statement on Multimodality Imaging in Thoracic Aortic Diseases.

Acute aortic syndromes comprise a range of interrelated conditions including aortic dissection, intramural hematoma, penetrating atherosclerotic ulcer, and contained or not contained aortic aneurysm rupture. These syndromes are potentially life threatening; therefore, a rapid and accurate diagnosis is crucial. A new Clinical Consensus Statement on Aortic and Peripheral Vascular Disease has recently been published, and we will try to highlight the main innovations in the document.

Outcomes and mechanical complications of acute myocardial infarction during the second wave pandemic in a Milan HUB center for cardiac emergencies.

Aims: COVID-19 has dramatically impacted the healthcare system. Evidence from previous studies suggests a decline in in-hospital admissions for acute myocardial infarction (AMI) during the pandemic. However, the effect of the pandemic on mechanical complications (MC) in acute ST-segment elevation myocardial infarction (STEMI) has not been comprehensively investigated. Therefore, we evaluated the impact of the pandemic on MC and in-hospital outcomes in STEMI during the second wave, in which there was a huge SARS-CoV-2 diffusion in Italy. Methods and results: Based on a single center cohort of AMI patients admitted with STEMI between February 1, 2019, and February 28, 2021, we compared the characteristics and outcomes of STEMI patients treated during the pandemic vs. those treated before the pandemic. In total, 479 STEMI patients were included, of which 64.5% were during the pandemic. Relative to before the pandemic, primary percutaneous coronary intervention (PCI) declined (87.7 vs. 94.7%, p = 0.014) during the pandemic. Compared to those admitted before the pandemic (10/2019 to 2/2020), STEMI patients admitted during the second wave (10/2020 to 2/2021) presented with a symptom onset-to-door time greater than 24 h (26.1 vs. 10.3%, p = 0.009) and a reduction of primary PCI (85.2 vs. 97.1%, p = 0.009). MC occurred more often in patients admitted during the second wave of the pandemic than in those admitted before the pandemic (7.0 vs. 0.0%, p = 0.032). In-hospital mortality increased during the second wave (10.6 vs. 2.9%, p = 0.058). Conclusion: Although the experience gained during the first wave and a more advanced hub-and-spoke system for cardiovascular emergencies persists, late hospitalizations and a high incidence of mechanical complications in STEMI were observed even in the second wave.

Feasibility and Accuracy of the Automated Software for Dynamic Quantification of Left Ventricular and Atrial Volumes and Function in a Large Unselected Population.

We aimed to evaluate the feasibility and accuracy of machine learning-based automated dynamic quantification of left ventricular (LV) and left atrial (LA) volumes in an unselected population. We enrolled 600 unselected patients (12% in atrial fibrillation) clinically referred for transthoracic echocardiography (2DTTE), who also underwent 3D echocardiography (3DE) imaging. LV ejection fraction (EF), LV, and LA volumes were obtained from 2D images; 3D images were analyzed using dynamic heart model (DHM) software (Philips) resulting in LV and LA volume-time curves. A subgroup of 140 patients also underwent cardiac magnetic resonance (CMR) imaging. Average time of analysis, feasibility, and image quality were recorded, and results were compared between 2DTTE, DHM, and CMR. The use of DHM was feasible in 522/600 cases (87%). When feasible, the boundary position was considered accurate in 335/522 patients (64%), while major (n = 38) or minor (n = 149) border corrections were needed. The overall time required for DHM datasets was approximately 40 seconds. As expected, DHM LV volumes were larger than 2D ones (end-diastolic volume: 173 ± 64 vs. 142 ± 58 mL, respectively), while no differences were found for LV EF and LA volumes (EF: 55% ± 12 vs. 56% ± 14; LA volume 89 ± 36 vs. 89 ± 38 mL, respectively). The comparison between DHM and CMR values showed a high correlation for LV volumes (r = 0.70 and r = 0.82, p < 0.001 for end-diastolic and end-systolic volume, respectively) and an excellent correlation for EF (r = 0.82, p < 0.001) and LA volumes. The DHM software is feasible, accurate, and quick in a large series of unselected patients, including those with suboptimal 2D images or in atrial fibrillation.

Multi-parametric "on board" evaluation of right ventricular function using three-dimensional echocardiography: feasibility and comparison to traditional two-and three dimensional echocardiographic measurements.

