Association between waist circumference and childhood-masked hypertension: A community-based study.

AIM: The aim of this study is to determine the association between waist circumference (WC) and childhood-masked hypertension. METHODS: A territory-wide, school-based cohort of 1385 Hong Kong students (672 boys and 713 girls) aged 8-17 years was analysed. The ambulatory blood pressure-monitoring assessment was performed using validated oscillometric recorders (A&D TM-2430 (A&D Inc., Tokyo, Japan)) following American Heart Association's recommendations. Subjects were considered normotensive if their casual blood pressure, 24-h daytime and night-time average systolic blood pressure and diastolic blood pressure (DBP) were <95th percentile. If one or more of the ambulatory blood pressure parameters was ≥95th percentile, subjects would be considered suffering from masked hypertension (MH). Subjects who had three successive casual blood pressure measurements above the 95th percentile were excluded. RESULTS: By body mass index, 148 (10.7%) subjects were obese, 182 (13.1%) overweight and 359 (25.9%) having larger WC (≥85th percentiles). MH was diagnosed in 217 subjects (15.7%). Subjects with larger WC or obesity were significantly associated with higher 24-h daytime and night-time systolic blood pressure (≥95th percentile) (odds ratios from 1.84 to 2.09 and from 2.07 to 3.54 for larger WC and obese respectively, all P < 0.05) as well as 24-h DBP for larger WC (odds ratio = 2, P = 0.015) than normal subjects adjusted by sex, age and height. CONCLUSION: Waist circumference and body mass index are independent risk factors of childhood and adolescent MH. WC appears a significant associated factor of elevated 24-h DBP in children aged 8-17 years.

Importance of chronotropic response and left ventricular long-axis function for exercise performance in patients with heart failure and preserved ejection fraction.

BACKGROUND: We evaluated the relationship between the degree of chronotropic incompetence and left ventricular (LV) impairment during exercise with severity of exercise intolerance in patients with heart failure and preserved ejection fraction (HFPEF). METHODS: All patients underwent exercise echocardiography during bicycle Ergometer exercise with the acquisition of long-axis tissue Doppler imaging (TDI). Peak heart rates during exercise were also recorded and the percentages of maximal age-predicted heart rate (%MPHR) and heart rate reserve (%HRR) were calculated thereby. Besides, cardiopulmonary exercise testing was performed with peak oxygen consumption (VO2) measuring averaged at the highest 30-second during exercise. RESULTS: Forty HFPEF patients (aged 65±9 years; 75% male) were divided into two groups according to the median of peak VO2: patients with peak VO2<16.5 and ≥16.5 ml/kg/min, respectively. Patients with lower peak VO2 had decreased peak heart rates, %MPHR, %HRR, stroke volume and cardiac indices (LVSI and LVCI) than those with higher peak VO2 (all p<0.05). The LV long-axis functions (TDI Sm, Em, s' and e') were reduced in patients with lower peak VO2 (all p<0.05). Moreover, peak VO2 correlated with the following parameters: peak heart rates, %MPHR, %HRR, LVSI, LVCI, TDI Sm, Em, s' and e'(all p<0.05). CONCLUSIONS: The degree of blunted chronotropic response and impaired LV long-axis function were more profound in HFPEF patients with poor exercise performance.

Predictors of mid-term functional tricuspid regurgitation after device closure of atrial septal defect in adults: Impact of pre-operative tricuspid valve remodeling.

