The effect of cardiac rehabilitation on blood pressure, and on left atrial and ventricular functions in hypertensive patients.

PURPOSE: Hypertension is associated with left ventricular (LV) hypertrophy, impaired LV relaxation, and left atrial (LA) enlargement. Cardiac rehabilitation (CR) improves clinical outcomes in a broad spectrum of cardiac disease. The aim of our study was to determine the effect of CR on blood pressure (BP), and on LA and LV functions in hypertensive patients. METHODS: Thirty consecutive hypertensive patients who would undergo CR program, and 38 hypertensive patients who refused to undergo CR program were included. All patients underwent ambulatory BP monitoring and transthoracic echocardiography, which were repeated after completion of the CR program, or 12 weeks later in the control group. LA and LV functions were assessed by both speckle tracking and 3-dimensional echocardiography. N-terminal pro-brain natriuretic peptide (NT-proBNP) levels were assessed before and after CR. RESULTS: Although initial ambulatory BP values and NT-proBNP levels were similar between the groups, daily, day-time, and night-time BP and NT-proBNP were significantly lower in the CR group after rehabilitation. LA reservoir strain and LV global longitudinal strain of the CR group significantly increased after CR while no significant increase was observed in controls. CONCLUSION: CR improves LA and LV strain while lowering BP and should be encouraged in routine management of hypertensive patients.

Short and Long Term Mortality Predictors in Octogenarians with Acute Coronary Syndromes.

PURPOSE: Octogenarians with acute coronary syndromes have higher mortality and morbidity due to higher prevalence of comorbidities and frailty. The aim of this study was to explore the predictors of short and long term mortality in octogenarians with ACS. METHODS: Ninety-eight consecutive octogenarians presenting with acute coronary syndrome (mean age:84±3 years, 56 male) were included. All patients underwent coronary angiography and were given optimal medical treatment. The primary end point was cardiovascular mortality in hospital and at one year. RESULTS: Fifteen patients died during hospitalization and 20 patients died after discharge within the first year. ST-segment-elevation myocardial infarction and hypotension were significantly more prevalent in the in-hospital mortality group while atrial fibrillation and hyponatremia were more prevalent in the long-term mortality group. All deceased patients had significantly lower left ventricular ejection fraction and glomerular filtration rate. Cox analysis revealed ST-segment-elevation myocardial infarction, hypotension and left ventricular ejection fraction as independent predictors of in-hospital mortality while hyponatremia, atrial fibrillation and renal dysfunction as independent predictors of long term mortality. CONCLUSION: It would be reasonable to pay further attention to octogenarians with acute coronary syndrome if they are presenting with ST-segment-elevation myocardial infarction, and have hypotension, impaired left ventricular function, hyponatremia, atrial fibrillation or renal dysfunction, which are associated with increased mortality.

Effect of acute sleep deprivation on left atrial mechanics assessed by three-dimensional echocardiography.

BACKGROUND: Although sleep deprivation (SD) affects cardiovascular system in many ways, physio-pathological changes in cardiac chamber volume and function have not been described well. The aim of the present study was to investigate the effect of SD on left atrial (LA) and ventricular function with three-dimensional (3D) echocardiography. METHODS: Thirty-two healthy individuals (12 females, mean age 33.25 ± 8.18) were evaluated. Echocardiographic examination was performed once after a night of regular sleep and a night of sleep debt. Beside conventional parameters, 3D phasic volumes and function were measured using a commercially available 3D echocardiography system and offline analysis software. RESULTS: Mean sleep duration of the study group was 8.15 ± 2.19 h in the day of regular sleep and 2.56 ± 2.25 h in the day of sleep deprivation. There was a significant prolongation in deceleration time (180.83 ± 15.34 vs. 166.44 ± 26.12; p = 0.044) and increase in E/e' (6.95 ± 1.26 vs. 6.38 ± 0.85; p = 0.005). Among 3D measurements, the difference in left ventricular ejection fraction (EF), LA EF, LA reservoir function and LA active EF were not significant. Mean LA passive EF of the individuals was significantly lower after night shift (24.10 ± 7.66 vs. 31.49 ± 7.75; p = 0.006). CONCLUSION: Acute SD is associated with a reduction in LA passive emptying function in healthy adults. 3D-derived indices were sufficient to show subclinical diastolic dysfunction according to impairment in passive phase of LA ejection. Prospective large-scale studies are needed to enlighten this issue.

