RESUMO
BACKGROUND AND AIMS: Reduction of left ventricular mass index (LVMi) during antihypertensive treatment is less likely to occur in obese subjects. The aim of the study was to assess whether weight loss influences reduction of LVMi in treated, obese, hypertensive patients. METHODS AND RESULTS: From the Campania Salute Network registry, we identified 1546 obese hypertensive patients (50 ± 9 years, 43% women) with more than 12 months follow-up. Echocardiographic reduction of LVMi was considered as achievement of normal values (<47 g/m2.7 in women or <50 g/m2.7 in men) or a reduction of ≥10% during follow-up. Weight loss was considered as ≥5% reduction in body weight, and occurred in 403 patients (26%) during a median follow-up of 50 months (IQrange:31-93). Median weight loss was 8.6% (IQrange:6.5-12). Patients with weight loss had higher baseline body mass index (p < 0.05), while there was no difference in age, sex, duration of hypertension, prevalence of diabetes, metabolic syndrome and average blood pressure during follow-up. During follow-up, 152 patients (9.8%) exhibited reduction of LVMi. Reduction of LVMi was more frequent (12.9% vs 9.1%, p < 0.030) in patients losing weight than in those who did not. In logistic regression analysis, weight loss was associated with reduction of left ventricular mass index (OR 1.51 [95%CI 1.02-2.23], p = 0.039), independent of significant associations with younger age, lower average systolic blood pressure during follow-up, longer follow-up time and higher LVMi at baseline. CONCLUSION: In treated obese hypertensive patients, weight loss during follow-up promotes significant reduction of LVMi, independent of baseline characteristics and blood pressure control.
Assuntos
Pressão Sanguínea , Abordagens Dietéticas para Conter a Hipertensão , Hipertensão/terapia , Hipertrofia Ventricular Esquerda/fisiopatologia , Obesidade/dietoterapia , Função Ventricular Esquerda , Remodelação Ventricular , Redução de Peso , Adulto , Anti-Hipertensivos/uso terapêutico , Pressão Sanguínea/efeitos dos fármacos , Feminino , Humanos , Hipertensão/diagnóstico , Hipertensão/epidemiologia , Hipertensão/fisiopatologia , Hipertrofia Ventricular Esquerda/diagnóstico por imagem , Hipertrofia Ventricular Esquerda/epidemiologia , Itália/epidemiologia , Estudos Longitudinais , Masculino , Pessoa de Meia-Idade , Obesidade/diagnóstico , Obesidade/epidemiologia , Obesidade/fisiopatologia , Sistema de Registros , Estudos Retrospectivos , Comportamento de Redução do Risco , Fatores de Tempo , Resultado do Tratamento , Função Ventricular Esquerda/efeitos dos fármacos , Remodelação Ventricular/efeitos dos fármacosRESUMO
BACKGROUND AND AIMS: Circulating uric acid (UA) is positively associated with body mass index (BMI), blood glucose, blood pressure (BP), markers of inflammation, and altered lipid profile. UA has also anti-oxidative properties which might be beneficial for cardiovascular (CV) system. It is still debated whether or not UA is independently associated with increased CV morbidity and/or mortality. METHODS AND RESULTS: We studied prognostic impact of UA in 8833 hypertensive adults (mean age 53 ± 12 yrs, 3857 women) from the Campania Salute Network, without prevalent CV disease and more than stage 3 CKD. We calculated standardized UA Z-score, adjusted for age, sex, glomerular filtration rate, and BMI. Low and high UA and UA Z-score quartiles were compared to the 2 middle quartiles assumed to be "normal". Prevalence of obesity and diabetes was higher in low and high than in normal UA Z-score group (all p < 0.001). Systolic BP, left ventricular mass, carotid intima thickness were significantly higher and ejection fraction was reduced in the presence of high UA Z-score (all p < 0.001). Over 33-months average follow-up, incident major CV end-points (MACE) were not significantly different among low, normal and high UA or UA Z-score. In the latter analysis, however, incident MACE tended to be more frequent in the low than the high UA Z-score. Despite the results of multivariable analyses, the effect of less aggressive therapy in low UA Z-score cannot be excluded with certainty. CONCLUSION: In treated hypertensive patients, high levels of UA normalized for major biological determinants do not independently predict CV outcome. CLINICALTRIALS. GOV IDENTIFIER: NCT02211365.