BACKGROUND: Functional TR occurs in adults with congenital atrial septal defect (ASD) due to left-to-right inter-atrial shunting and enlarged right heart. The prevalence and the predictors of TR following ASD closure in adults remain unknown. Moreover, whether preoperative anatomical parameters of tricuspid valve related to TR after ASD closure is understudied. METHODS: Comprehensive transthoracic echocardiography was performed in 64 consecutive secundum ASD patients before and at 3 months after device closure. Tricuspid valve parameters [annulus diameter (TAD), tenting area, tenting height, distal tricuspid septal leaflet angle (TSLA)], right ventricular (RV) function, pulmonary arterial pressures and severity of TR were recorded. Post-closure TR was defined as PISA radius ≥ 6 mm at 3 months. RESULTS: The TR severity was reduced after ASD closure with post-closure TR in 31 patients (48%) at follow-up. TR patients had larger ventricles, more TR, greater TAD, and larger tenting area/height and TSLA but similar RV long-axis function and pulmonary pressures at baseline. Pre-closure TAD [odds ratio (OR): 6.076, p=0.032] and TSLA (OR: 1.218, p=0.001) were the independent predictors for TR. A TAD >3.5 cm and a TSLA >30° had sensitivity, specificity, and area under the curve of 97%, 76%, and 0.82 and 100%, 78%, and 0.84, respectively. Assessment of TSLA showed an incremental value over TAD for predicting TR after closure (χ(2)=21.3 vs. 9.9, p<0.001). CONCLUSION: Nearly half of adults had TR following device closure of ASD. It was related to the excessive pre-operative structural remodeling in tricuspid valve rather than changes in RV.

Quantification of left ventricular performance in different heart failure phenotypes by comprehensive ergometry stress echocardiography.

BACKGROUND: We evaluated the left ventricular (LV) performance in patients with heart failure and preserved ejection fraction (HFPEF) during exercise as compared to those with heart failure and reduced ejection fraction (HFREF) and healthy subjects. METHODS: All subjects received echocardiographic (Vivid7, GE Healthcare) examination with symptom-limited exercise testing on a semi-recumbent and tilting bicycle ergometer (Lode BV, Netherlands). The exercise images for 2-dimensional (2D) speckle tracking were acquired with heart rate of 90-100 bpm, while exercise images for tissue Doppler imaging (TDI) and M-mode echocardiography were stored with attainment of >85% of maximal age-predicted heart rate. RESULTS: Stress echocardiographic examinations were performed in 40 HFPEF (aged 65 ± 9 years; 53% male), 40 HFREF (aged 62 ± 9 years; 90% male) and 30 normal controls (aged 56 ± 5 years; 33% male). Trends of progressive decline in 2D global longitudinal, circumferential and radial strains (GLS, GCS and GRS); TDI septal s' and Sm; and M-mode mitral annular plane systolic excursion (MAPSE) were observed from control, HFPEF to HFREF groups (p<0.05 for all). LV twist was preserved in HFPEF but reduced in HFREF patients as compared to normal controls (p<0.05). Diastolic function measured by TDI septal e', Em and septal E/e' progressively decreased from controls, HFPEF to HFREF patients (all p<0.05). Stroke volumes and cardiac indices (LVSI & LVCI) were preserved in HFPEF but deteriorated in HFREF than controls. CONCLUSIONS: This study provides the reference values of LV performance during exercise in HFPEF and knowledge about these changes provide important insights for future clinical studies.

Validation of A&D TM-2430 upper-arm blood pressure monitor for ambulatory blood pressure monitoring in children and adolescents, according to the British Hypertension Society protocol.

OBJECTIVE: The A&D TM-2430 ambulatory blood pressure (BP) monitor has been validated in adults but not in a young population. We sought to validate the device monitoring in children and adolescents, according to the British Hypertension Society (BHS) protocol. METHODS: The A&D TM-2430 is an automated oscillometric upper-arm device for ambulatory BP monitoring. Nine consecutive measurements were taken in 61 children (mean age, 9.8 years; range, 5-15 years) according to the BHS criteria. Overseen by an independent supervisor, measurements were recorded by two observers blinded from each other's readings and from the device readings. RESULTS: The mean difference ± SD between the observers and device measurements was 0.73 ± 1.64 mmHg for systolic blood pressure (SBP) and -1.23 ± 1.65 mmHg for diastolic blood pressure (DBP), respectively, with an interobserver difference of 4 mmHg. The cumulative percentages of differences within 5, 10, and 15 mmHg were 89, 95, and 98% for SBP and 67, 88, and 98% for DBP. The device achieved a grade A rating for SBP and a B grade for DBP. CONCLUSION: The A&D TM-2430 upper-arm BP monitor has fulfilled the required BHS standards and can be recommended for measuring ambulatory BP in children and adolescent populations.