Postoperative Atrial Fibrillation after Coronary Artery Bypass Grafting Surgery: A Two-dimensional Speckle Tracking Echocardiography Study.

BACKGROUND: Postoperative atrial fibrillation (POAF) may develop after coronary artery bypass grafting (CABG). The aim of the study was to explore the relationship between preoperative left atrial function and atrial fibrosis and POAF after CABG. METHODS: Forty-eight consecutive patients undergoing CABG (mean age: 61.6±8.9 years, 39 male) were included. All patients were in sinus rhythm during surgery. Patients were followed by continuous electrocardiography monitoring and daily electrocardiogram. Left atrial function was assessed by both conventional and speckle tracking echocardiography. Atrial fibrosis was determined by samples taken from right atrium. RESULTS: Postoperative atrial fibrillation was detected in 13 patients. Female sex and number of bypassed vessels were significantly higher and cardiopulmonary bypass time was significantly longer in patients with POAF. Left atrial volume index (LAVI) was significantly higher while left atrial reservoir strain was significantly lower in POAF patients. The percentage of patients with severe fibrosis was higher in the POAF group. Regression analysis revealed fibrosis and LAVI as independent predictors of POAF. Left atrial volume index ≥36mL/m(2) predicted POAF with a sensitivity of 84.6% and specificity of 68.6% in our cohort. CONCLUSION: Patients who developed POAF after CABG had more fibrosis, increased LAVI and lower left atrial reservoir strain. Preoperative echocardiography might be helpful in discriminating these patients.

A Case of Iatrogenic Chordal Rupture after Transcatheter Aortic Valve Implantation Procedure Requiring a Second Valve.

Transcatheter aortic valve implantation (TAVI) has emerged as a therapeutic option for high-risk aortic stenosis. Malposition of the prosthesis and severe residual aortic regurgitation are known complications of the procedure, which might require a second valve implantation. Although the implantation of a second valve seems to be an effective method, very few data are available describing this technique. Herein is reported a case of iatrogenic chordal rupture in a TAVI procedure which required a second valve implantation due to dislodgment of the first prosthesis.

Effect of acute sleep deprivation on heart rate recovery in healthy young adults.

BACKGROUND: Sleep deprivation (SD) is known to be associated with increased incidence of adverse cardiovascular events, but underlying pathophysiological mechanism has not been clearly demonstrated. Autonomic nervous system plays an important role in the regulation of cardiovascular function, and impairment in this system is associated with increased cardiovascular mortality. The aim of the current study was to investigate the effect of acute SD on autonomic regulation of cardiac function by determining heart rate recovery (HRR). METHODS: Twenty-one healthy security officers and nine nurses (mean age 33.25 ± 8.18) were evaluated. Treadmill exercise test was applied once after a night with regular sleep and once after a night shift in hospital. The HRR was calculated as the reduction in heart rate from peak exercise to the 30th second (HRR30), 1st minute (HRR1), 2nd minute (HRR2), 3rd minute (HRR3), and 5th minute (HRR5). The change in blood pressure (BP) measurements was also determined. RESULTS: Exercise capacity of individuals with SD was significantly lower (10.96 ± 1.01 vs. 11.71 ± 1.30 metabolic equivalent task (MET)s; p = 0.002), and peak systolic BP was significantly higher (173.8 ± 16.3 vs. 166.2 ± 9.9; p = 0.019). There was a signicant difference in HRR30 (12.74 ± 6.19 vs. 17.66 ± 5.46; p = 0.003) and HRR1 (31 ± 6.49 vs. 36.10 ± 7.78; p = 0.004). The ratio of these indices to peak HR was also significantly lower with SD (HRR%30 8.04 ± 4.26 vs. 10.19 ± 3.21; p = 0.025 and HRR%1: 18.66 ± 4.43 vs. 20.98 ± 4.72; p = 0.013). The difference in other indices of HRR was not significant. CONCLUSION: Our findings suggest that SD blunts cardiovascular autonomic response, and consequences of this relation might be more pronounced in subjects who are exposed to sleeplessness regularly or in subjects with baseline cardiovascular disease.