Three-dimensional echocardiographic (3DE) of right ventricle (RV) has been validated in many clinical settings. However, the necessity of complicated and off-line dedicated software has reduced its diffusion. A new simplified "on board" 3DE software (OB) has been developed to obtain RV volumes and ejection fraction (EF) together with several conventional parameters automatically derived from 3DE: tricuspid annular plane systolic excursion (TAPSE), fractional area change (FAC), longitudinal strain (LS). Aims of this study were to evaluate feasibility and accuracy of OB RV analysis. A complete 2DE and 3DE with OB 3DRV evaluation was obtained in 35 normal subjects and 105 patients with different pathologies. Results were compared with the conventional off-line software (OFL) and with the 2D-derived corresponding values. A subgroup of 22 patients underwent also cardiac CMR. OB 3DRV was feasible in 133/140 cases (95%) in a mean time of 97.5 ± 33 s lower than OFL analysis (129 ± 52 s plus dataset loading 80 ± 24 s). Imaging quality was good in 84%. OB and OFL 3DE RV volumes and EF were similar. 3DE derived FSA and LS (but not TAPSE) were similar to 2DE values and correlated with tissue Doppler systolic peak velocity, dP/dt, systolic pulmonary pressure and myocardial performance index. OB RV volumes and EF well correlated with CMR. (bias + SD: - 21.5 ± 20 mL for EDV; - 8.2 ± 12.4 mL for ESV; - 1 ± 5.9% for EF). OB 3DE method is feasible, simple, time saving. It easily provides 3DE RV volumes and multiple functional parameters. Off-line operator border adjustment may improve accuracy of 3DE TAPSE.

Linking cell function with perfusion: insights from the transcatheter delivery of bone marrow-derived CD133+ cells in ischemic refractory cardiomyopathy trial (RECARDIO).

BACKGROUND: Cell therapy with bone marrow (BM)-derived progenitors has emerged as a promising therapeutic for refractory angina (RA) patients. In the present study, we evaluated the safety and preliminary efficacy of transcatheter delivery of autologous BM-derived advanced therapy medicinal product CD133+ cells (ATMP-CD133) in RA patients, correlating perfusion outcome with cell function. METHODS: In the phase I "Endocavitary Injection of Bone Marrow Derived CD133+ Cells in Ischemic Refractory Cardiomyopathy" (RECARDIO) trial, a total of 10 patients with left ventricular (LV) dysfunction (ejection fraction ≤ 45%) and evidence of reversible ischemia, as assessed by single-photon emission computed tomography (SPECT), underwent BM aspiration and fluoroscopy-based percutaneous endomyocardial delivery of ATMP-CD133. Patients were evaluated at 6 and 12 months for safety and preliminary efficacy endpoints. ATMP-CD133 samples were used for in vitro correlations. RESULTS: Patients were treated safely with a mean number of 6.57 ± 3.45 ×  106 ATMP-CD133. At 6-month follow-up, myocardial perfusion at SPECT was significantly ameliorated in terms of changes in summed stress (from 18.2 ± 8.6 to 13.8 ± 7.8, p = 0.05) and difference scores (from 12.0 ± 5.3 to 6.1 ± 4.0, p = 0.02) and number of segments with inducible ischemia (from 7.3 ± 2.2 to 4.0 ± 2.7, p = 0.003). Similarly, Canadian Cardiovascular Society and New York Heart Association classes significantly improved at follow-up vs baseline (p ≤ 0.001 and p = 0.007, respectively). Changes in summed stress score changes positively correlated with ATMP-CD133 release of proangiogenic cytokines HGF and PDGF-bb (r = 0.80, p = 0.009 and r = 0.77, p = 0.01, respectively) and negatively with the proinflammatory cytokines RANTES (r = - 0.79, p = 0.01) and IL-6 (r = - 0.76, p = 0.02). CONCLUSION: Results of the RECARDIO trial suggested safety and efficacy in terms of clinical and perfusion outcomes in patients with RA and LV dysfunction. The observed link between myocardial perfusion improvements and ATMP-CD133 secretome may represent a proof of concept for further mechanistic investigations. TRIAL REGISTRATION: ClinicalTrials.gov, NCT02059681 . Registered 11 February 2014.

