Interaction of malnutrition, N-terminal pro-B-type natriuretic peptide and ventricular remodeling in patients on maintenance hemodialysis.

AIMS: The aim of the present study was to investigate the interaction of nutritional status, N-terminal probrain-type natriuretic peptide (NT-proBNP) and ventricular remodeling in hemodialysis patients. METHODS: NT-proBNP was measured by immunoassay. Nutritional status was assessed using the subjective global assessment (SGA) and malnutrition-inflammation score (MIS). Transthoracic echocardiographic examinations were performed on all patients. RESULTS: 44 patients undergoing maintenance hemodialysis were enrolled in this study. Malnourished patients had higher levels of extracellular water (ECW) per kg body weight (BWt) than well-nourished patients and higher levels of NT-proBNP. MIS was positively correlated with left ventricular mass index (LVMI), log NT-proBNP and ECW/BWt, and negatively correlated with fat mass and LV systolic dysfunction. LV systolic dysfunction, LVMI and MIS were independently associated with log NT-proBNP levels. Multiple regression analysis showed that log NT-proBNP, mean arterial pressure and ECW/BWt were independently associated with LVMI. However, MIS did not have an independent relationship to LVMI. CONCLUSIONS: Malnutrition in hemodialysis patients is accompanied by volume overload and associated with increased log NT-proBNP levels independent of volume status, and these levels are independently associated with increased LVMI. This suggests a possibility that nutritional status may affect ventricular remodeling in hemodialysis patients.

A case of asymptomatic isolated double-chambered right ventricle in an adult man.

Double-chambered right ventricle is a rare congenital heart disease. An anomalous muscle band divides the right ventricle into two cavities, causing a variable degree of obstruction. Most cases of double-chambered right ventricle are diagnosed and treated during childhood, whereas cases of initial presentation during adulthood are very rare. We report a case of asymptomatic isolated double-chambered right ventricle incidentally found in an adult man.

Noncompaction of the myocardium coexistent with bronchiectasis and polycystic kidney disease.

Noncompaction of the ventricular myocardium (NCM) is a disorder of unknown aetiology characterised by numerous, prominent ventricular trabeculations and deep intertrabecular recesses. Polycystic kidney disease (PKD) is characterised by the formation of multiple cysts in the kidneys and liver and, less frequently, in the pancreas. Cardiovascular abnormalities in PKD involve hypertension, mitral valve prolapse, intracranial aneurysms and pulmonary abnormalities include primary ciliary dyskinesia and bronchiectasis. Several case reports have described the possible association between PKD and NCM. However, NCM, PKD and bronchiectasis have not previously been correlated. This is the first case of NCM coupled with PKD and bronchiectasis.

Clinical features and genetic analysis of Korean patients with Loeys-Dietz syndrome.

Loeys-Dietz syndrome (LDS) is an inherited disorder that is characterized by the triad of arterial tortuosity and aneurysms, hypertelorism and a bifid uvula or cleft palate. The disease is caused by heterozygous mutations in the genes encoding transforming growth factor ß receptors 1 and 2 (TGFBR1 and TGFBR2, respectively). However, studies of patients with LDS are limited in Korea. From June 2000 to December 2010, 13 patients (10 probands) diagnosed with LDS were enrolled. The multidisciplinary data of the patients were reviewed retrospectively. The frequency of each clinical manifestation in Korean patients with LDS was compared with Western populations as described in the report by Loeys et al. Twelve (92%) of the 13 LDS patients had arterial tortuosity, 9 (69%) patients had hypertelorism and 11 (85%) patients had bifid uvula or cleft palate. Mutations in either TGFBR1 or TGFBR2 were detected in nine probands (90%). Of the mutations, five novel mutations were detected; three in TGFBR2 and two in TGFBR1. Blue sclera and atrial septal defect were not observed in the Korean patients, and the frequency of blue sclera was significantly lower in our Korean population than previously-described Western population (0 vs 40%; P=0.005). Despite the restricted number of patients in our study, we identified five novel mutations in the TGFBR1 and TGFBR2 genes and, except for blue sclera, no differences in phenotype are apparent between Korean patients and Western patients.

