Pulmonary hypertension in patients with end stage renal disease undergoing hemodialysis.

BACKGROUND: Pulmonary hypertension (PH) is a serious cardiovascular complication in patients with end stage renal disease (ESRD) undergoing hemodialysis (HD) via arterio-venous fistulas (AVF). AIM: The aim of this study was to assess pulmonary vascular resistance (PVR), AVF flow volume (AVF-FV) and cardiac output (CO) and to highlight the impact of their augmentation, as well as of the duration of HD, on the occurrence of PH in patients with ESRD. METHODS: Our study group consisted of 51 dialyzed patients, with ESRD, without history of PH. We determined by ultrasonography the systolic pulmonary arterial pressure (PAPs), the left ventricular ejection fraction (EF), the cardiac output (CO), PVR and AVF-FV. RESULTS: We documented PH in 27 (52.94%) patients. All had elevated PVR, higher AVF-FV and CO comparing to patients without PH. They were undergoing HD for a longer period and had lower EF than those without PH. For all patients, we documented strong correlations between PAPs and PVR (r = 0.933, P < 0.001) and the duration of HD (r = 0.702, P < 0.001), but moderate ones with AVF-FV (r = 0.583, P < 0.001) and CO (r = 0.519, P < 0.001). CONCLUSION: In patients with ESRD undergoing HD, PH was a common finding being associated with increased PVR, a longer duration of HD and chronic glomerulonephritis as etiology for ESRD. The majority of patients with PH had altered left ventricular systolic function, predisposing them to an increased risk to develop heart failure.

Assessment of arterial stiffness in patients with CKD stage 5 when initiating chronic hemodialysis for vascular access and for preventing cardiovascular events.

We consider that re-assessment of the vascular status is necessary, even mandatory, in patients with CKD when initiating dialysis because of two reasons:--assessment of vascular remodelling is important for establishing the artery-venous fistula as it can supply appreciative data on its success and duration;--vascular remodelling plays an important part in cardio-vascular pathology of patients dialysed, with the required consecutive prophylactic measures. In chronic kidney disease, calcium deposits at extra-skeletal level also affect the vessels, determining calcifications of both the vascular intima and media. Atherosclerosis and arteriosclerosis are present in patients with CKD and they contribute to diminishing the elasticity of the artery wall by vascular remodelling. Vascular remodelling determines thickening of the artery wall, respectively of the thickness of the arterial intima-media. Thus, arteries lose their elasticity, and the wall of the arterial tree wall turns stiff. Arterial stiffness is a process that precedes the development-proper of atherosclerosis, determined by cumulative exposure to various risk factors. Atherosclerosis is a focal process, in which indemne areas alternate with areas with atheroma plaques at intima level, and arteriosclerosis is a diffuse process located at the level of the arterial media. Non-invasive assessment of arterial stiffness can be achieved by analyzing pulse wave velocity and the augmentation index. We studied a group of 35 patients with chronic kidney insufficiency, CKD, stage 5, with an average age of 52.03 +/- 17.36 years, of whom 15 (43%) were females and 20 (57%) were males. The investigated parameters presented the following average values: PWV = 16.7 +/- 1.27 m/s; IMT = 1.63 +/- 0.18 mm; Aix = 36.14 +/- 9.98%; AAI = 0.78 +/- 0.2. The assessment of vascular stiffness in chronically dialysed patients offers better appreciation of vascular stiffness. Knowing the amplitude of the vascular remodelling process is of special importance for deciding the place and modality of performing the vascular access with regard to replacing the kidney function and to preventing cardiovascular events in dialysed patients.

The influence of left bundle branch-block and cardiac dyssynchrony on 2D-strain parameters in patients with heart failure complicating ischemic cardiomyopathy.

UNLABELLED: Coronary artery disease is the underlying cause in approximately two-thirds of patients with heart failure. Torsional and longitudinal deformations are essential components of left ventricular (LV) performance. Electric conduction defects can reduce LV ejection fraction (LVEF) and decrease cardiac output. AIM: To investigate the influence of left bundle branch-block (LBBB) and cardiac dyssynchrony on 2D-strain parameters in patients with HF complicating ischemic cardiomyopathy. METHODS: We analyzed 106 consecutive patients with HF complicating ischemic cardiomyopathy, in sinusal rhythm. LV strain, LV twist and LV torsion were measured by echocardiographic 2D-strain imaging. LV dyssynchrony was assessed using validated tissue Doppler parameters. Patients were divided into three groups: HF with normal LVEF (group 1), HF with reduced LVEF without LBBB (group 2) and with LBBB (group 3). RESULTS: LVEF, LV strain, LV torsion and LV twist were significantly better in group 1 (each p < 0.01). In group 3, LV torsion and LV twist were significantly lower compared to group 2 (0.80 +/- 0.4 vs. 1.21 +/- 0.23 degrees/cm, p = 0.007, and 5.18 +/- 2.4 vs. 8.31 +/- 1.5 degrees, p = 0.004, respectively), but LV strain and LVEF were not different between group 3 and 2 (-4.91 +/- 2.3 vs. -6.28 +/- 1.8%, p = 0.056, and 30.6 +/- 8.8 vs. 34.4 = 8.3%, p = 0.11, respectively). Cardiac dyssynchrony induces a reduction of all 2D-strain analyzed parameters (each p < 0.05). CONCLUSION: In HF complicating ischemic cardiomyopathy, LBBB and cardiac dyssynchrony induce a reduction of LV strain, torsion and twist. In patients with reduced LVEF, LBBB induces predominantly a significant reduction ofLV torsion and LV twist, while LV strain was apparently not influenced.