The Evolving Role and Use of Echocardiography in the Evaluation of Cardiac Source of Embolism.

This report will review the role of echocardiography in the diagnosis of cardiac sources of embolism. Embolism of cardiac origin accounts for around 15%-30% of ischemic strokes. The diagnosis of a cardioembolic source of stroke is frequently uncertain and relies on the identification of a potential cardiac source of embolism in the absence of significant autochthonous cerebrovascular occlusive disease. Transthoracic and/or transesophageal echocardiography serves as a cornerstone in the evaluation, diagnosis, and management of these patients. This article reviews potential cardiac sources of embolism and discusses the role of echocardiography in clinical practice. Recommendations for the use of echocardiography in the diagnosis of cardiac sources of embolism are given including major and minor conditions associated with the risk of embolism.

Prevalence of calcification of the mitral valve annulus in patients undergoing surgical repair of mitral valve prolapse.

Factors correlating to mitral annulus calcification (MAC) include risk factors predisposing to atherosclerosis. In patients with mitral valve (MV) prolapse (MVP), other anatomic or mechanical factors have been supposed to facilitate MAC. The aims of this study were, in patients with MVP undergoing MV repair, (1) to describe the prevalence and characteristics of MAC, (2) to correlate MAC with clinical risk factors, coronary involvement, and aortic valve disease, and (3) to describe prevalence, site, and extension of MAC in fibroelastic deficiency (FED) versus Barlow's disease (BD) and correlate MAC to surgical outcomes (repair vs replacement). In 410 consecutive patients with MVP suitable for surgical MV repair, detailed clinical and echocardiographic data were collected to characterize MAC in BD and FED. MAC was found in 99 patients (24%). Age, female gender, coronary artery disease, and cardiovascular risk factors were correlated with MAC. MAC was equally distributed in FED and BD groups despite patients with FED being older with more cardiovascular risk factors. The most common localization of MAC was annular involvement adjacent to P2 (75%), P1 (31%), and P3 (35%). The presence of MAC affected surgical outcomes in both groups (8% patients with MAC underwent replacement after a first attempt of repair vs 3% without MAC). MAC is a common finding in patients undergoing MV repair, and several clinical characteristics correlate with MAC either in FED or BD. In conclusion, despite very high percentage of repairability, MAC influences surgical outcomes and very detailed echo evaluation is advocated.

Incidence of spontaneous echocontrast, 'sludge' and thrombi before cardioversion in patients with atrial fibrillation: new insights into the role of transesophageal echocardiography.

OBJECTIVES: Transesophageal echocardiography (TEE)-guided cardioversion has been demonstrated to be well tolerated in patients with atrial fibrillation. Guidelines do not suggest whether patients with severe spontaneous echocontrast (SEC) and sludge can be safely submitted to cardioversion. In our observational study, we analyzed the prevalence of SEC in patients with atrial fibrillation taking different anticoagulant therapies, the incidence of embolic complications after cardioversion in patients with severe SEC or sludge and the usefulness of TEE in reducing embolic complications in these patients. METHODS: The study population consisted of 1104 patients with atrial fibrillation, candidates for cardioversion and submitted to TEE. They were divided into four groups: effective conventional oral anticoagulation, short-term anticoagulation, subtherapeutic anticoagulation and effective oral anticoagulation for less than 3 weeks for different clinical reasons. Cardioversion was postponed in patients with atrial thrombosis; in the presence of severe SEC, the decision to cardiovert was left to the treating physician. RESULTS: Atrial thrombosis was detected in 65 (5.9%) patients, and SEC was detected in the majority of patients independent of the anticoagulant scheme; in 131 patients, it was severe and, in this group, sludge was identified in 57 patients. Cardioversion was performed in 922 patients and was successful in 849 (including 22 patients with severe SEC and four with sludge) with one minor embolic event. CONCLUSION: SEC and sludge are frequently observed in patients with atrial fibrillation undergoing cardioversion. A TEE approach may prevent the risk of embolic events. In the presence of severe SEC and sludge, treating physicians frequently postpone cardioversion, even though in the patients submitted to cardioversion, no events were observed.

Is right ventricular systolic function reduced after cardiac surgery? A two- and three-dimensional echocardiographic study.