Factors related to prehospital time delay in acute ST-segment elevation myocardial infarction.

Despite recent successful efforts to shorten the door-to-balloon time in patients with acute ST-segment elevation myocardial infarction (STEMI), prehospital delay remains unaffected. Nonetheless, the factors associated with prehospital delay have not been clearly identified in Korea. We retrospectively evaluated 423 patients with STEMI. The mean symptom onset-to-door time was 255 ± 285 (median: 150) min. The patients were analyzed in two groups according to symptom onset-to-door time (short delay group: ≤ 180 min vs long delay group: > 180 min). Inhospital mortality was significantly higher in long delay group (6.9% vs 2.8%; P = 0.048). Among sociodemographic and clinical variables, diabetes, low educational level, triage via other hospital, use of private transport and night time onset were more prevalent in long delay group (21% vs 30%; P = 0.038, 47% vs 59%; P = 0.013, 72% vs 82%; P = 0.027, 25% vs 41%; P < 0.001 and 33% vs 48%; P = 0.002, respectively). In multivariate analysis, low educational level (1.66 [1.08-2.56]; P = 0.021), symptom onset during night time (1.97 [1.27-3.04]; P = 0.002), triage via other hospital (1.83 [1.58-5.10]; P = 0.001) and private transport were significantly associated with prehospital delay (3.02 [1.81-5.06]; P < 0.001). In conclusion, prehospital delay is more frequent in patients with low educational level, symptom onset during night time, triage via other hospitals, and private transport, and is associated with higher inhospital mortality.

Annuloaortic ectasia in a 16 year-old boy with Loeys-Dietz syndrome.

Loeys-Dietz syndrome (LDS) is a rare genetic disorder with an autosomal dominant inheritance due to mutations in the transforming growth factor beta-receptor type 1 or type 2. The disease is characterised by the triad of hypertelorism, bifid uvula or cleft palate, arterial tortuosity and aortic aneurysms. These phenotypic characteristics distinguish LDS from other connective tissue disorders related to transforming growth factor beta-receptor. Patients with LDS have a high risk of aortic dissection or rupture at a younger age and smaller aortic diameters. So, clinical suspicion of LDS followed by genotyping is important to prevent aortic dissection, leading cause of death, by surgical treatment.

Coronary arteriovenous fistula.

Congenital coronary arteriovenous fistulas represent abnormal communication between coronary arteries and any cardiac chambers, pulmonary artery, coronary sinus, superior vena cava or pulmonary vein. We reported an interesting case of very long and tortuous coronary arteriovenous fistulas originated from the left circumflex coronary artery, which drained into bronchial arteries in right lower lung field diagnosed by coronary angiography and multidetector computed tomography.

Inverted Tako-Tsubo cardiomyopathy associated with bronchoalveolar lavage.

Tako-Tsubo cardiomyopathy (TTC), also known as transient left ventricular (LV) ballooning syndrome or stress-induced cardiomyopathy, is characterised by transient LV dysfunction in the absence of significant angiographic coronary stenoses, frequently provoked by an episode of emotional or physical stress. In TTC, typically transient akinesis or dyskinesis of the LV apical segments with normal or hypercontractile basal wall motions is observed. Recently, several cases of atypical or inverted transient TTC sparing the LV apex have been reported. We report a case of inverted TTC showing akinesis of the basal and mid-ventricular segments of the LV with apical hyperkinesia triggered by bronchoscopy with bronchoalveolar lavage.

Preoperative, postoperative and one-year follow-up of N-terminal pro-B-type natriuretic peptide levels in volume overload of aortic regurgitation: comparison with pressure overload of aortic stenosis.