Evaluation of cardiac function by two-dimensional speckle tracking echocardiography in ulcerative colitis patients.

PURPOSE: Although ulcerative colitis (UC) shows obvious similarities with other autoimmune diseases, cardiac consequences have not adequately introduced. The aim of our study was to evaluate left ventricular (LV) function in UC patients by using novel echocardiographic parameters. RESULTS: Forty-five UC patients (mean age 37, 18 female) and 90 age- and sex-matched healthy volunteers (mean age 40, 38 female) included in the study. The mean disease activity score according to partial Mayo score was 2.16 ± 2.13. Mean global longitudinal strain (GLS) and global longitudinal strain rate (GLSR) measurements were significantly lower (-21.16 ± 2.71 vs. -23.36 ± 3.34; p < 0.001 and -1.33 ± 0.24 vs. -1.43 ± 0.24; p = 0.037, respectively), whereas global circumferential (-22.67 ± 3.66 vs. -23.37 ± 3.99; p = 0.140) and global radial strain (43.07 ± 8.58 vs. 44.12 ± 9.32; p = 0.545) measurements of the LV were similar in patients with UC compared with controls. The correlation coefficient (r) between GLS and partial Mayo score was -0.578 (p < 0.001). CONCLUSION: Our study suggests that systolic cardiac deformation values are impaired in UC patients. Reduced GLS and GLSR might be an early indicator of cardiac involvement in this population.

Left ventricular and atrial functions in hypertrophic cardiomyopathy patients with very high LVOT gradient: a speckle tracking echocardiographic study.

BACKGROUND: Determination of myocardial deformation (strain) by two-dimensional (2D) speckle tracking echocardiography (STE) is a new method for evaluating left ventricular (LV) regional function in patients with hypertrophic cardiomyopathy (HCM). The aim of this study was to assess LV and left atrial (LA) functions with 2DSTE in HCM patients and to investigate relation between strain analysis and LV outflow tract (LVOT) gradient. METHODS: Forty consecutive HCM patients (26 male, mean age: 47.7 ± 15.2 years), and 40 healthy volunteers (22 male, mean age: 46.6 ± 11.2 years) were included in the study. All subjects underwent a transthoracic echocardiography for evaluation of LV and LA functions with 2DSTE. The HCM patients were divided into 2 groups according to the presence of resting LVOT gradient >100 mmHg. RESULTS: Left ventricular global longitudinal strain (GLS), global radial strain (GRS), and global circumferential strain (GCS) were significantly lower in patients with HCM compared with controls (-20.3 ± 3.6% vs. -24.1 ± 3.4% P < 0.001, 38.1 ± 12.8% vs. 44.8 ± 10.2% P = 0.012, and -22.0 ± 4.4% vs. -23.9 ± 4.0% P = 0.045, respectively). Although basal and apical rotation were similar between the groups, mid-rotation was significantly clockwise in HCM patients (-1.53 ± 2.06° vs. 0.05 ± 1.7° P < 0.001). Both LA reservoir functions and LA conduit functions were significantly lower in HCM patients (21.6 ± 9.1% vs. 39.4 ± 10.6% P < 0.001, and 10.5 ± 4.3% vs. 15.7 ± 5.3%, P < 0.001). Fifteen patients had a resting LVOT gradient of >100 mmHg and they had significantly decreased GLS, twist and untwist compared to the HCM patients with lower resting LVOT gradient (-18.7 ± 2.3% vs. -21.2 ± 3.9% P = 0.016, 19.4 ± 4.3° vs. 23.5 ± 7.4° P = 0.038 and -94.0 ± 29.1°/sec vs. -134.9 ± 55.8°/sec, 0.005, respectively). Although basal and apical rotation were similar between the 2 groups, mid-rotation was significantly clockwise in HCM patients with higher LVOT gradient (-2.52 ± 1.76° vs. -0.96 ± 2.03°, P = 0.018). Correlation analysis revealed that LVOT peak velocity was associated with GLS (r = -0.358, P = 0.023), LV mid-rotation (r = -0.366, P = 0.024), and LV untwist (r = -0.401, P = 0.013). CONCLUSIONS: Left ventricular and LA functions are impaired in patients with HCM. 2DSTE is useful in determining patients with impaired myocardial mechanics. High LVOT gradient may be one of the responsible factors that trigger deterioration of LV longitudinal strain and twist mechanics in patients with HCM. Further studies are required to clarify the preliminary results of this study.