Assuntos
Doenças Cardiovasculares/epidemiologia , Hipertensão/epidemiologia , Hiperuricemia/sangue , Ácido Úrico/sangue , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Anti-Hipertensivos/uso terapêutico , Pressão Arterial/efeitos dos fármacos , Biomarcadores/sangue , Índice de Massa Corporal , Doenças Cardiovasculares/diagnóstico , Doenças Cardiovasculares/fisiopatologia , Doenças Cardiovasculares/prevenção & controle , Feminino , Taxa de Filtração Glomerular , Humanos , Hipertensão/diagnóstico por imagem , Hipertensão/tratamento farmacológico , Hipertensão/fisiopatologia , Hiperuricemia/diagnóstico , Hiperuricemia/epidemiologia , Incidência , Itália/epidemiologia , Rim/fisiopatologia , Masculino , Pessoa de Meia-Idade , Obesidade/epidemiologia , Obesidade/fisiopatologia , Prevalência , Prognóstico , Sistema de Registros , Insuficiência Renal Crônica/epidemiologia , Insuficiência Renal Crônica/fisiopatologia , Fatores de Risco , Fatores de Tempo , Regulação para Cima , Adulto JovemRESUMO
AIM: The aim of this study was to assess the relationship between echocardiographic indexes of left ventricular (LV) hypertrophy with LV mass (LVM) obtained at cardiac magnetic resonance (CMR) in a population of patients with hypertrophic cardiomiopathy (HCM). METHODS: Thirty-nine patients with HCM underwent echocardiography and CMR. By echocardiography maximal wall thickness (MWT), Spirito' and Maron's hypertrophy index and the Wigle's score were obtained. Absolute LVM was measured through CMR and indexed to body surface area (LVMi). Data were analysed using linear regression analysis. RESULTS: In 31% of patients there was an incomplete echocardiographic LV anatomic characterization. However, there was a good correlation between MWT measured at echocardiography and at CMR (P<0.001; r=0.755). Overall echocardiographic indexes of LV hypertrophy correlate with either LVM and LVMi: MWT (P=0.008, r=0.420 and P=0.003, r=0.467, respectively); Spirito' and Maron's hypertrophy index (P=0.003, r=0.551 and P=0.001, r=0.606, respectively) and Wigle's score (P=0.004, r=0.522 and P=0.004, r=0.522, respectively). CONCLUSION: In our HCM population, although a complete anatomic LV anatomic characterization was not obtained by echocardiography in all patients, echocardiographic hypertrophic indexes showed a good correlation with LVM obtained by CMR.
Assuntos
Cardiomiopatia Hipertrófica/diagnóstico , Ecocardiografia , Ventrículos do Coração/patologia , Imageamento por Ressonância Magnética/métodos , Adulto , Cardiomiopatia Hipertrófica/diagnóstico por imagem , Feminino , Humanos , Hipertrofia Ventricular Esquerda/diagnóstico , Masculino , Pessoa de Meia-Idade , Análise de RegressãoRESUMO
AIM: The aim of this study was to evaluate the effect of insulin-like growth factor 1 (IGF1) and transforming growth factor beta-1 (TGFbeta-1) on collagen turnover, left ventricular (LV) hypertrophy and on passive diastolic function of the LV in hypertrophic cardiomyopathy (HCM). METHODS: This study group comprised 34 patients with non-dilated HCM. Procollagen I amino-terminal propeptide (PINP) and collagen I carboxy-terminal telopeptide (ICTP) were measured by radioimmunoassay. Matrix metalloproteinase 9 (MMP 9), IGF1 and TGFalfa-1 were determined by enzyme-linked immunosorbent assay. The difference in duration between transmitral forward (A) and pulmonary venous retrograde (Ar) waves, was considered as an estimate of passive diastolic function; the ratio between the peak flow velocity at rapid filling at the mitral level (E) and E' measured by tissue Doppler was considered an estimate of active diastolic function. LV mass was measured and normalized to body surface area (LVMi) by cardiac magnetic resonance imaging. RESULTS: LVMi correlates to E/E' (r=0.597, P=0.019 ) and is inversely related to A-Ar (r=0.453, P=0.015). TGFbeta-1 is directly related to active MMP 9 (r=0.439, P=0.012 ). IGF1 is directly related to PICP-ICTP (r=0.347, P=0.501), that expresses the balance between collagen I synthesis and its degradation. CONCLUSION: The study demonstrated that in HCM, LVMi influences active and passive diastolic dysfunction and that IGF1 stimulates collagen synthesis and TGFbeta-1 is related to LV hypertrophy.