Quality of life after percutaneous coronary intervention in the elderly with acute coronary syndrome.

BACKGROUND: Health-related quality of life (HRQoL) is an important but often neglected outcome measure in acute coronary syndrome (ACS) management. The prevalence of elderly presenting with ACS and undergoing percutaneous coronary intervention (PCI) is rising. We aimed to explore the impact of PCI on health status in elderly ACS patients. METHODS: We prospectively enrolled 624 patients admitted to our institution with ACS from February 2006 to May 2008. Short Form (SF)-36 health survey was used to assess HRQoL at baseline and 6 months. Baseline characteristics and HRQoL were compared for patients treated with PCI within 30 days of index ACS admission vs. medical therapy across 3 age groups (<60, 60-79 and ≥80 years). RESULTS: PCI was performed in 73.6%, 55.7% and 21.3% in patients aged <60, 60-79 and older than 80 years, respectively (p<0.01). Elderly patients were more likely to be female (16.9 vs. 35.4 vs. 54.6%, p<0.01) and had more co-morbidities (p<0.01). Older patients were less likely to undergo angiography (84.8 vs. 65.2 vs. 24.8%, p<0.01). Baseline HRQoL decreased with advancing age (p<0.01). However, elderly patients who underwent PCI experienced the most improvement in physical health than younger age groups. PCI was an independent predictor (Odds Ratio = 1.79, 95% CI: 1.10-2.92) of better physical health status at 6 months. CONCLUSION: Elderly ACS patients who underwent PCI experienced the most improvement in physical health compared to younger patients. Our findings suggest that age per se should not deter against revascularization because of potential benefits in HRQOL.

New pulmonary vein Doppler echocardiographic index predicts significant interatrial shunting in secundum atrial septal defect.

BACKGROUND: The relation between pulmonary venous flow (PVF) pattern and degree of left-to-right interatrial shunting (IAS) in patients with secundum atrial septal defect (ASD) is unknown. METHODS: Fifty consecutive ASD patients (14 males, 36 ± 17 years) received transthoracic echocardiography (TTE) before and 1 day after transcatheter closure and their results were compared to 40 controls. The ratio of pulmonary-to-systemic flows (Qp/Qs) was assessed by TTE and invasive oximetry. RESULTS: Pre-closure PV systolic (PVs), diastolic (PVd) velocities and velocity-time integral (PV-VTI) increased, time from onset of ECG Q-wave to the peak PV diastolic wave (Q-PVd) shortened and atrial reversal (PVar) velocity significantly decreased as compared to normals. These findings normalized after closure. Patients with large IAS (defined as invasive Qp/Qs ≥ 2) had higher PVs, PVd and PV-VTI, shorter Q-PVd but lower PVar (all p<0.01) than those with small IAS. Invasive Qp/Qs ratios correlated with PVs, PVd, PV-VTI, Q-PVd and TTE-derived Qp/Qs ratios, ASD sizes and RV end-diastolic dimensions (all p<0.05). PV-VTI (ß=0.49) and ASD size (ß=0.48) remained independent predictors of large IAS after multivariate analysis. The corresponding sensitivity, specificity and AUC were 89%, 82% and 0.90 respectively for a PV-VTI of 30 cm (p<0.001). CONCLUSION: ASD patients with significant IAS have distinguishable PVF features. Doppler evaluation of PV-VTI is a novel additional tool for assessing the magnitude of shunting in these patients non-invasively.

Left atrial remodeling and reduced atrial pump function after chronic right ventricular apical pacing in patients with preserved ejection fraction.