Regional myocardial dysfunction assessed by two-dimensional speckle tracking echocardiography in systemic sclerosis patients with fragmented QRS complexes.

BACKGROUND: The aim of the study was to explore the relation between regional myocardial dysfunction and fragmented QRS (fQRS) complexes in systemic sclerosis (SSc). METHODS: Fifty-three SSc patients and 26 controls were included. All subjects underwent speckle tracking echocardiography for evaluation of left ventricular (LV) function and ECG to check for fQRS complexes. RESULTS: SSc patients had significantly lower LV global longitudinal, radial and circumferential strain and twist compared to controls. Thirteen SSc patients had fQRS (DII, DIII, aVF leads in eleven patients and V1 to V5 leads in two patients) and they had significantly lower global longitudinal and circumferencial strain compared to SSc patients with normal QRS. The SSc patients with fQRS in DII, DIII, and aVF leads had impaired longitudinal strain and delay in time to peak longitudinal strain in inferior LV segments compared to those with normal QRS. CONCLUSION: fQRS is associated with lower strain measures in SSc patients indicating impairment in LV function.

No harmful effect of dialysis-induced hypotension on the myocardium in patients who have normal ejection fraction and a negative exercise test.

BACKGROUND: We investigated the effects of dialysis-induced hypotension (DIH) on the myocardium of patients who have a normal ejection fraction and normal treadmill stress tests. METHODS: This study included 26 end-stage renal disease (ESRD) patients with DIH, 30 ESRD patients without DIH (non-DIH), and 30 control subjects. Mitral-myocardial systolic velocity (MSV), the mitral E'/A' ratio, the left ventricle filling pressure index (E/E' ratio), tricuspid-MSV, and the tricuspid E'/A' ratio were calculated. RESULTS: Biventricular systolic and diastolic functions were impaired in dialysis patients. The mitral and tricuspid MSV were similar between DIH and non-DIH patients (8.03 ± 0.90 cm/s vs. 8.31 ± 1.68 cm/s, p = 0.896, and 13.27 ± 2.97 cm/s vs. 13.15 ± 2.37 cm/s, p = 0.980). Mitral and tricuspid E'/A' were similar between DIH and non-DIH patients. (1.30 ± 0.53 vs. 1.16 ± 0.56, p = 0.695, and 0.70 ± 0.24 vs. 0.68 ± 0.33, p = 0.976). Likewise, the E/E' ratio was similar between DIH and non-DIH patients (8.20 ± 2.83 vs. 8.28 ± 2.53, p = 0.990). CONCLUSION: Although biventricular systolic and diastolic function is impaired in dialysis patients compared to controls, DIH episodes did not have an adverse effect on the myocardial functions.

Role of left ventricular dyssynchrony in predicting remodeling after ST elevation myocardial infarction.

BACKGROUND: Intraventricular dyssynchrony is associated with worsening systolic function, adverse remodeling, and clinical events. The aim of this study is to investigate whether intraventricular dyssynchrony assessed by tissue Doppler imaging (TDI) can predict left ventricular (LV) remodeling after first ST segment elevation myocardial infarction (STEMI) treated successfully with primary percutaneous coronary intervention (pPCI). METHODS: Fifty-two consecutive patients who presented with first acute STEMI were included in the study. All patients underwent successful pPCI. Standard echocardiography was performed within 48 hours of admission. LV dyssynchrony was assessed by color-coded TDI. Dyssynchrony (Ts-diff) was calculated by maximal temporal difference between time to peak systolic velocities (Ts) of six basal segments. Echocardiographic examination was repeated after 6 months to reassess LV volumes. LV remodeling was defined as >15% increase in LV end-systolic volume index (LVESVI) after 6 months. RESULTS: Eleven patients (23%) developed LV remodeling. Baseline dyssynchrony was found to be correlated with percent change in LVESVI and LV end-diastolic volume index (LVEDVI) after 6 months. Ts-diff, creatine kinase-MB and mitral inflow E-wave deceleration time (DT) were the independent predictors of remodeling after STEMI in multivariate logistic regression analysis. Receiver operating characteristic curve analysis showed that Ts-diff >56 msec had 72.7% sensitivity and 83.8% specificity for predicting remodeling. CONCLUSIONS: LV dyssynchrony is a strong predictor of LV remodeling after acute myocardial infarction (AMI). It could be useful in risk stratification of patients after AMI.