Assuntos
Cardiomiopatia Hipertrófica/diagnóstico , Cardiomiopatia Hipertrófica/metabolismo , Colágeno/metabolismo , Hipertrofia Ventricular Esquerda/diagnóstico , Hipertrofia Ventricular Esquerda/metabolismo , Fator de Crescimento Insulin-Like I/metabolismo , Fator de Crescimento Transformador beta1/metabolismo , Adulto , Algoritmos , Biomarcadores/metabolismo , Colágeno Tipo I , Ecocardiografia Doppler , Ensaio de Imunoadsorção Enzimática , Feminino , Humanos , Imageamento por Ressonância Magnética , Masculino , Metaloproteinase 9 da Matriz/metabolismo , Pessoa de Meia-Idade , Miocárdio/metabolismo , Fragmentos de Peptídeos/metabolismo , Peptídeos , Pró-Colágeno/metabolismo , Radioimunoensaio , Disfunção Ventricular Esquerda/diagnóstico , Disfunção Ventricular Esquerda/metabolismoRESUMO
Reduced myocardial mechano-energetic efficiency (MEE), estimated as stroke volume/heart rate ratio per g of left ventricular (LV) mass (LVM), and expressed in µl s-1 g-1 (MEEi), is a strong predictor of cardiovascular (CV) events, independently of LV hypertrophy and other confounders, including type II diabetes (DM). Decreased MEEi is more frequent in patients with diabetes. In the present analysis we evaluated the interrelation among MEEi, DM and metabolic syndrome (MetS) in the setting of arterial hypertension. Hypertensive patients from the Campania Salute Network, free of prevalent CV disease and with ejection fraction >50% (n=12 503), were analysed. Coexistence of MetS and DM was ordinally categorized into 4 groups: 8235 patients with neither MetS nor DM (MetS-/DM-); 502 without MetS and with DM (MetS-/DM+); 3045 with MetS and without DM (MetS+/DM-); and 721 with MetS and DM (MetS+/DM+). After controlling for sex, systolic blood pressure, body mass index, relative wall thickness (RWT), antihypertensive medications and type of antidiabetic therapy, MEEi was 333 µl s-1 g-1 in MetS-/DM-, 328 in MetS-/DM+, 326 in MetS+/DM- and 319 in MetS+/DM+ (P for trend <0.0001). In pairwise comparisons (Sidak-adjusted), all conditions, except MetS-/DM+, were significantly different from MetS-/DM- (all P<0.02). No statistical difference was detected between MetS-/DM+ and MetS+/DM-. Both MetS and DM are associated with decreased MEEi in hypertensive patients, independently to each other, but the reduction is statistically less evident for MetS-/DM+. MetS+/DM+ patients have the lowest levels of MEEi, consistent with the alterations of energy supply associated with the combination of insulin resistance with insulin deficiency.
Assuntos
Pressão Arterial , Diabetes Mellitus/epidemiologia , Metabolismo Energético , Hipertensão/epidemiologia , Síndrome Metabólica/epidemiologia , Miocárdio/metabolismo , Disfunção Ventricular Esquerda/epidemiologia , Função Ventricular Esquerda , Adulto , Idoso , Anti-Hipertensivos/uso terapêutico , Pressão Arterial/efeitos dos fármacos , Comorbidade , Diabetes Mellitus/sangue , Diabetes Mellitus/tratamento farmacológico , Diabetes Mellitus/fisiopatologia , Metabolismo Energético/efeitos dos fármacos , Feminino , Frequência Cardíaca , Humanos , Hipertensão/sangue , Hipertensão/tratamento farmacológico , Hipertensão/fisiopatologia , Hipoglicemiantes/uso terapêutico , Resistência à Insulina , Itália/epidemiologia , Masculino , Síndrome Metabólica/sangue , Síndrome Metabólica/fisiopatologia , Pessoa de Meia-Idade , Prevalência , Sistema de Registros , Fatores de Risco , Volume Sistólico , Disfunção Ventricular Esquerda/sangue , Disfunção Ventricular Esquerda/fisiopatologia , Função Ventricular Esquerda/efeitos dos fármacosRESUMO
Diastolic dysfunction is common in hypertrophic cardiomyopathy (HC). Previous studies suggest that Doppler transmitral flow velocity profiles, and the left atrial (LA) M-mode echogram can be used noninvasively to evaluate left ventricular (LV) diastolic function. However, this has not been proved in HC. In this study we determined the relation of Doppler transmitral flow velocity profiles and the LA M-mode echograms to invasive indexes of LV diastolic function in patients with HC. We studied 25 patients with HC, while off drugs, and calculated LA global and active fractional shortening and the slope of both early and late displacement of the posterior aortic wall during LA emptying by M-mode echocardiography. We calculated peak velocity of early (E) and atrial (A) filling, E to A ratio, and E-wave deceleration time by pulsed Doppler echocardiography, and simultaneous radionuclide angiography, LV pressures, time constant of isovolumic relaxation tau, and the constant of chamber stiffness k by cardiac catheterization. The time constant of isovolumic relaxation tau correlated with the slope of early posterior aortic wall displacement (r = 0.59; p <0.01). LV end-diastolic pressure correlated with global LA fractional shortening (r = -0.75; p <0.001); the constant of chamber stiffness k correlated with active LA fractional shortening (r = -0.53; p <0.02). In a subset of 13 patients, in whom echocardiography and cardiac catheterization were performed simultaneously, similar results were found. LA M-mode recordings provide a more reliable noninvasive assessment of diastolic function in HC than mitral Doppler indexes.