BACKGROUND: This prospective study was to examine the impact of right ventricular apical (RVA) pacing on atrial remodeling and function. METHODS AND RESULTS: 103 patients (age 70 ± 11 years; 53 men) with preserved left ventricular (LV) ejection fraction (LVEF>45%) who received RVA pacing had Doppler echocardiography performed at baseline and after one year follow up. At one year follow up, left atrial (LA) volumes (pre-atrial contraction volume and the minimal volume) and their indexes were significantly increased with reduction in passive emptying fraction and total emptying fraction (all p<0.05). LA segmental tissue velocities - mean peak systolic (Sm-la), peak early diastolic (Em-la) and late diastolic (Am-la) - were also significantly reduced (all p<0.001). A reduction of Am-la>30% occurred in 24% of patients, and was more prevalent in patients with an elevation of LV filling pressure (E/e'>15) at one year (44.1% vs. 11.7%, χ(2)=12.75, p<0.001) as well as those with a reduction of LVEF ≥ 5% (34.0% vs. 14.3%, χ(2)=5.140, p=0.023). By multivariate regression analysis, E/e'>15 at one year (odds ratio [OR] 5.213; 95% confidence interval [CI] 1.778-15.281) and reduction of LVEF ≥ 5% (OR 3.181; 95% CI 1.045-9.686) were independent predictors of reduction of Am-la>30%. CONCLUSIONS: Chronic RVA pacing results in LA remodeling and reduced atrial function. This is related to elevated filling pressures and impairment of LV systolic function.

The association between in utero hyperinsulinemia and adolescent arterial stiffness.

AIM: To determine the relationship between in utero hyperinsulinemia and children's arterial stiffness at adolescence. METHODS: Indices of arterial stiffness were measured using the SphygmoCor apparatus in 129 adolescents (42 offsprings of mother with gestational diabetes and 87 offsprings of mother with normal glucose tolerance during pregnancy) at 15 years of age. RESULTS: Adolescent of mothers with gestational diabetes had similar central aortic blood pressure, augmentation pressure (AP), augmentation index (AI), and carotid-femoral pulse wave velocity (PWV) as that of controls. However, both umbilical cord C-peptide and insulin levels correlated positively AI (R=0.28 and 0.24; p=0.011 and 0.035, respectively), and umbilical insulin level correlated positively with AP (R=0.25; p=0.025). The correlations were significant between umbilical cord C-peptide and AP (R=0.24; p=0.035) and AI (R=0.29; p=0.011) after adjustment for subjects' age, sex, body weight and height. Adolescents who had umbilical cord C-peptide levels at highest quartile (n=25), based on the reference ranges of the original cohort, had a significant greater PWV (5.26±0.12 m/s vs 4.98±0.12 m/s; p=0.0049) than those with C-peptide levels at the lower 3 quartiles (n=57) after adjustment for age, sex, body weight and height. CONCLUSIONS: In utero hyperinsulinemia appears to increase the offspring's arterial stiffness at early adolescence.

Albumin levels predict survival in patients with heart failure and preserved ejection fraction.

AIMS: Low serum albumin is common in patients with systolic heart failure and is associated with increased mortality. However, the relationship between albumin and outcome in patients with heart failure and preserved ejection fraction (HFPEF) is not known. The aim of this study was to investigate the effect of serum albumin level on survival in patients with HFPEF. METHODS AND RESULTS: We studied 576 consecutive HFPEF patients (left ventricular ejection fraction ≥50%) admitted to our hospital from 2006 to 2009. Standard demographics, transthoracic echocardiography, and routine blood testing including albumin levels were obtained shortly after admission. Outcome was assessed at 1 year after admission. Hypoalbuminaemia (≤34 g/L) was detected in 160 (28%) at admission; and all patients were then divided into hypoalbuminaemia and non-hypoalbuminaemia groups. In the hypoalbuminaemia group, the prevalence of chronic renal failure history, serum creatinine, and urea nitrogen levels were higher when compared with those without hypoalbuminaemia (all P < 0.05). Kaplan-Meier analysis showed that patients with hypoalbuminaemia had a significantly lower survival rate (53% vs. 84%, log-rank χ(2) = 53.3, P < 0.001) and a higher rate of cardiovascular death (21.8% vs. 8.9%, log-rank χ(2) = 19.7, P < 0.001) when compared with those without hypoalbuminaemia. Cox regression further revealed that hypoalbuminaemia, a history of cerebrovascular disease, and older age were the most powerful independent predictors of all-cause mortality in HFPEF patients at 1 year. CONCLUSIONS: Hypoalbuminaemia is common in HFPEF patients and is associated with increased risk of death. Renal dysfunction may be the main pathophysiological mechanism underlying hypoalbuminaemia in HFPEF patients.