OBJECTIVES: Limited data are available regarding the impact of pressure or volume overload on the clinical or echocardiographic parameters and the levels of N-terminal pro-B-type natriuretic peptide (NT-proBNP) in patients with chronic severe aortic valve diseases. We aimed to investigate and compare the relationships between these parameters in such patients. METHODS: One hundred twenty-four consecutive patients who underwent aortic valve replacement for chronic severe aortic valve diseases were enrolled. Plasma NT- proBNP was measured and echocardiographic parameters were recorded before surgery, before discharge and 12 months after surgery. RESULTS: NT-proBNP levels were significantly higher in patients with aortic regurgitation (AR) (n = 63) than in those with aortic stenosis (n = 61) (1,836.0 ± 376.1 vs. 508.4 ± 74.5 pg/ml, p = 0.001). There was a significant relationship between NT-proBNP levels and left ventricular mass index (LVMI) in AR (r = 0.436, p = 0.002) and a weaker, but significant, relationship between NT-proBNP levels and LVMI in aortic stenosis patients (r = 0.290, p = 0.046). In the AR group, preoperative NT-proBNP levels positively correlated with LVMI regression during the 12 months after surgery (r = 0.488, p = 0.001). CONCLUSION: NT-proBNP levels may reflect LVMI changes that are caused by volume overload rather than pressure overload in chronic aortic valve diseases. Higher preoperative NT-proBNP levels may predict left ventricular reverse remodeling early after surgery for chronic severe AR.

Noninvasive assessment of left ventricular stroke work index in patients with severe mitral regurgitation: correlation with invasive measurement and exercise capacity.

BACKGROUND: Noninvasively measured left ventricular stroke work index (LVSWI) may be an ideal indicator that can provide more relevant information about cardiac performance in severe mitral regurgitation (MR). We sought to correlate the noninvasive LVSWI with invasive measure of LVSWI and validate its clinical usefulness by comparing the noninvasive LVSWI with exercise capacity. METHODS: Twenty-nine patients with severe MR who underwent cardiac catheterization and 61 patients with severe MR who underwent cardiopulmonary exercise test were evaluated for comparison of noninvasive LVSWI with invasive LVSWI via cardiac catheterization and peak exercise capacity, respectively. RESULTS: Mean noninvasive LVSWI was 33.1 ± 9.7 g·m/m², which was in a good agreement with invasive LVSWI (34.9 ± 15.1 g·m/m², intraclass correlation coefficient = 0.72, P < 0.001). Noninvasive LVSWI (ß= 0.35, P = 0.001) was independently related with peak exercise capacity. Indexed left atrial volume (ß=-0.27, P = 0.042), mean blood pressure (ß=-0.21, P = 0.030), age (ß=-0.47, P < 0.001) estimated pulmonary artery systolic pressure (ß=-0.21, P = 0.030) and male gender (ß= 0.36, P = 0.001) were also independently associated with exercise capacity. CONCLUSIONS: Noninvasive LVSWI has a good correlation with invasively measured LVSWI and is a clinically useful parameter for evaluating true cardiac performance in patients with severe MR.

Presence of Renal Simple Cysts Is Associated With Increased Risk of Abdominal Aortic Aneurysms.

We compared the incidence of renal simple cysts in 271 patients with abdominal aortic aneurysm (AAA) and 1387 patients without AAA (controls) using computed tomography (CT) angiography and abdominal CT, as a health screening program. The AAA group had significantly higher prevalence of renal simple cysts (55% vs 19%, P = .001) and chronic obstructive pulmonary disease (COPD; 12% vs 1%, P = .011) than the controls. After propensity score matching (n = 164), the prevalence of renal simple cysts was still significantly higher in the AAA group. In multivariate analysis, independent predictors of AAA were age, male gender, smoking history, hypertension, high-sensitivity C-reactive protein, creatinine, COPD, and renal simple cysts. The structural weakness predisposing for renal simple cysts may be associated with the initiation of AAA formation. More studies are needed to determine whether the presence of renal simple cysts can be considered as a risk factor for AAA.