Assuntos
Cardiomiopatia Hipertrófica/fisiopatologia , Diástole/fisiologia , Função Ventricular Esquerda/fisiologia , Adolescente , Adulto , Velocidade do Fluxo Sanguíneo , Cateterismo Cardíaco , Cardiomiopatia Hipertrófica/diagnóstico por imagem , Ecocardiografia Doppler em Cores , Estudos de Avaliação como Assunto , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Valva Mitral/fisiologia , Variações Dependentes do Observador , Angiografia Cintilográfica , Análise de Regressão , Reprodutibilidade dos Testes , Pressão VentricularRESUMO
The aim of this study was to assess whether left ventricular (LV) cavity size relates to functional impairment and syncope in patients with hypertrophic cardiomyopathy (HC). LV diastolic dysfunction influences functional limitation in HC. A reduced LV end-diastolic dimension may underlie impaired diastolic properties and be implicated in hemodynamic syncope. Eighty-two consecutive patients with HC (off drugs, in sinus rhythm) underwent echocardiography to measure LV end-diastolic dimension in the short-axis view (indexed to the body surface area) and radionuclide angiography (n = 50) to calculate peak filling rate (normalized to stroke counts/s). Patients in New York Heart Association functional classes II to IV had smaller LV end-diastolic dimension (23.2 +/- 2.6 vs 25.5 +/- 2.5 mm/M2, p = 0.0001) and lower peak filling rate (4.3 +/- 1.4 vs 5.1 +/- 1.3 stroke counts/s, p = 0.036) than those in New York Heart Association class I. LV end-diastolic diameter was correlated to peak filling rate (r = 0.37; p = 0.008). The most potent predictors of functional limitation were LV end-diastolic dimension (relative risk [RR] 0.63, confidence interval [CI] 0.45 to 0.88; p = 0.008), age (RR 1.09, CI 1.03 to 1.17; p = 0.003), and LV thickness score (RR 1.08, CI 1.02 to 1.13; p = 0.003). LV cavity size was smaller in patients with functional limitation irrespective of obstruction and hypertrophy. Patients with differed from those without a history of syncope for a smaller LV end-diastolic dimension (23.2 +/- 2.5 vs 25.0 +/- 2.7 mm/M2, p = 0.008), which was the only independent predictor of syncope (RR 0.77, CI 0.63 to 0.95; p = 0.013). Thus, a small LV cavity size is associated with functional limitation and history of syncope in HC.
Assuntos
Cardiomiopatia Hipertrófica/patologia , Ventrículos do Coração/patologia , Adolescente , Adulto , Idoso , Cardiomiopatia Hipertrófica/diagnóstico por imagem , Cardiomiopatia Hipertrófica/fisiopatologia , Feminino , Ventrículos do Coração/diagnóstico por imagem , Humanos , Masculino , Pessoa de Meia-Idade , Angiografia Cintilográfica , Ultrassonografia , Função Ventricular Esquerda , Obstrução do Fluxo Ventricular Externo/fisiopatologiaRESUMO
Hypertrophic cardiomyopathy (HC) is characterized by impaired diastolic function and, in about 1/4 of patients, left ventricular (LV) outflow tract obstruction. Atrioventricular (AV) pacing diminishes LV outflow tract gradient in HC, but impairs diastolic function in the experimental animal and in different categories of patients. To investigate the effects of AV pacing on hemodynamics and LV function in obstructive HC, 16 patients with HC were studied by cardiac catheterization and simultaneous radionuclide angiography during atrial and AV pacing. The resting LV outflow tract gradient decreased with AV pacing from 60 +/- 34 to 38 +/- 37 mm Hg (mean +/- SD; p <0.001). Regional ejection fraction decreased significantly at the septal level from 0.81 +/- 0.21% to 0.69 +/- 0.27% (p <0.01). Pulmonary artery wedge pressure increased from 10 +/- 5 to 15 +/- 6 mm Hg (p <0.001). AV pacing induced asynchrony (i.e., the coefficient of variation of the time to end-systole increased from 7 +/- 4% to 14 +/- 10% (p <0.01). The time constant of isovolumetric relaxation (t) increased from 58 +/- 24 to 74 +/- 33 ms (p <0.02), and peak filling rate decreased from 491 +/- 221 to 416 +/- 184 ml/s (p <0.05). Thus, AV pacing greatly diminishes resting obstruction through a reduction in septal ejection fraction (i.e., an increase in LV outflow tract width in systole), but impairs active diastolic function and increases filling pressures. These latter effects are potentially detrimental in patients with HC in whom diastolic dysfunction is present.