Attenuated cardiovascular response to sympathetic system activation during exercise in patients with dialysis-induced hypotension.

BACKGROUND: We wished to investigate potential causes of dialysis-induced hypotension (DIH), including the attenuated cardiovascular response to sympathetic system activation during exercise and myocardial dysfunction. METHODS: This study included 26 end-stage renal disease (ESRD) patients with DIH, 30 ESRD patients without DIH (Non-DIH), and 30 control subjects. Each patient was evaluated with echocardiography and a symptom-limited treadmill stress test. The chronotropic index (CRI), heart rate recovery (HRR), systolic blood pressure response to exercise (SBP response), and tissue Doppler systolic myocardial velocities were calculated. RESULTS: The HRR and velocities were reduced in dialysis patients compared to controls; however, they were similar in patients with and without DIH. Patients with DIH had the lowest CRI compared to the Non-DIH group (0.62 ± 0.15 vs. 0.73 ± 0.17, p = 0.020) and controls (0.62 ± 0.15 vs. 0.86 ± 0.11, p < 0.001). Similarly, patients with DIH had the lowest SBP response values compared to the Non-DIH (34.88 ± 15.01 vs. 55.67 ± 25.42, p = 0.002) and controls (34.88 ± 15.01 vs. 59.70 ± 23.04, p < 0.001). CONCLUSION: Patients with DIH have inadequate sympathetic activity of the cardiovascular system during exercise and impaired left ventricular systolic function. Both factors could contribute to the development of hypotension during hemodialysis.

The predictive value of flow-mediated dilation and carotid artery intima-media thickness for occult coronary artery disease.

BACKGROUND: Multidetector row computed tomography (MDCT) is an attractive noninvasive alternative to assess overall coronary artery disease (CAD) burden and may reveal coronary plaques, which may be underestimated by conventional coronary angiography. The aim of this study was to determine whether brachial artery flow-mediated dilation (FMD) and carotid artery intima-media thickness (CIMT) might accurately predict patients with occult coronary plaques whose conventional coronary angiographies revealed normal coronary arteries (NCA). METHODS: Thirty-five patients with angiographically NCA were consecutively recruited into the study. They underwent MDCT and were divided into NCA group (18 patients; 8 male; 47 ± 9 years) and occult CAD group (17 patients; 11 male; 50 ± 10 years) according to presence of coronary plaque. Nineteen consecutive patients with evident CAD (16 male; 54 ± 7 years) and 19 healthy subjects (10 male; 50 ± 6 years) were included as control groups. FMD and CIMT were measured by brachial and carotid artery ultrasonography. RESULTS: Occult CAD group had significantly lower FMD and insignificantly higher CIMT than NCA group whereas they had significantly higher FMD and insignificantly lower CIMT than evident CAD group. NCA group had significantly lower CIMT than evident CAD group. Receiver operating characteristic curve analysis demonstrated FMD < 8% (sensitivity: 94.4%; specificity: 73.0%; PPV: 77.3%; NPV: 93.1%) and CIMT ≥ 0.65 cm (sensitivity: 72.2%; specificity: 62.2%; PPV: 65.0%; NPV: 69.7%) could predict patients with CAD. FMD and CIMT were independent predictors of CAD (P < 0.001; OR: 45.630; 95%CI: 5.38-386.983 and P = 0.015; OR: 14.226; 95%CI: 1.666-121.467, respectively). CONCLUSION: FMD and CIMT might predict patients with occult CAD and be helpful in selecting patients for MDCT.