Echocardiographic evidences of increased left ventricular pressure and atrial dilatation in patients with drug-resistant paroxystic atrial fibrillation and structurally normal heart.

UNLABELLED: Global myocardial index (GMI) has been significantly related to left ventricular filling pressure. We hypothesized that GMI and echographic indicators of atrial dilatation were significantly different in pAF pts compared to normals. METHODS: 39 patients (pts) without structural heart disease, aged 52+/-10 years with pAF were compared to 36 control-matched pts aged 48+/-16 years. Following parameters were assessed: P-wave duration (Pd), GMI, left atrial dimensions (LAd=M-mode, parasternal, LAt and LAI are measurements of short and long-axis apical four chamber view), surface (LAs), volume (LAv), total ejection fraction (LA EF), right atrial dimension (RAd) and surface (RAs), total atrial surface (TAs=LAs+RAs). LAv was calculated using ellipse formula pi/6 (LAdxLAlxLAt). RESULTS: There was no difference between the 2 groups concerning Pd (p=0.1), LA EF (p=0.23), LAd (p=0.08) and LAt (p=0.06) while the rest of the parameters were significantly higher in pAF pts: GMI: 0.5+/-0.17 vs 0.36+/-0.06 (p=0.001); LAI: 5.4+/-0.5 vs 4.5+/-0.3 cm2 (p=0.001); LAs was founded increased in pAF pts (20.6+/-5.7 vs 16.3+/-2.1 cm2, p=0.001); TAs: 40.6+/-6.9 vs 30.6+/-5.1 cm2, p=0.0001; LAv: 51.6+/-10.4 vs 37.2+/-9.3 ml (p=0.0001). CONCLUSIONS: Although apparently without structural heart disease, pAF pts presented evidence of increased filling pressions in left ventricle and indirect markers of atrial stretch. The role of increased intra-atrial pressure in pts pFA and predictive value of these parameters need to be evaluated in a larger number of patients.

Absence of correlation between QRS duration and echographic parameters of ventricular desynchronization. Can we still trust the electrocardiographic criteria?

UNLABELLED: The aim of the study was to assess if echographic ventricular desynchronization parameters measured in patients with dilated cardiomyopathy (DCM) and severe heart failure are correlated with the duration of the QRS on surface electrocardiogram. METHODS: This study included 51 pts aged 58.8 +/- 7.4 years with idiopathic DCM. The following parameters were measured: QRS duration; effective contraction time (ECT) measured as the interval between QRS onset and closure of aortic valve, interventricular delay (IVD) measured as the time between onset of aortic and pulmonary flow, left ventricular mechanical delay (LVD) as the time from maximal interventricular septum contraction and posterior wall contraction, posterior (P), lateral (L) and posterolateral (PL) wall delays, as the time from QRS onset to maximal wall contraction. Regional postsystolic contraction was defined in a given wall as the difference (contraction delay - ECT)> 50ms. RESULTS: 29 pts presented complete LBBB, 22 pts had QRS duration < 120 ms. 39 pts had a postsystolic contraction of the PL wall (32 pts of the L wall and 26 pts of the P wall). 16 pts with QRS duration <120 had a postsystolic contraction of the PL wall (as for the LBBB the rest of 39 pts). In 40 pts the sequence of regional ventricular contraction was: P-L-PL wall (16 pts with QRS<120). LVD was > 100 ms in 36 pts (26 pts with LBBB and 10 with QRS<120). 27 of pts with LBBB and 6 with QRS <120 ms presented IVD> 30ms. There was no correlation between the QRS duration and the parameters listed above. CONCLUSIONS: In DCM pts there is no correlation between the duration of the QRS and echocardiographic parameters of ventricular desynchronization. Mechanical ventricular de-synchrony can be observed in patients with QRS duration < 120 ms.

Global myocardial index in patients with multisite pacing.