Assuntos
Cardiomiopatia Hipertrófica/fisiopatologia , Cardiomiopatia Hipertrófica/terapia , Hemodinâmica , Obstrução do Fluxo Ventricular Externo/prevenção & controle , Obstrução do Fluxo Ventricular Externo/fisiopatologia , Adulto , Estimulação Cardíaca Artificial/métodos , Cardiomiopatia Hipertrófica/complicações , Diástole , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Resultado do Tratamento , Função Ventricular Esquerda , Obstrução do Fluxo Ventricular Externo/etiologiaRESUMO
Hypertrophic cardiomyopathy (HC) is characterized by impaired diastolic function, and left ventricular (LV) outflow tract obstruction in about one-fourth of patients. Verapamil improves diastolic properties, but may have dangerous adverse effects. This study investigates the effects of diltiazem on hemodynamics and LV function in 16 patients with HC who were studied with cardiac catheterization and simultaneous radionuclide angiography. Studies were performed during atrial pacing (15 beats above spontaneous rhythm) at baseline and during intravenous diltiazem administration (0.25 mg x kg(-1) over 2 minutes, and 0.014 mg x kg(-1) x min(-1). Diltiazem induced a systemic vasodilation (cardiac index: 3.4 +/- 1.0 to 4.0 +/- 1.0 L x min(-1) x m(-2), p = 0.003; aortic systolic pressure: 116 +/- 16 to 107 +/- 19 mm Hg, p = 0.007; systemic resistance index: 676 +/- 235 to 532 +/- 193 dynes x s x cm(-5) x m(-2), p = 0.006), not associated with changes in the LV outflow tract gradient. The end-systolic pressure/volume ratio decreased (30 +/- 42 to 21 +/- 29 mm Hg x ml(-1) x m(-2); p = 0.044). Pulmonary artery wedge pressure (11 +/- 5 to 15 +/- 6 mm Hg, p = 0.006), and peak filling rate increased (4.1 +/- 1.3 to 6.0 +/- 2.4 stroke counts x s(-1), p = 0.004). The time constant of isovolumetric relaxation tau decreased (74 +/- 40 to 59 +/- 38 ms, p = 0.045). The constant of LV chamber stiffness did not change. Thus, active diastolic function is improved by the acute administration of diltiazem by both direct action and changes in hemodynamics and loading conditions. LV outflow tract gradient does not increase despite systemic vasodilation. In some patients, however, a marked increase in obstruction and a potentially harmful elevation in pulmonary artery wedge pressure do occur. Passive diastolic function is not affected.
Assuntos
Bloqueadores dos Canais de Cálcio/uso terapêutico , Cardiomiopatia Hipertrófica/tratamento farmacológico , Fármacos Cardiovasculares/uso terapêutico , Diltiazem/uso terapêutico , Função Ventricular Esquerda/efeitos dos fármacos , Adulto , Pressão Sanguínea/efeitos dos fármacos , Bloqueadores dos Canais de Cálcio/administração & dosagem , Cateterismo Cardíaco , Débito Cardíaco/efeitos dos fármacos , Estimulação Cardíaca Artificial , Volume Cardíaco/efeitos dos fármacos , Cardiomiopatia Hipertrófica/fisiopatologia , Fármacos Cardiovasculares/administração & dosagem , Diástole , Diltiazem/administração & dosagem , Feminino , Átrios do Coração , Frequência Cardíaca/efeitos dos fármacos , Humanos , Injeções Intravenosas , Masculino , Pessoa de Meia-Idade , Contração Miocárdica/efeitos dos fármacos , Pressão Propulsora Pulmonar/efeitos dos fármacos , Angiografia Cintilográfica , Sístole , Resistência Vascular/efeitos dos fármacos , Vasodilatadores/administração & dosagem , Vasodilatadores/uso terapêutico , Obstrução do Fluxo Ventricular Externo/tratamento farmacológico , Obstrução do Fluxo Ventricular Externo/fisiopatologiaRESUMO
Prosthetic cardiac thrombosis is a life-threatening complication that needs prompt diagnosis and therapy. We used recombinant tissue-type plasminogen activator (rT-PA), followed by heparin, in three patients with mitral prosthetic thrombosis, which was evident in two and suspect in one. Transthoracic and transesophageal echocardiography were employed in the diagnosis of both thrombosis and its resolution. No complications occurred. Immediately after the end of treatment with rT-PA, clinical status and echocardiographic data improved in all cases: transthoracic echocardiography showed the normalization of prosthetic function and transesophageal echocardiography showed resolution of thrombosis. One patient needed reoperation for rethrombosis due to the presence of prosthetic fibrous clot. rT-PA, followed by heparin, led to a good clinical result without bleeding and embolic complications in selected patients with mitral prosthetic thrombosis. Transthoracic and transesophageal echocardiography are complementary diagnostic tools in the diagnosis and management of patients with prosthetic thrombosis.