Coronary artery disease and cardiovascular outcomes in patients with non-alcoholic fatty liver disease.

OBJECTIVE: Non-alcoholic fatty liver disease (NAFLD) is the hepatic manifestation of metabolic syndrome and is associated with cardiovascular risk. The aim of this study was to determine the role of fatty liver in predicting coronary artery disease and clinical outcomes in patients undergoing coronary angiogram. METHODS: This was a prospective cohort study carried out in a University hospital. Consecutive patients who underwent coronary angiogram had ultrasound screening for fatty liver. Significant cardiovascular disease was defined as ≥50% stenosis in at least one coronary artery. The primary outcome was a composite end point comprising cardiovascular deaths, non-fatal myocardial infarction and the need for further coronary intervention during prospective follow-up. RESULTS: Among 612 recruited patients, 356 (58.2%) had fatty liver by ultrasonography, 318 (52.0%) had elevated serum alanine aminotransferase and 465 (76.0%) had significant coronary artery disease. Coronary artery disease occurred in 84.6% of patients with fatty liver and 64.1% of those without fatty liver (p<0.001). After adjusting for demographic and metabolic factors, fatty liver (adjusted OR 2.31; 95% CI 1.46 to 3.64) and alanine aminotransferase level (adjusted OR 1.01; 95% CI 1.00 to 1.02) remained independently associated with coronary artery disease. At a mean follow-up of 87±22 weeks, 30 (10.0%) patients with fatty liver and 18 (11.0%) patients without fatty liver reached the composite clinical end point (p=0.79). CONCLUSIONS: In patients with clinical indications for coronary angiogram, fatty liver is associated with coronary artery disease independently of other metabolic factors. However, fatty liver cannot predict cardiovascular mortality and morbidity in patients with established coronary artery disease.

Prevalence and determinants of incomplete right atrial reverse remodeling after device closure of atrial septal defects.

Whether the relief of chronic right atrial (RA) volume load by device closure of an atrial septal defect (ASD) normalizes RA size is unknown. The present study evaluated the prevalence and determinants of incomplete RA reverse remodeling (RAR) after ASD closure in adults. Transthoracic echocardiography was performed in 44 consecutive patients with secundum ASD (age 43 ± 17 years, 10 men) without a history of atrial arrhythmia shortly before and at 3 months after device closure of ASD. The pulmonary/systemic flow ratio was derived using invasive oximetry. The RA size had significantly decreased at 3 months of follow-up (RA volume index [RAVI] 52 ± 29 to 27 ± 17 ml/m(2), p <0.001). Incomplete RAR (defined as a RAVI of ≥21 ml/m(2)) was detected in 25 patients (57%) after closure. They were older, had a larger pulmonary/systemic flow ratio, a higher pulmonary arterial systolic pressure, more tricuspid regurgitation, and larger RA, left atrial, and right ventricular sizes before closure than those with a normalized right atrium. Before closure, RAVI was the only independent determinant for incomplete RAR (odds ratio 1.115, 95% confidence interval 1.019 to 1.220; p = 0.018). A cutoff value of RAVI of ≥40 ml/m(2) has a sensitivity of 84% and specificity of 72% in the receiver operating characteristic curve. The preclosure RAVI correlated moderately with the shunt-duration index, calculated by multiplying the age to pulmonary/systemic flow ratio (r = 0.64, p <0.01). In conclusion, incomplete RAR occurred in >1/2 of the adult patients at 3 months after ASD device closure and was related to excessive preclosure RA dilation.

High prevalence of subclinical left ventricular dysfunction in patients with psoriatic arthritis.