AIMS: A reduction in tricuspid annular plane systolic excursion (TAPSE) and peak systolic velocity (PSV) of tricuspid annulus after cardiac surgery is a well-known phenomenon, even though its origin is not well established. Recently, a new three-dimensional (3D) echocardiographic software adapted for right ventricular (RV) analysis has been validated. Aims of this study were to evaluate RV function in patients with mitral valve prolapse undergoing surgical valvular repair and to compare and correlate 3D RV ejection fraction (RVEF) with TAPSE and PSV before and after surgery. METHODS AND RESULTS: Forty patients were studied by transthoracic 2D and 3D echocardiography pre- and 3, 6, and 12 months post-surgery. TAPSE (15.5 +/- 3, 16.5 +/- 3, and 18.5 +/- 4 mm at 3, 6, and 12 months, respectively) and PSV (11.9 +/- 2, 12 +/- 2, and 12.8 +/- 3 cm/s at 3, 6, and 12 months, respectively) were significantly (P < 0.001) lower after surgery in comparison with pre-surgical values (TAPSE: 25.3 +/- 4 mm; PSV: 17.8 +/- 4 cm/s). On the contrary, pre-operative RVEF (58.4 +/- 4%) did not change after surgery (56.9 +/- 5, 59.5 +/- 5, and 58.5 +/- 5% at each step). CONCLUSION: Despite the post-operative reduction of RV performance along the long axis suggested by TAPSE and PSV, the absence of a decrease in 3D RVEF leads to caution in the interpretation of these 2D and Doppler parameters after cardiac surgery, supporting the hypothesis of geometrical rather than functional changes in the right ventricle.

High-grade video compression of echocardiographic studies: a multicenter validation study of selected motion pictures expert groups (MPEG)-4 algorithms.

BACKGROUND: Large files produced by standard compression algorithms slow down spread of digital and tele-echocardiography. We validated echocardiographic video high-grade compression with the new Motion Pictures Expert Groups (MPEG)-4 algorithms with a multicenter study. METHODS: Seven expert cardiologists blindly scored (5-point scale) 165 uncompressed and compressed 2-dimensional and color Doppler video clips, based on combined diagnostic content and image quality (uncompressed files as references). One digital video and 3 MPEG-4 algorithms (WM9, MV2, and DivX) were used, the latter at 3 compression levels (0%, 35%, and 60%). RESULTS: Compressed file sizes decreased from 12 to 83 MB to 0.03 to 2.3 MB (1:1051-1:26 reduction ratios). Mean SD of differences was 0.81 for intraobserver variability (uncompressed and digital video files). Compared with uncompressed files, only the DivX mean score at 35% (P = .04) and 60% (P = .001) compression was significantly reduced. At subcategory analysis, these differences were still significant for gray-scale and fundamental imaging but not for color or second harmonic tissue imaging. Original image quality, session sequence, compression grade, and bitrate were all independent determinants of mean score. CONCLUSIONS: Our study supports use of MPEG-4 algorithms to greatly reduce echocardiographic file sizes, thus facilitating archiving and transmission. Quality evaluation studies should account for the many independent variables that affect image quality grading.

Feasibility and accuracy of a routine echocardiographic assessment of right ventricular function.

The evaluation of right ventricular (RV) systolic function is important for its clinical and prognostic value but difficult to obtain due to RV complex anatomy. Aims of this study were to evaluate the feasibility of a routine use of RV fractional shortening area (FSA), systolic excursion (TAPSE) and peak systolic velocity (PSV) of tricuspidal annular motion in a large series of cases (900 pts), to determine the values in normal subjects (150) and in patients (750) with different pathologies and to correlate these indexes to clinical and echo-Doppler variables. FSA (50.3+/-10% vs 54.6+/-9% p<0.01), TAPSE (20.2+/-5 vs 24.7+/-4 mm, p<0.01) and PSV (16.2+/-4 vs 20+/-4 cm/s, p<0.01) were lower in patients than in normals, correlated positively to left ventricular ejection fraction and negatively to the pulmonary pressure. The values of 17 mm for TAPSE, 12 cm/s for PSV and 37% for FSA identified patients with high specificity. The values in subgroups of pathological patients were evaluated and compared.