Assuntos
Ecocardiografia Doppler , Ecocardiografia Transesofagiana , Próteses Valvulares Cardíacas/efeitos adversos , Trombose/diagnóstico por imagem , Trombose/tratamento farmacológico , Ativador de Plasminogênio Tecidual/uso terapêutico , Adulto , Idoso , Feminino , Heparina/uso terapêutico , Humanos , Masculino , Pessoa de Meia-Idade , Valva Mitral , Trombose/etiologiaRESUMO
OBJECTIVE: Redo operations for bioprosthesis malfunction can sometimes be technically very demanding and cardiac structures may be damaged. Excising only the leaflets of the damaged bioprosthesis and leaving the old ring in situ on which the 'new' mechanical valve is sutured can, in very selected cases, represent a solution. METHODS: Twenty-two patients were operated on, with the valve-on-valve technique, from September 1991 through December 1992. There were three operative deaths. RESULTS: The surviving 19 patients were followed-up from 83 to 98 months (mean 90.5 months.). There were two late deaths. The patients were examined clinically and with transthoracic and transesophageal echocardiograms. All patients were in good condition and the echocardiographic examinations showed no clinically important gradients across the prostheses. CONCLUSIONS: The valve-on-valve technique, in certain difficult situations, can give successful mid-term results.
Assuntos
Bioprótese , Implante de Prótese de Valva Cardíaca/métodos , Próteses Valvulares Cardíacas , Falha de Prótese , Adulto , Idoso , Valva Aórtica/cirurgia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Valva Mitral/cirurgia , Reoperação , Resultado do TratamentoRESUMO
Removal of a failing bioprosthesis can be a delicate operation and extensive damage can be caused. Eighteen patients with failing bioprostheses underwent excision of the leaflets, then the "new" mechanical valve was sewn onto the "old" bioprosthetic ring. At follow-up, clinical and 2D color-flow echo-Doppler evaluations showed good hemodynamic performance of the mechanical valves.
Assuntos
Bioprótese , Próteses Valvulares Cardíacas/métodos , Adulto , Idoso , Valva Aórtica , Ecocardiografia , Feminino , Seguimentos , Humanos , Masculino , Pessoa de Meia-Idade , Valva Mitral , Falha de Prótese , Reoperação , Valva TricúspideAssuntos
Cardiomiopatia Hipertrófica/fisiopatologia , Função Ventricular Esquerda/fisiologia , Adolescente , Adulto , Idoso , Cardiomiopatia Hipertrófica/diagnóstico por imagem , Criança , Diástole , Ecocardiografia Doppler , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Contração MiocárdicaRESUMO
BACKGROUND: Nonuniformity is a determinant of diastolic function. In patients with hypertrophic cardiomyopathy, hypertrophy, abnormal calcium handling, and regional ischemia can also play a role. This study was designed to assess regional mechanics, asynchrony, and asynergy in patients with hypertrophic cardiomyopathy. METHODS AND RESULTS: Nine control subjects and 22 patients with hypertrophic cardiomyopathy were studied by biplane left ventriculography and high-fidelity pressure tracings for the assessment of diastolic function by computing the time constant of isovolumic relaxation, peak filling rate, and the constant of passive chamber stiffness. Regional mechanics were evaluated by dividing the left ventricle into six sectors in the right and left anterior oblique projections. Systolic and diastolic asynchrony were assessed from the coefficient of variation of the regional time intervals from end diastole to end systole and to peak filling rate, respectively. Asynergy was evaluated from the coefficient of variation of the regional area reduction. Regional passive elastic properties were estimated by computing the regional constant of chamber stiffness. In patients with hypertrophic cardiomyopathy, isovolumic relaxation was prolonged (time constant of isovolumic relaxation 101 +/- 41 versus 51 +/- 16 milliseconds in control subjects; P < .001) and the constant of chamber stiffness was increased (0.056 +/- 0.038 versus 0.025 +/- 0.010 mL-1; P < .001). Both systolic and diastolic asynchrony as well as asynergy were found. Regional mechanics showed hyperkinesia in the free wall, whereas the septum exhibited normal wall motion and increased constant of chamber stiffness. CONCLUSIONS: Diastolic function is impaired in hypertrophic cardiomyopathy, and such an impairment is the consequence of nonuniformity and hypertrophy. The regions where the myopathic process is more pronounced show normal wall motion but increased stiffness. The inhomogeneity of regional wall motion with regional hyperkinesia and normokinesia of neighboring regions results in left ventricular asynergy.
