Observer variation in the echocardiographic measurement of maximum atrial septal excursion: a comparison of M-mode with two-dimensional or transesophageal echocardiography.

BACKGROUND: Atrial septal aneurysm is typically diagnosed by transthoracic two-dimensional or transesophageal echocardiography (2DE or TEE). Such techniques are highly dependent on visual inspection which predisposes to observer variation. This study compares inter- and intraobserver variations in the measurement of maximum atrial septal excursion (MASE) obtained using transthoracic M-mode echocardiography (MME) with that obtained using 2DE or TEE. METHODS: Consecutive patients with highly mobile atrial septal motion by visual inspection during 2DE or TEE were studied. MASE was estimated visually on 2DE or TEE. MME tracings were obtained with the cursor bisecting the parabola formed by the atrial septum at its maximum deviation from the midline. Electronic calipers were used to measure MASE for all echocardiographic techniques. Two observers provided two measurements each. Observer variation was determined by assessing standard deviation and confidence intervals of inter- and intraobserver differences. RESULTS: Interobserver analysis showed standard deviations of 0.077 cm (95% CI 0.065-0.094) for MME and 0.280 cm (95% CI 0.242-0.334) for 2DE or TEE. Intraobserver analysis showed standard deviations of 0.08 cm (95% CI 0.068-0.101) for MME and 0.318 cm (95% CI 0.274-0.381) for 2DE or TEE. The mean magnitude of measured MASE was 0.44 cm higher with MME than with 2DE or TEE (95% CI 0.068-0.101). CONCLUSIONS: MME assessment of MASE is associated with substantially lower inter- and intraobserver variation than 2DE or TEE assessment. The magnitude of MASE is substantially higher with MME than with 2DE or TEE.

Percutaneous coronary intervention and the use of glycoprotein IIb/IIIa inhibitors in patients with chronic kidney disease on dialysis: a single center experience.

Patients on dialysis constitute a major healthcare burden with high prevalence of coronary artery disease frequently requiring coronary revascularization. Prior studies have reported high complications rates with revascularization in patients on dialysis. However, information on the use glycoprotein and direct thrombin inhibitors in this patient population undergoing percutaneous revascularization is limited. We retrospectively analyzed the procedural success and in-hospital outcomes of percutaneous coronary revascularization in 56 consecutive patients on dialysis compared with 524 patients without renal failure, between January 2001 and August 2007 at our facility. Additionally, we also analyzed the off-label use of glycoprotein IIb/IIIa (GP IIb/IIIa) inhibitors during revascularization in this high-risk group of patients to evaluate for possible increased bleeding complications. In the study group, 7 interventions were performed on peritoneal dialysis and 49 on hemodialysis patients. Sixty-one percent of these patients had diabetes mellitus. A total of 72 lesions were intervened upon; 12 underwent angioplasty and 60 underwent stenting. Four of 72 interventions were not successful, giving a procedural success rate of 94%. There were 6 immediate complications (10.7%), but no deaths. Thirty-two patients (57%) received GP IIb/IIIa inhibitors while direct thrombin inhibitors were used during percutaneous coronary intervention in 11(20%) patients. There were no bleeding complications with use of either GP IIb/IIIa inhibitors or direct thrombin inhibitors. In our experience, percutaneous coronary intervention has high procedural success in dialysis patients and concomitant use of GP IIb/IIIa inhibitors is not associated with any major bleeding complications, making this a feasible, safe and effective revascularization option for patients on dialysis; however, this merits further study in a randomized prospective trial.

How does volume status affect BNP and troponin levels as markers of cardiovascular status in peritoneal dialysis?

Cardiac biomarkers such as brain natriuretic peptide, amino-terminal pro-B-type natriuretic peptide (NT-proBNP), and cardiac troponin provide information on cardiovascular morbidity and mortality in patients with normal renal function. In a considerable number of chronic hemodialysis patients, both biomarkers-NT-proBNP and troponin-are elevated despite the absence of cardiac ischemia. The elevation of cardiac biomarkers in chronic hemodialysis patients is of prognostic value with respect to cardiovascular morbidity and mortality. Furthermore, they can serve as tools for volume assessment for optimization of the fluid management aspect of dialysis. However, the association of both these markers in peritoneal dialysis is not clear. Therefore, the authors reviewed the literature to examine the role of these markers in peritoneal dialysis patients both as prognostic indicators as well as tools for volume assessment.