UNLABELLED: Global myocardial index (GMI) is a sensitive echocardiographic indicator of overall cardiac function. The aim of this study was to compare the GMI changes induced by Bi-V pacing to the variations in clinical, electrocardiographic and echocardiographic parameters currently used for evaluation of ventricular resynchronization in order to test the potential marker of positive clinical response. PATIENTS AND METHODS: This study included 35 consecutive patients (pts), aged 65.7+/-7.5 years, implanted with an endocavitary Bi-V pacemaker for drug refractory severe heart failure. NYHA class was evaluated before implantation and at day 30. QRS duration (QRSd), echocardiographic interventricular delay (IVD), and GMI were determined in the paced and non-paced situation at day 1, 7 and 30 after implantation. RESULTS: NYHA class improved from 3.5+/-0.3 to 2.4+/-0.4 (p<0.01). GMI improved significantly (p<0.0001) after Bi-V in all pts from 1.25 +/- 0.5 to 0.77 +/- 0.34 and remained stable all along the study. GMI decrease (dGMI) in pts with NYHA functional class improvement > 0.5 was 0.52 +/- 0.16while dGMI in pts with NYHA functional class improvement < or = 0.5 was 0.21+/- 0.19. dGMI was statistically correlated with IVD shortening (r=0.67, p<0.0001) but not with QRSd shortening. CONCLUSION: The GMI improves during Bi-V pacing, mostly in responders pts and the improvement remains unchanged after the implant. The GMI decrease induced by Bi-V pacing is correlated with the IVD shortening and NYHA functional class improvement.

Assessment of treatment with orotate magnesium in early postoperative period of patients with cardiac insufficiency and coronary artery by-pass grafts (ATOMIC).

The benefit of the treatment with magnesium orotate (magnerot) was assessed in a randomised, single blind and placebo controlled study. Respecting the inclusion criteria were selected 32 patients with ischemia chronic failure in early postoperative period after CABG. The main improvements induced by magnesium orotate are the increase in exercise capacity (distance ambulated during 6 minutes walk test and ergospirometric parameters) and the reduction of ventricular premature beats. The treatment was well tolerated and the adverse reactions were not significant. The study strongly suggests the benefit of magnesium orotate added to classical antiischemic therapy in the complex management of coronary patients after CABG.

[Results, complications and long-term follow-up of percutaneous ablation of atrioventricular conduction. Apropos of 85 cases]. / Résultats, complications et suivi au long cours de l'ablation percutanée de la conduction auriculo-ventriculaire. A propos de 85 observations.

This retrospective study reports the immediate and long-term results of percutaneous ablation of atrioventricular conduction. Between July 1983 and January 1992, 85 consecutive patients (51 men, age 64 +/- 10 years, range 43-84 years) presenting with supraventricular arrhythmias (atrial fibrillation n = 53; atrial flutter n = 50; atrial tachycardia n = 17; junctional tachycardia n = 6) resistant to antiarrhythmic therapy (number of drugs used: 4 +/- 1.3, range 1-6) underwent interruption of atrioventricular conduction by fulguration (n = 65) or radiofrequency energy (n = 13) or by an association of the two methods (n = 7). The 75 pacemakers implanted (10 patients had pacemakers before the procedure) comprised 55 VVIR, 11 VVI, 5 DDD and 4 DDDR units. The immediate results included two sudden deaths at the 4th and 7th day in patients undergoing fulguration and three complications with a favourable outcome (staphylococcal septicaemia, pulmonary embolism and haematoma at the site of implantation of the pacemaker). None of the patients was lost to follow-up and the average follow-up was 31 +/- 18 months (range 2-108 months). During follow-up, 15 patients died and there was a recurrence of symptoms in 11 patients after 1 to 9 months requiring a repeat procedure. In the 68 survivors, the follow-up is now 38 +/- 18 months (range 12-108 months). Sixty one patients have 2nd (2) or 3rd (59) degree atrioventricular block, giving 90% good electrocardiographic results.(ABSTRACT TRUNCATED AT 250 WORDS)

[Left-sided His bundle ablation after failure of right-sided approach: technique and initial results]. / Ablation du faisceau de His par voie gauche après échec d'un abord droit: technique et résultats préliminaires.

Although interruption of atrioventricular conduction has been widely used over the last decade in patients with supraventricular arrhythmias and rapid conduction resistant to antiarrhythmic therapy, the incidence of atrioventricular block obtained by delivering the energy at the tricuspid ring ranges from 45 to 92%. Failure of this technique is usually related to the inhability to record endocavitary electrogrammes compatible with probable success by the right-sided approach. The authors report four cases of interruption of atrioventricular conduction in 4 men (average age 61.5 +/- 10 years) by the retrograde arterial catheterisation after one or more (1 to 3) failures by the right-sided approach. After arterial puncture, the ablation catheter is positioned against the interventricular septum below the aortic cusps to record the His bundle electrogram. His bundle ablation was obtained after an average of 2 radio frequency energy applications (range 1 to 3). At the time of effective application, the average amplitude of the endocavitary electrogram was as follows: auriculogram 0.09 mV (range 0.05 to 0.2 mV), His bundle electrogram 0.19 mV (0.15-0.22 mV), ventriculogram 1.36 mV (1.0 to 1.7 mV). No complications were observed. After an average follow-up of 4 months, the 4 patients were still in complete atrioventricular block. This preliminary series shows that left-sided interruption of atrioventricular conduction is effective and safe. It may be proposed after failure of a right-sided attempt.