Assuntos
Cardiomiopatia Hipertrófica/fisiopatologia , Função Ventricular Esquerda , Adulto , Cateterismo Cardíaco , Cardiomiopatia Hipertrófica/diagnóstico por imagem , Diástole , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Radiografia , Obstrução do Fluxo Ventricular Externo/fisiopatologiaRESUMO
The impact of the duration of atrioventricular (AV) delay on obstruction in hypertrophic cardiomyopathy was evaluated in 12 patients by cardiac catheterization, and in 8 of them also by Doppler echocardiography. The AV delay was programmed in random order at 125, 100 and 75 ms in the invasive study and at 120, 100 and 80 ms after pacemaker implantation. The arterial pressure did not changed throughout the studies, whereas the gradient decreased significantly by reducing the AV delay value; the greater gradient reduction was obtained, in both studies, with the AV delay set between 75 or 80 and 100 ms. QRS duration increased significantly by reducing the AV delay during both studies. The widest QRS was not associated with the smallest gradient in all patients. Changes in gradients were similar during the invasive and noninvasive protocols.
Assuntos
Nó Atrioventricular/fisiopatologia , Estimulação Cardíaca Artificial , Cardiomiopatia Hipertrófica/terapia , Obstrução do Fluxo Ventricular Externo/fisiopatologia , Adolescente , Adulto , Idoso , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Fatores de TempoRESUMO
AIMS: The left ventricle in hypertrophic cardiomyopathy is anatomically and functionally non-uniform. This study was undertaken to verify whether a heterogeneity in the pattern of diastolic filling can be detected along the left ventricular inflow tract in hypertrophic cardiomyopathy. METHODS AND RESULTS: Early (E) and late (A) diastolic velocities were recorded by Doppler echocardiography at mitral and at mid-ventricular level in 16 normal volunteers and 30 patients with hypertrophic cardiomyopathy. Patients with hypertrophic cardiomyopathy also underwent radionuclide angiography to assess left ventricular function. E wave decreased significantly in normal volunteers (80 +/- 15 to 60 +/- 14 cm x s(-1); P<0.001), but it increased in hypertrophic cardiomyopathy (76 +/- 22 to 87 +/- 28 cm x s(-1) P=0.04), whereas the A wave decreased similarly in both. By multivariate analysis, systolic asynchrony and the ejection fraction of left ventricular lateral wall were directly related to the pattern of early filling progression (r=0.656, F=9.467; P<0.002). Moreover, systolic asynchrony showed a univariate direct correlation with changes in E velocity (r=0.42; P=0.02). CONCLUSION: Many patients with hypertrophic cardiomyopathy have an acceleration of filling within the left ventricular inflow tract; this phenomenon is directly related to systolic asynchrony and ejection fraction of the left ventricular lateral wall, suggesting increased suction.
Assuntos
Cardiomiopatia Hipertrófica/fisiopatologia , Ecocardiografia Doppler , Angiografia Cintilográfica , Disfunção Ventricular Esquerda , Adolescente , Adulto , Cardiomiopatia Hipertrófica/diagnóstico por imagem , Criança , Diástole , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Análise MultivariadaRESUMO
BACKGROUND: The origin of artifacts of the ascending aorta during transesophageal echocardiography has not been widely studied. This study was undertaken to investigate in vivo whether anatomic features could determine the appearance of artifacts. METHODS AND RESULTS: Transesophageal echocardiograms of 46 patients studied for suspected dissection with proven diagnosis (30 patients with and 16 without ascending aortic dissection) were reviewed. The incidence of artifacts was 46%, and it was similar in patients with and those without dissection (chi-square 0.516; P = not significant). Artifacts were located in the aortic lumen twice as far from the transducer as the atrial-aortic interface. The aortic diameter was larger in patients with than in those without artifacts (6.4 +/- 1.1 vs 4.2 +/- 0.9 cm, P <.001). An aortic diameter >5 cm and an atrial-aortic ratio =0.6 predicted the artifact appearance with good sensitivity, specificity, positive and negative predictive values, and diagnostic accuracy; these parameters reached a value of 100% by analysis only of patients without dissection. CONCLUSIONS: An ascending aortic diameter >5.0 cm that exceeds the left atrial diameter with an atrial-aortic ratio =0.6 creates in vivo the conditions for the reverberation of the atrial-aortic interface within the aorta. Therefore, in patients with such anatomic features, artifacts must be suspected in the presence of linear structures within the aorta.