Ventricular reverse remodeling early after mitral valve repair for severe chronic mitral regurgitation with atrial fibrillation.

OBJECTIVE: Chronic mitral regurgitation (MR) results in volume overload followed by left ventricular (LV) and left atrial remodeling. The aim of this study was to investigate the relation of clinical, echocardiographic findings and N-terminal B-type natriuretic peptide (NT-proBNP) to LV reverse remodeling (LVRR) early after valve repair for severe chronic MR concomitant with modified maze procedure for atrial fibrillation (AF). METHODS: We retrospectively evaluated 60 patients who were surgically treated for severe chronic MR and AF. Plasma NT-proBNP and echocardiographic measurements were performed before surgery, before discharge and 12 months after surgery. Echocardiogram was additionally performed at 6 months. LVRR was assessed by looking at regression of LV mass index (LVMI) using echocardiography. RESULTS: Fifty-two patients (87%) were classified in the LVRR group, defined as having a postoperative reduction in LVMI. The remaining patients were classified in the non-LVRR group. The non-LVRR group was older (p = 0.004), had a significantly higher ratio of patients with hypertension (p = 0.022), higher NT-proBNP levels (p = 0.007) and lower ejection fraction (p = 0.034) compared to the LVRR group. In multivariate analysis, age (odds ratio 0.874, p = 0.013) and NT-proBNP levels (odds ratio 0.185, p = 0.040) were independent predictors of LVRR. CONCLUSIONS: Preoperative lower NT-proBNP levels and younger age may predict LVRR early after surgical correction of chronic MR with AF.

Longitudinal 2D strain at rest predicts the presence of left main and three vessel coronary artery disease in patients without regional wall motion abnormality.

AIMS: Non-invasive echocardiographic detection of coronary artery disease (CAD), even in left main or three-vessel CAD, usually requires a stress test since regional wall motion abnormalities (RWMA) are not always evident at rest. Strain is a more sensitive parameter of myocardial systolic function and may be abnormal in patients with severe CAD. METHODS AND RESULTS: We evaluated whether peak systolic longitudinal strain (PSLS) of left ventricle using 2D speckle tracking method might be useful for screening of severe CAD. One hundred and eight patients who underwent echocardiography and coronary angiography were evaluated. Patients were grouped according to the coronary angiographic findings as follows; high-risk group with left main or three-vessel CAD (n = 38), low-risk group with one- or two-vessel CAD (n = 28), and control group without CAD (n = 30). PSLSs of all left ventricular segments were obtained successfully in 96 (89%) patients. None had RWMA at resting echocardiogram. PSLS was significantly reduced, especially in mid- and basal segments, in the high-risk group. Receiver operating characteristic (ROC) curve analysis demonstrated that mid- and basal PSLSs could effectively detect patients with severe CAD (area under ROC curve = 0.83, 95% CI 0.75-0.91). According to ROC curve analysis, -17.9% appears to be a helpful cutoff value for discriminating those with severe CAD (specificity 79% and sensitivity 79%). CONCLUSION: PSLS at rest was significantly lower in patients with left main or three-vessel CAD without RWMA, and might be useful for identifying patients with a severe CAD.

Pulse wave velocity is more closely associated with cardiovascular risk than augmentation index in the relatively low-risk population.

Pulse wave velocity (PWV) and augmentation index (AI) are both indirect indicators of arterial stiffness, which is an independent predictor of morbidity and mortality in cardiovascular diseases. The aim of this study was to assess the association between carotid AI (CAI), carotid-femoral PWV (CFPWV), and Framingham risk score (FRS), and to evaluate the factors determining CAI and CFPWV. Carotid AI and CFPWV were measured by applanation tonometry in 177 consecutive subjects without evidence of significant cardiovascular disease. Correlations between CAI and FRS and CFPWV and FRS were analyzed and major determinants of CAI and CFPWV were assessed. The mean age was 60.5 +/- 11.9 years and 112 (63%) of study patients were men. There was a significant association between CFPWV and FRS (r = 0.417, P < 0.001) and a weaker but also significant relation between CAI and FRS (r = 0.267, P < 0.001). CFPWV was significantly related to FRS in both men and women (P < 0.001 in both sexes), whereas the relation between CAI and FRS was significant only in women (P < 0.001). Our results suggest that CFPWV may be associated with CVD risk irrespective of sex, whereas CAI may be associated with CVD risk in women only.