Fragmented QRS complexes are associated with cardiac fibrosis and significant intraventricular systolic dyssynchrony in nonischemic dilated cardiomyopathy patients with a narrow QRS interval.

BACKGROUND: Myocardial scar causes heterogeneous ventricular activation, which results in fragmentation of QRS complexes on ECG. Myocardial fibrosis in patients with nonischemic cardiomyopathy (NDCM) can be identified as late gadolinium enhancement (LGE) areas on cardiac magnetic resonance (CMR) studies. We investigated the association of fragmented QRS (fQRS) complexes with systolic dyssynchrony and myocardial fibrosis in patients with NDCM. METHODS: Twenty patients with NDCM and sinus rhythm who had fQRS complexes were evaluated with CMR. The association of fQRS complexes with LGE and systolic dyssynchrony was investigated. RESULTS: Nineteen patients had significant systolic dyssynchrony with echocardiography. Among 19 patients with significant dyssynchrony, 14 (74%) patients had fQRS complexes in the most delayed contracting segment or one of the dyssynchronous segments, whereas five patients (26%) had fQRS complexes in a lead which is discordant with the dyssynchronous segment on echocardiography. Seventeen patients had LGE in their CMR. Among the 17 patients with LGE; 13 patients (76%) had fQRS complexes concordant with LGE present segments. CONCLUSION: Fragmentation of QRS complexes on ECG is associated with intraventricular systolic dyssynchrony and subendocardial fibrosis in NDCM patients with a narrow QRS interval and sinus rhythm.

The role of isovolumic acceleration in predicting subclinical right and left ventricular systolic dysfunction in hypertensive obese patients.

OBJECTIVES: Isovolumic acceleration assessed by tissue Doppler imaging has been proposed as a preload-independent indicator of left ventricular contractility. We investigated the utility of isovolumic acceleration in the prediction of preclinical right and left ventricular systolic dysfunction in hypertensive and obese subjects. STUDY DESIGN: Seventy-eight obese subjects (BMI >30 kg/m2; 57 women, 21 men; mean age 51±8 years) were prospectively enrolled. Fifty patients (64.1%) had hypertension and 33 patients (42.3%) had diabetes mellitus. All the subjects were assessed by conventional and tissue Doppler echocardiography. Myocardial velocities of the left ventricular septal and lateral mitral annulus and lateral tricuspid annulus were determined. Isovolumic contraction wave was defined as the preceding wave of the systolic wave that began before the peak of the R wave on the electrocardiogram. Myocardial isovolumic acceleration was measured by dividing the peak velocity by the time passed from the onset of the wave (zero-crossing) during isovolumic contraction to the peak velocity of the wave. RESULTS: Waist circumference was in positive correlation with left ventricular end-systolic (r=0.22, p=0.047) and end-diastolic (r=0.384, p=0.001) diameters, and in negative correlation with the peak systolic velocity of the tricuspid annulus (r=-0.311, p=0.006). Although hypertensive and normotensive (n=28) obese subjects had similar myocardial velocities, lateral tricuspid annular isovolumic acceleration (p=0.027), septal isovolumic acceleration (p=0.026), and septal isovolumic contraction myocardial velocity (p=0.018) were significantly lower in hypertensive patients. CONCLUSION: Isovolumic acceleration and isovolumic contraction myocardial velocity analysis may be useful in the diagnosis of subclinical left and right ventricular dysfunction in hypertensive obese patients.

Predictors of Concomitant Coronary Artery Disease and Major Cardiovascular Events in Patients with Acute Ischemic Stroke.