OBJECTIVE: Endothelial dysfunction and early atherosclerosis have been found in patients with psoriatic arthritis (PsA) without cardiovascular disease (CVD) risk factors. Few studies have investigated whether there is any early impairment of myocardial function. The aims of our study were to determine the prevalence of subclinical left ventricular (LV) dysfunction in PsA patients and the disease-related risk factors. METHODS: Ninety-four PsA patients without clinical evidence of CVD and 63 healthy subjects were enrolled. All underwent conventional echocardiography and tissue Doppler imaging. RESULTS: Sixty-one (65%) patients with PsA had evidence of subclinical LV dysfunction as defined by mean myocardial peak systolic velocity (Sm) of basal 6 segments < 4.4 cm/s, lateral E' < 11.5 cm/s, and/or lateral E/E' > 10. Thirty-six (38%) patients had only diastolic dysfunction, 4 (4%) had only systolic dysfunction, and 21 (22%) had both systolic and diastolic dysfunction. PsA patients with subclinical LV dysfunction were older, had a higher age at diagnosis of PsA and of psoriasis, a longer disease duration, a higher prevalence of hypertension and hyperlipidemia, higher levels of serum creatinine, and more antihypertensive treatment than those with normal LV function. Multivariate regression showed that age at diagnosis of PsA > 40 years (OR 3.388, 95% CI 1.065-10.777, p = 0.039) and hypertension (OR 4.732, 95% CI 1.345-16.639, p = 0.015) were independent predictors of subclinical LV dysfunction. CONCLUSION: PsA patients without established CVD disease and in the absence of traditional CV risk factors have a high prevalence of subclinical LV dysfunction.

Resting global and regional left ventricular contractility in patients with heart failure and normal ejection fraction: insights from speckle-tracking echocardiography.

UNLABELLED: OBEJCTIVE: To compare left ventricular (LV) systolic performance and contractility in patients with heart failure and normal ejection fraction (HFNEF), compared with patients with heart failure and reduced ejection fraction (HFREF) and healthy subjects using newer echocardiographic techniques. DESIGN: A case-control trial. SETTING: University teaching hospital (tertiary referral centre). PATIENTS: Sixty healthy control subjects (53 ± 10 years), 112 patients with HFNEF (74 ± 12 years) and 175 patients with HFREF (67 ± 13 years). INTERVENTIONS: All underwent standard two-dimensional, Doppler and speckle-tracking echocardiography. MAIN OUTCOME MEASURES: Effective arterial (Ea) and LV end-systolic elastance (Ees), stress-corrected mid-wall shortening, preload recruitable stroke work, two-dimensional strain and torsion. Comparisons were adjusted for age, gender and body size. RESULTS: Besides diastolic dysfunction, patients with HFNEF had impaired load-independent ventricular contractility with a progressive decrease of the corrected Ees from controls (2.9 ± 0.8 mm Hg/g) to HFNEF (2.2 ± 0.9 mm Hg/g) followed by HFREF (0.8 ± 0.3 mm Hg/g; all p<0.001). Ventricular-arterial coupling ratio was preserved in the HFNEF subgroup (normal 0.48 ± 0.09 vs 0.65 ± 0.16; p = NS) at the expense of both increased LV systolic stiffness and Ea. In addition, there was progressive decrease of global 2D circumferential, radial and longitudinal strain as well as torsion from normal, HFNEF to HFREF groups, even after adjustment for LV end-systolic wall stress or end-diastolic volume (all p<0.01). About 50% of patients with HFNEF had ≥ 1 global strain or torsion parameter depressed below normal after correction for LV end-systolic wall stress, with >85% falling below their corresponding stress-corrected mean. CONCLUSIONS: Impaired myocardial contractility is evident in many patients with HFNEF and this may contribute towards pathophysiology of HFNEF more than previously thought.

A novel multi-layer approach of measuring myocardial strain and torsion by 2D speckle tracking imaging in normal subjects and patients with heart diseases.