Reduced peak atrial systolic mitral annular velocity predicts the development of nonvalvular atrial fibrillation.

We investigated whether the echocardiographic parameters of the left atrium (LA) can predict the development of nonvalvular atrial fibrillation (AF). Among 14,062 patients (>20 years old) who underwent an echocardiographic examination were evaluated, 2,606 patients who underwent follow-up ECG with an interval of >6 months were investigated. Newly developed AF was noted in 42 (1.6%) patients with follow-up duration of 31.8 +/- 8.9 months. Cox regression analysis revealed that a higher left atrial volume index (hazard ratio [HR]=1.06; 95% confidence interval [CI] 1.03-1.09, P < 0.001), relative wall thickness (RWT) of>or=0.407 (HR=2.74, 95% CI 1.39-5.41, P=0.004), a reduced peak atrial systolic mitral annular velocity (HR=0.845, 95% CI 0.72-0.99, P=0.037), and an advanced age (HR=1.04, 95% CI 1.01-1.07, P=0.009) were independently related to the development of nonvalvular AF. Therefore, reduced A', which is parameter of LA contractile function, might be an important predictor for the development of nonvalvular AF.

Comorbidities frequency in Takotsubo syndrome: an international collaborative systematic review including 1109 patients.

BACKGROUND: To identify predisposing factors that can result in the onset of takotsubo syndrome, we performed an international, collaborative systematic review focusing on clinical characteristics and comorbidities of patients with takotsubo syndrome. METHODS: We searched and reviewed cited references up to August 2013 to identify relevant studies. Corresponding authors of selected studies were contacted and asked to provide additional quantitative details. Data from each study were extracted by 2 independent reviewers. The cumulative prevalence of presenting features and comorbidities was assessed. Nineteen studies whose authors sent the requested information were included in the systematic review, with a total of 1109 patients (951 women; mean age, 59-76 years). Evaluation of risk factors showed that obesity was present in 17% of patients (range, 2%-48%), hypertension in 54% (range, 27%-83%), dyslipidemia in 32% (range, 7%-59%), diabetes in 17% (range, 4%-34%), and smoking in 22% (range, 6%-49%). Emotional stressors preceded takotsubo syndrome in 39% of patients and physical stressors in 35%. The most common comorbidities were psychological disorders (24%; range, 0-49%), pulmonary diseases (15%; range, 0-22%), and malignancies (10%; range, 4%-29%). Other common associated disorders were neurologic diseases (7%; range, 0-22%), chronic kidney disease (7%; range, 2%-27%), and thyroid diseases (6%; range, 0-37%). CONCLUSIONS: Patients with takotsubo syndrome have a relevant prevalence of cardiovascular risk factors and associated comorbidities. Such of associations needs to be evaluated in further studies.

The QT prolongation and clinical features in patients with takotsubo cardiomyopathy: Experiences of two tertiary cardiovascular centers.