BACKGROUND: Coronary artery disease (CAD) and ischemic stroke share the same risk factors. OBJECTIVE: The aim of the study was to explore the prevalence and predictors of concomitant CAD in acute ischemic stroke patients. METHODS: One hundred and five patients (64.3 ± 15.0 years, 61 male) presenting with acute ischemic stroke documented by neuroimaging were consecutively included. All patients were carefully evaluated to determine their cardiovascular disease risk scores. The patients who had been previously shown to have ≥50% stenosis in at least one of the major coronary arteries by coronary angiography were grouped as CAD patients. RESULTS: Of the 105 stroke patients, 27 patients had documented concomitant CAD. The stroke patients with CAD had higher cardiovascular risk scores and troponin I levels and carotid plaques were more prevalent. ROC analysis determined cut-off values as ≥22% for Framingham Heart Study Risk Score, ≥0.05 ng/mL for Troponin I, and ≥0.80 mm for carotid artery intima-media thickness to predict concomitant CAD. During 6 months of follow-up, among the 78 stroke patients without documented CAD, 16 patients had experienced major cardiovascular events including myocardial infarction, recurrent stroke, or cardiovascular death. These patients had higher Framingham Heart Study Risk Score and high-sensitive C reactive protein levels. CONCLUSION: Our study suggests stroke patients with higher Framingham Heart Study Risk Score and troponin I levels and carotid plaques be further investigated for the presence of concomitant CAD.

The importance of papillary muscle dyssynchrony in predicting the severity of functional mitral regurgitation in patients with non-ischaemic dilated cardiomyopathy: a two-dimensional speckle-tracking echocardiography study.

AIMS: In our study, we investigated the impact of papillary muscle systolic dyssynchrony (DYS-PAP) and the configuration of mitral leaflets in the prediction of significant functional mitral regurgitation (MR) with two-dimensional (2D) speckle-tracking strain analysis in non-ischaemic dilated cardiomyopathy (DCM) patients with sinus rhythm. METHODS: Thirty-six non-ischaemic DCM patients (left ventricular ejection fraction <40%) with sinus rhythm were recruited. The quantification of functional MR was performed using the proximal isovelocity surface area method. The configuration of mitral leaflets [mitral annulus, coaptation height (CH), and tethering distances for papillary muscles] was evaluated in the parasternal long-axis and apical four-chamber views. The assessment of DYS-PAP was performed by applying 2D speckle-tracking imaging to the apical four-chamber view for anterolateral papillary muscle and to the apical long-axis view for posteromedial papillary muscle. RESULTS: Fifteen (41.6%) patients had mild MR and 21 (58.3%) patients had moderate or moderate-to-severe MR. Patients with higher levels of MR had larger mitral annulus size (P = 0.02), tethering-AL (P = 0.04), higher MR volume (P < 0.0001), effective regurgitant orifice area (P < 0.0001), and DYS-PAP (P < 0.0001) values, but lower CH (P = 0.001), global longitudinal (P = 0.005), radial (P = 0.03), and circumferential strain (P = 0.01) than those with mild MR. Receiver operating characteristic analysis was performed to assess the utility of DYS-PAP to predict moderate or moderate-to-severe functional MR. A DYS-PAP value >30 ms predicted moderate-to-severe MR with 85% sensitivity and 87% specificity [area under the curve: 0.897, 95% confidence interval (CI): 0.781-0.999, P < 0.0001]. Logistic regression analysis revealed that DYS-PAP (odds ratio: 3.2, 95% CI: 1.22-47.7, P = 0.037) was the only independent predictor of moderate or moderate-to-severe functional MR. CONCLUSION: DYS-PAP is correlated with functional MR in non-ischaemic DCM patients with sinus rhythm. A DYS-PAP cut-off value of 30 ms is a useful tool to identify patients with moderate-to-severe functional MR.

Impact of systemic sclerosis on electromechanical characteristics of the heart.

Primary myocardial involvement is common in systemic sclerosis (SSc). We evaluated the atrial and ventricular electromechanical characteristics by using tissue Doppler echocardiography in SSc patients with subclinical cardiac involvement. Twenty-seven consecutive patients (24 women; mean age +/- SD 49.9 +/- 11.3 years) presenting with SSc without pulmonary arterial hypertension or symptomatic heart failure were prospectively studied. Electrocardiographic P-wave dispersion (Pd), corrected QT dispersion (QTcd), interatrial, intra-atrial, interventricular, and intraventricular electromechanical delays were analyzed by tissue Doppler echocardiography, and brain natriuretic peptide levels were measured. Results were compared with 17 healthy controls. There was no difference in conventional and tissue Doppler parameters between the two groups. However, patients with SSc had higher mean Pd (mean [+/-SD] 46.8 +/- 15 and 36 +/- 8 ms, respectively, P = 0.004) and mean interatrial electromechanical delay time (DT) (mean [+/-SD] 32.2 +/- 9.2 and 24.7 +/- 9.7 ms, respectively, P = 0.01), mean electromechanical delay time for all segments (Mean Ts) (mean [+/-SD] 148.8 +/- 18.8 and 129.3 +/- 13.4 ms, respectively, P < 0.001), and intraventricular DT (mean [+/-SD] 27.6 +/- 12.5 and 16.2 +/- 7.2 ms, respectively, P < 0.001). Intraventricular DT was the only parameter that correlated significantly with the Mean Ts. Brain natriuretic peptide levels were within normal limits in both groups; however, they were higher in patients with SSc than in controls (mean [+/-SD] 37.5 +/- 28.5 and 23.1 +/- 16.0 pg/ml, respectively, P = 0.03). The evaluation of atrial and ventricular electromechanical parameters by using tissue Doppler echocardiography seems to be useful for detection of subclinical cardiac involvement in SSc patients with normal conventional echocardiographic findings.