BACKGROUND: This study adopted a new multi-layer approach of measuring myocardial deformation by two-dimensional (2D) speckle tracking imaging to examine whether a transmural gradient exists in normal subjects and cardiac diseases. METHODS: Eighty patients were included with 20 in each group: (1) normal control; (2) acute coronary syndrome (ACS) with ejection fraction (EF) >45%; (3) right ventricular apical (RVA) pacing with EF>45%; (4) systolic heart failure (SHF) with EF<45%. Circumferential strain (ε-circum), torsion (Tor) and systolic dyssynchrony defined as the maximal difference in the time to peak circumferential strain were measured in the subendocardial and subepicardial myocardium layers (QLab 6.0, Philips). RESULTS: In all the 4 groups, a subendocardial to subepicardial gradient was present in both ε-circum (-20.7 ± 7.6 vs. -14.9 ± 5.6%, p<0.001) and Tor (12.0 ± 6.0 vs. 9.3 ± 4.7°, p<0.05), with higher values in the subendocardial layer. However, it was significantly narrowed for ε-circum (2.7 ± 1.2%) and Tor (0.8 ± 0.9°) in SHF patients (all p ≤ 0.001 vs. other groups). On the contrary, systolic dyssynchrony measured in the 2 layers showed no difference (264 ± 107 vs. 273 ± 110 ms, p = NS) and a homogenous distribution in ε-circum was observed from basal to apical planes (-17.0 ± 6.8 vs. -18.1 ± 7.4 vs. -18.1 ± 7.8%, all p = NS). CONCLUSIONS: A transmural gradient exists in circumferential strain and torsion, with higher values in the subendocardial layer. It might be reduced when systolic function is impaired. Therefore, the multi-layer approach of 2D speckle tracking imaging provides further information on assessment of myocardial diseases.

Enhanced detection of patent foramen ovale by systematic transthoracic saline contrast echocardiography.

OBJECTIVE: We aimed to evaluate the effectiveness of transthoracic saline contrast echocardiography (TSCE) in detecting patent foramen ovale (PFO). BACKGROUND: Transesophageal echocardiography (TEE) is semi-invasive and not ideal for PFO screening. METHODS: 112 patients (48 males, 46 ± 14 years) with suspected PFO received intravenous agitated-saline contrast at rest and stress (strain and release phases of Valsalva maneuver and coughing). The presence of interatrial shunting was defined as >5 bubbles appearing in the left heart within 3 cardiac cycles. The stage of the maneuver at which interatrial shunting occurred was recorded. The TSCE findings were validated by TEE. RESULTS: TEE identified PFO in 45% of patients. The sensitivities of TSCE in detecting PFO at rest, during strain and release of Valsalva maneuver, and coughing were 12.0%, 38.0%, 80.0% and 94.0% respectively (each p<0.05 when compared to previous stage). Specificities were similar and >95% for all stages. Moreover, the release phase of the maneuver improved the diagnostic accuracy [defined as (number of true positives+true negatives) divided by total in sample] with incremental value over the preceding strain phase (89.2 vs. 70.5%, p<0.001). CONCLUSIONS: Patent foramen ovale can be identified confidently with proper conduct of the Valsalva maneuver during the transthoracic saline contrast echocardiography.

Different determinants of improvement of early and late systolic mitral regurgitation contributed after cardiac resynchronization therapy.

BACKGROUND: Functional mitral regurgitation (MR) at different phases of the regurgitant period may respond differently to cardiac resynchronization therapy (CRT). The aims of this study were to examine the impact of CRT on the phasic changes of MR (early vs late systole) and to explore the mechanisms of such changes. METHODS: Instantaneous MR flow rate and total MR volume were evaluated in 60 patients who had more than mild functional MR before and 3 months after CRT. In addition, indices of global left ventricular (LV) remodeling, mitral deformation, and LV systolic dyssynchrony were assessed. RESULTS: CRT diminished MR volume (38 ± 18 vs 32 ± 20 mL) by reducing both the early (72 ± 47 vs 58 ± 48 mL/sec) and late (48 ± 42 vs 40 ± 42 mL/sec) systolic components (all p values < .01). In patients with ≥10% reductions in total MR volume but not in patients without this improvement, there were significant reductions in LV end-systolic volume, increases in LV +dP/dt, decreases in mitral valvular tenting, and improvements of systolic dyssynchrony at 3 months (all P values < .05). By multivariate regression, the reductions in LV end-systolic volume and tenting area were independent determinants of a reduction in total MR volume: the reductions in LV end-systolic volume and global dyssynchrony determined the reduction in early systolic MR, and the reductions in tenting area and global dyssynchrony determined reduction in late systolic MR. CONCLUSIONS: CRT decreases MR volume by reducing both early and late systolic MR. The determinants of the phasic improvement in functional MR are different.