OBJECTIVE: There are few data regarding clinical characteristics, laboratory parameters, electrocardiographic and echocardiographic findings in takotsubo cardiomyopathy patients presenting with QT prolongation. Aim of this study was to investigate the differences in these parameters between takotsubo cardiomyopathy patients presenting with and those without QT prolongation. METHODS: We performed an observational retrospective study. One hundred five patients were enrolled from the takotsubo cardiomyopathy registry database and divided according to the presence of QT prolongation. Fifty patients presented with QT prolongation (QT group) and 55 did not (NQT group). Statistical analysis was performed using Student's t-test or Mann-Whitney U test and chi-square test. RESULTS: QT group had higher prevalence of dyspnea (66 versus 40%, p=0.008) and cardiogenic shock (46 versus 24%, p=0.016) than NQT group. QT group had higher prevalence of ST elevation (82 versus 64%, p=0.036), T wave inversion (96 versus 58%, p=0.001), ventricular tachycardia/ventricular fibrillation (8 versus 0%, p=0.032) and classic ballooning pattern (92 versus 66%, p=0.003), but lower left ventricular ejection fraction (mean, 39.2 versus 43.5%, p=0.005). In addition, QT group had significant higher hs-C-reactive protein (median, 6.6 versus 1.7 mg/L, p=0.023), creatine kinase-MB (median, 18.6 versus 7.6 ng/mL, p=0.032) and NT-pro-brain natriuretic peptide levels (median, 3637 versus 2145 pg/mL, p=0.044). QT group required more frequent use of inotropics (46 versus 24%, p=0.016) and diuretics (58 versus 38%, p=0.042) than NQT group. CONCLUSION: The clinical features of takotsubo cardiomyopathy are different according to the presence of QT prolongation. The QT group was lesser likely to have preserved cardiovascular reserve and more likely to require hemodynamic support than the NQT group despite the entire prognosis of takotsubo cardiomyopathy is excellent regardless of QT prolongation.

A rare case of partial absence of the right ventricular musculature in asymptomatic adult man: partial Uhl's anomaly.

Uhl's anomaly is a myocardial disorder of unknown cause that is characterized by complete or partial absence of the myocardium of the right ventricle. The disease may represent a cause of right heart dilatation and failure. Although most cases of Uhl's anomaly end fatally in infancy or childhood, an initial presentation during adulthood has been reported in rare cases. We report a very rare case of partial absence of the right ventricular musculature or partial Uhl's anomaly that incidentally found in asymptomatic adult man.

Impact of propofol anesthesia induction on cardiac function in low-risk patients as measured by intraoperative Doppler tissue imaging.

BACKGROUND: Despite a few experimental studies showing a dose-dependent myocardial depressive effect of propofol anesthesia induction, few clinical data are available to determine its precise impact on myocardial function, probably because of its brevity and a lack of appropriate evaluation tools. The purpose of this study was to examine the impact of propofol-based anesthesia induction on left ventricular (LV) function using Doppler tissue and speckle-tracking imaging. METHODS: In 19 low-risk patients with normal LV systolic and diastolic function undergoing noncardiac surgery (all women; mean age, 42 years), propofol bolus (2.0 mg/kg) was administered intravenously for anesthesia induction. LV ejection fraction, global peak systolic longitudinal strain, and tissue Doppler-derived indices of mitral annular velocity during systole (S'), early diastole (e'), and atrial contraction (a') were determined by intraoperative transthoracic echocardiography before and 1, 3, and 5 min after propofol bolus (T0, T1, T2, and T3, respectively). RESULTS: The following at T1, T2, and T3 were significantly less in magnitude than at T0: septal S' (5.61, 5.61, and 5.51 vs 7.60 cm/sec, P < .001), lateral S' (5.75, 5.89, and 5.94 vs 8.12 cm/sec, P < .001), septal e' (10.10, 10.26, and 10.07 vs 11.4 cm/sec, P < .01), septal a' (6.70, 6.21, and 6.13 vs 8.58 cm/sec, P < .01), lateral a' (7.29, 6.81, and 6.85 vs 9.01 cm/sec, P < .01), and longitudinal strain (-19.36%, -19.71%, and -19.61% vs -22.28%, P < .001). LV ejection fraction was not significantly changed (P = .361). CONCLUSIONS: Propofol anesthesia induction diminished LV and atrial contraction in low-risk patients with prior normal LV function. Further studies are needed to understand the clinical implications, particularly for higher risk populations.