The effect of cardiac fibrosis on left ventricular remodeling, diastolic function, and N-terminal pro-B-type natriuretic peptide levels in patients with nonischemic dilated cardiomyopathy.

BACKGROUND: Cardiac fibrosis is common and associated with poor prognosis in patients with heart failure. We investigated the effect of cardiac fibrosis on the left ventricular (LV) diastolic function, functional capacity, LV remodeling, and biochemical parameters in patients with nonischemic dilated cardiomyopathy (NIDC). In addition, we investigated the biochemical and echocardiographic predictors of cardiac fibrosis in this group. METHODS AND RESULTS: Forty patients with NIDC were enrolled. Cardiac fibrosis was evaluated according to the presence of late gadolinium enhancement (LGE) on cardiac magnetic resonance (CMR) imaging. Nineteen patients had cardiac fibrosis (Group I) and 21 patients did not have cardiac fibrosis (Group II). LV systolic and diastolic parameters were assessed with conventional and tissue Doppler echocardiography. N-terminal pro-B-type natriuretic peptide (NT-pro BNP) levels of each patient were recorded. Patients with cardiac fibrosis had impaired diastolic function, higher functional class and NT-pro BNP levels, and significant LV remodeling than the patients without cardiac fibrosis. A correlation analysis revealed that the cardiac fibrosis severity was associated with functional class, cardiac chamber sizes, NT-pro BNP levels, diastolic parameters such as E/Se. A linear regression analysis demonstrated that NT-pro BNP and E/Se were the independent predictors of cardiac fibrosis. CONCLUSION: Cardiac fibrosis correlates with impaired LV diastolic function and functional capacity, elevated NT-proBNP levels, and adverse cardiac remodeling in patients with NIDC. Therefore, the assessment of cardiac fibrosis can be useful in the management of these patients.

Grading functional mitral regurgitation by tissue Doppler-derived isovolumic acceleration parameters in patients with nonischemic dilated cardiomyopathy.

Functional mitral regurgitation (FMR) is relatively common in heart failure and it is associated with adverse prognosis. The severity of FMR is usually assessed by echocardiography. Tissue Doppler echocardiography is used to acquire signals to determine the myocardial systolic functional parameters, including systolic ejection velocity and the systolic isovolumic acceleration (IVAs) rate. We investigated the utility of isovolumic acceleration parameters to grade the severity of FMR in nonischemic dilated cardiomyopathy (DC) patients. We analyzed the left ventricular systolic IVA rate, systolic isovolumic contraction (IVCs) velocity, and IVA duration (IVAd) values in 73 patients with DC. Patients were subgrouped according to FMR grade (Group I = mitral regurgitation mild and moderate; Group II = mitral regurgitation severe). IVAs was similar between two groups; however IVCs and IVAd were significantly higher in Group II than Group I. The IVCs cutoff value to predict severe FMR was 1.2 cm/sec (sensitivity 75% and specificity 70%). The IVAd cutoff value to predict severe FMR was 33 ms (sensitivity 77% and specificity 77%). Patients with IVCs ≥ 1.2 cm/sec and IVAd ≥ 33 ms had significantly higher FMR volume than the other subgroups. IVCs and IVAd values are useful to determine FMR severity in patients with DC.