Assuntos
Aorta Torácica/diagnóstico por imagem , Artefatos , Ecocardiografia Transesofagiana , Dissecção Aórtica/diagnóstico por imagem , Aneurisma da Aorta Torácica/diagnóstico por imagem , Diagnóstico Diferencial , Humanos , Variações Dependentes do Observador , Valor Preditivo dos Testes , Reprodutibilidade dos Testes , Estudos RetrospectivosRESUMO
AIMS: Atrial and brain natriuretic peptide levels closely reflect impaired left ventricular function in patients with heart failure. In the present study we assessed the determinants and the clinical significance of atrial and brain natriuretic peptide plasma levels in hypertrophic cardiomyopathy. METHODS AND RESULTS: In 44 patients with hypertrophic cardiomyopathy (40+/-15 years) we evaluated: (a) atrial and brain natriuretic peptide plasma levels; (b) left ventricular hypertrophy; (c) left ventricular ejection fraction; (d) transmitral and pulmonary venous flow velocity patterns, and left atrial fractional shortening; (e) left ventricular outflow tract gradient; (f) maximal oxygen consumption. Left ventricular hypertrophy influenced only brain natriuretic peptide levels (r=0.32;P<0.05). Atrial and brain natriuretic peptide plasma levels did not correlate with left ventricular ejection fraction, but correlated with left ventricular outflow tract gradient (r=0.35;P<0.05; and r=0.40, P=0.022, respectively) and left atrial fractional shortening (r=-0.57;P<0.001, and r=-0.35;P<0.05, respectively). Atrial but not brain natriuretic peptide plasma levels were inversely related to maximal oxygen consumption (r=-0.35;P<0.05). By stepwise multiple regression analysis, left atrial fractional shortening and left ventricular outflow tract gradient were the only predictors of atrial and brain natriuretic peptide plasma levels, respectively. CONCLUSIONS: In hypertrophic cardiomyopathy, atrial natriuretic peptide plasma levels are mainly determined by diastolic function: this explains the relationship with exercise tolerance. In contrast, brain natriuretic peptide plasma levels are mainly determined by left ventricular outflow tract gradient.
Assuntos
Fator Natriurético Atrial/sangue , Cardiomiopatia Hipertrófica/sangue , Peptídeo Natriurético Encefálico/sangue , Adolescente , Adulto , Idoso , Cardiomiopatia Hipertrófica/diagnóstico por imagem , Cardiomiopatia Hipertrófica/fisiopatologia , Ecocardiografia Doppler , Teste de Esforço , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Contração Miocárdica , Análise de Regressão , Volume Sistólico , Função Ventricular EsquerdaRESUMO
AIM: The aim of the present study was to evaluate [123I] MIBG uptake and clearance in patients with hypertrophic cardiomyopathy (HCM) and to assess their relationships with left ventricular function (systolic and diastolic) and perfusion. METHODS: Eleven consecutive patients with HCM (8 men and 3 women; mean age 38+/-12 years, none in the dilated phase) underwent (in separate days, in random order) [123I]-MIBG scintigraphy, [(99m)Tc]-MIBI SPET at rest, and echocardiography. All patients were studied in fasting condition, and all medications were discontinued. [(99m)Tc]-MIBI SPET study was performed 1 hour after tracer injection. [123I]-MIBG study was acquired 5 minutes (planar) and 4 hours (planar and SPET) after the i.v. injection of [123I]-MIBG. Heart to mediastinum ratio (H/M) was computed at 4 hours. Wash out rate (WOR) was computed as: (H early - H delayed)/(H early), after decay correction. Both [123I]-MIBG and [(99m)Tc]-MIBI SPET were analyzed on 3 short axis views (apical, middle, and basal). Left ventricular outflow tract gradient (LVOTG), ejection fraction, volumes, septum thickness, and left atrial fractional shortening (LAFS) were evaluated on echocardiography. RESULTS: [123I]-MIBG WOR showed a positive relationship with LVOTG (r=0.84, p<0.001) and septum thickness (r=0.76, p<0.01), while a negative one was found with LAFS (r= -0.66, p<0.05). The study group was divided into: Group A (n=5) with higher, and Group B (n=6) with lower WOR than the median value (i.e. 11%). Group A patients had significantly lower LAFS (17.6+/-4.8 vs 26.8+/-7.2%, p<0.05), higher LVOTG (49+/-35 vs 3+/-3 mmHg), and thicker septum (21+/-2 vs 17+/-2 mm) than Group B patients. Inferior and septal wall [123I]-MIBG uptake on 4 hour SPET was significantly lower in Group A than in Group B. On the other hand, no differences were found in (99m)T-MIBI SPET rest regional uptake between the 2 subgroups of patients. CONCLUSION: These results suggest that cardiac sympathetic activity correlates to cardiac anatomy (i.e. degree of hypertrophy) and diastolic function in patients with HCM.