Hyperoxemic perfusion of the left anterior descending coronary artery after primary angioplasty in anterior ST-elevation myocardial infarction.

OBJECTIVES: To assess left ventricle function recovery, ST-segment changes, and enzyme kinetic in ST-elevation myocardial infarction patients treated with intracoronary hyperoxemic perfusion (IHP) after primary percutaneous coronary intervention and compare them with the results obtained in control patients. BACKGROUND: IHP has been shown to attenuate microvascular reperfusion injury, which may result in poor LV function recovery despite successful primary percutaneous coronary intervention. METHODS: Twenty seven anterior ST-elevation myocardial infarction patients treated < or = 12 hr after symptom onset by primary percutaneous coronary intervention were subjected to selective IHP into the left anterior descending coronary artery for 90 min. They were compared with 24 anterior ST-elevation myocardial infarction control patients matched in clinical and angiographic characteristics and treated with conventional primary percutaneous coronary intervention. Left ventricular function recovery was evaluated by serial 2D contrast echocardiography. RESULTS: Left anterior descending coronary artery recanalization was successful in all patients. After IHP (100% successful, duration 90 +/- 5.4 min), patients showed a 4.8 +/- 2.2 hr shorter time-to-peak creatine kinase release (P = 0.001), a shorter creatine kinase half-life period (23.4 +/- 8.9 hr vs. 30.5 +/- 5.8 hr, P = 0.006), and a higher rate of complete ST-segment resolution (78% vs. 42%, P = 0.01). A significant improvement of mean left ventricular ejection fraction (from (44 +/- 9)% to (55 +/- 11)%, P < 0.001) and wall motion score index (from 1.77 +/- 0.2 to 1.39 +/- 0.4, P < 0.001) was observed at 3 months in IHP patients only. CONCLUSION: After successful primary coronary intervention, IHP is associated with significant left ventricular function recovery when compared to conventional treatment. Enzyme kinetic and ST-segment changes suggest faster and more complete microvascular reperfusion and may explain the salutary effects of this new therapy on left ventricular function.

Feasibility and diagnostic accuracy of quantitative assessment of mechanical prostheses leaflet motion by transthoracic and transesophageal echocardiography in suspected prosthetic valve dysfunction.

Transthoracic (TTE) and transesophageal echocardiography (TEE) are the standard techniques for the evaluation of prosthetic valve function. However, quantitative evaluation of leaflet(s) motion is not routinally carried out, although leaflet(s) opening and closing angle measurements are important information to recognize prosthetic dysfunction. For this purpose, cinefluoroscopy is considered the "gold standard" technique. The aim of this study was the evaluate the diagnostic accuracy of TTE and TEE in the quantitative assessment of leaflet motion in patients with mechanical protheses. One hundred-eleven patients with mitral (single disk 18; bileaflet 48) and aortic (single disk 22; bileaflet 23) prostheses, were referred to TTE, TEE, and cinefluoroscopy for electrical cardioversion of atrial fibrillation (n = 40) or suspected prosthesis dysfunction (n = 71). Echocardiographic evaluation included leaflet(s) opening and closing angle measurements; results were compared with cinefluoroscopy. For mitral prostheses, opening and closing angles were correctly identified by TTE in 85% and by TEE in 100% of patients, regardless of prosthetic valve type, with a good concordance with cinefluoroscopy. For aortic prostheses, opening angles were correctly identified by TTE and TEE, respectively, in 40% and 77% of patients with single-disk and in 13% and 35% of patients with bileaflet prostheses. Both TTE and TEE were rarely able to identify closing angles. In conclusion, quantitative evaluation of mitral leaflet(s) motion may be accurately achieved with TTE and TEE, leading to increased diagnostic efficacy of prosthetic valve dysfunction. In the aortic position, TTE and TEE allow a quantitative evaluation of leaflet(s) dynamics only in a minority of patients and cinefluoroscopy still remains the first-choice technique.

Clinical validation of different echocardiographic motion pictures expert group-4 algorythms and compression levels for telemedicine.

Tele-echocardiography is not widely used because of lengthy transmission times when using standard Motion Pictures Expert Groups (MPEG)-2 lossy compression algorythms, unless expensive high bandwidth lines are used. We sought to validate the newer MPEG-4 algorythms to allow further reduction in echocardiographic motion video file size. Four cardiologists expert in echocardiography read blindly 165 randomized uncompressed and compressed 2D and color Doppler normal and pathologic motion images. One Digital Video and 3 MPEG-4 compression algorythms were tested, the latter at 3 decreasing compression quality levels (100%, 65% and 40%). Mean diagnostic and image quality scores were computed for each file and compared across the 3 compression levels using uncompressed files as controls. File dimensions decreased from a range of uncompressed 12-83 MB to MPEG-4 0.03-2.3 MB. All algorythms showed mean scores that were not significantly different from uncompressed source, except the MPEG-4 DivX algorythm at the highest selected compression (40%, p=.002). These data support the use of MPEG-4 compression to reduce echocardiographic motion image size for transmission purposes, allowing cost reduction through use of low bandwidth lines.

Incidence and characteristics of left ventricular false tendons and trabeculations in the normal and pathologic heart by second harmonic echocardiography.

We sought to review echocardiographic incidence of anomalous images (AI) as false tendons and trabeculations of the left ventricle (LV) in light of recent advancements in echocardiographic evaluation of heart anatomy. In 1580 patients the presence of false tendons, trabeculations, or thrombi was evaluated with transthoracic echocardiography and correlated to clinical characteristics and echocardiographic parameters. Incidence of AI was 46.7% (75% false tendons, 23% trabeculations, 2% thrombi), slightly higher in pathologic (48.9%) than in normal hearts (40.8%). AI were more frequent in male patients (52%) than in female patients (39.7%) and associated with LV dilatation, hypertrophy, and systolic dysfunction. False tendons and trabeculations were not related to age. Male sex was the most significant independent predictor of AI. In 2 patients, isolated LV noncompaction of myocardium was diagnosed and confirmed by magnetic resonance imaging. This study shows a high prevalence of AI for patients with and without pathologic hearts suggesting the need of updating LV echocardiographic anatomy. It also emphasizes the necessity for an awareness of these anatomic variants when evaluating patients for mural thrombi and cardiomyopathies.

Effects of acute angiotensin-converting enzyme inhibition on diastolic ventricular interaction in the dilated heart.

BACKGROUND: The normal and dilated heart behaves as a single functional unit during preload reduction: volume unloading in the setting of diastolic ventricular interaction allows for increased left ventricular (LV) filling. HYPOTHESIS: We hypothesized that reduction of venous return induced by a physiologic stimulus (tilting) or by acute angiotensin-converting enzyme (ACE) inhibitors in dilated heart is likely to have a marked and similar effect on ventricular chamber geometry and filling. This study was designed to assess how the normal and dilated heart adapts to preload reduction. METHODS: Twenty normal subjects and 20 patients with moderate heart failure due to dilated cardiomyopathy were studied with two-dimensional and Doppler echocardiography in supine position (B) and after 40 degrees of head-up tilting (T). The following day, patients repeated supine (C) and tilting test (TC) after administration of captopril (25 mg s.l.). Right ventricular (RV) and LV dimensions, LV geometry, and tricuspid, mitral, and pulmonary venous flow patterns were recorded at each step of the study. RESULTS: In the two groups, T was associated with reduction of RV area and LV volumes; C and TC produced a similar effect on RV and LV. Changes in LV septal-lateral diameter and anterior-posterior diameter were different at each step of the study: during T (both groups) and after C and TC, the septallateral diameter increased slightly while the anterior-posterior diameter decreased. During T, mitral and tricuspid peak flow velocities decreased, peak late velocities were unchanged, and the deceleration time of mitral flow increased; the systolic forward flow of pulmonary venous flow decreased, the diastolic forward flow did not change, and the difference in duration between reverse pulmonary flow and mitral peak late flow decreased: C and CT induced similar changes. CONCLUSION: Preload reduction induced by tilting or by ACE inhibitors induces profound and similar effects on LV and RV dimensions, LV geometry, and biventricular filling. Reduction of RV dimension is associated with adaptation of LV geometry and decrease of LV diastolic pressure, which facilitates LV filling and pulmonary venous drainage: ACE inhibition associated with tilting exerts an additional effect on these changes. These data confirm the role of ventricular interaction in modulating LV filling in heart failure.