Predictive role of left atrial and ventricular mechanical function in postoperative atrial fibrillation: a two-dimensional speckle-tracking echocardiography study.

OBJECTIVE: The aim of this study was to determine the role of left-sided mechanical parameters in postoperative atrial fibrillation (POAF) in patients undergoing coronary artery bypass grafting (CABG). METHODS: Ninety patients with coronary artery disease and normal left ventricular (LV) function in sinus rhythm were enrolled in the study. Preoperative LV and left atrial (LA) mechanics were evaluated by two-dimensional (2D) speckle-tracking echocardiography (STE), including strain and rotation parameters, and volume indices. Patients were monitored in order to detect POAF during the postoperative period. RESULTS: Twenty-three of 90 patients (25.6%) developed POAF. Age (p<0.001) and preoperative beta blocker usage (p=0.001) were the clinical parameters associated with POAF. Left atrial maximum volume index (LAV[max]i) increased, and peak left atrial longitudinal strain (PALS) was impaired in POAF patients (p=0.001, p<0.001, respectively). Left ventricular twist (LVtw) and left ventricular peak untwisting velocity (UntwV) were augmented in POAF patients (p=0.013, p=0.009, respectively). Receiver operating characteristic analysis showed N-terminal pro-brain natriuretic peptide (NT-proBNP) levels above 70 pg/ml and predicted POAF with a sensitivity of 74% and specificity of 78% (area under curve: 0.758, 95% confidence interval [CI] 0.631-0.894, p<0.001). Logistic regression analysis demonstrated that age (odds ratio [OR] 1.1, CI 1.01-1.20, p=0.034), preoperative beta blocker usage (OR 8.84, CI 1.36-57.28, p=0.022), NT-proBNP (values >70 pg/ml, OR 22.377, CI 3.286-152.381, p<0.001), PALS (OR 0.86, CI 0.75-0.98, p=0.023), and UntwV (OR 1.02, CI 1.00-1.04, p=0.029) were the independent predictors of POAF. CONCLUSION: The combination of 2D STE, clinical, and biochemical parameters may help predict POAF.

Early Detection of Bi-ventricular and Atrial Mechanical Dysfunction Using Two-Dimensional Speckle Tracking Echocardiography in Patients with Sarcoidosis.

PURPOSE: Sarcoidosis is a systemic inflammatory disease with unknown etiology involving several organs. Myocardial involvement, pericarditis, severe rhythm abnormalities, and heart valve disease due to papillary muscle dysfunction are some of the cardiac manifestations. Conventional echocardiographic methods remain insufficient for the determination of subclinical myocardial dysfunction in patients with sarcoidosis. In our study, we investigated the impact of sarcoidosis on bi-ventricular and atrial functions using two-dimensional (2D) speckle tracking echocardiography (STE). METHODS: Forty patients with sarcoidosis and 20 age and sex-matched controls were recruited into study. All subjects underwent a transthoracic echocardiography for the evaluation of ventricular and atrial functions with 2D STE. RESULTS: Left ventricular (LV) dimensions, LV ejection fraction, and right ventricular (RV) systolic velocity were similar between the two groups. Left atrial (LA) diameter was significantly higher in sarcoidosis patients than controls. Eighteen (45%) patients in the sarcoidosis group and 1 (5%) patient in the control group had LV diastolic dysfunction. LV global longitudinal, radial, circumferential strain, twist, untwists, and RV global longitudinal strain values were significantly lower in sarcoidosis patients compared to controls. LA and RA reservoir functions were also significantly lower in sarcoidosis patients than controls. CONCLUSION: Although impaired LV diastolic function was detected using conventional parameters, only novel advanced echocardiographic modalities demonstrated impaired bi-ventricular and atrial mechanical functions in patients with sarcoidosis.

Two-dimensional strain and strain rate imaging of the left atrium and left ventricle in adult patients with atrial septal defects before and after the later stage of percutaneous device closure.

AIM: Atrial septal defect (ASD) causes chronic volume overload of the right heart. The potential adverse effects of this long-standing volume overload to left atrium (LA) and left ventricle (LV) and their response to ASD closure has been poorly studied. METHODS: We studied 20 ASD patients before the procedure, at the 24-hour and 1 month following the percutaneous closure. Twenty age-matched controls served as the control group. The analysis for atrial deformation was performed on the lateral wall, mid segment of the LA from apical four-chamber view. Peak longitudinal strain (S) and strain rate (SR) during LA reservoir, passive emptying, atrial contraction phases and LV global longitudinal systolic S and SR were measured. RESULTS: Peak S and SR at LA reservoir, conduit and late contraction phases in ASD patients were similar to controls. All of these parameters increased immediately after the closure of the defect. Similarly, SLV and SRLV in ASD patients were not significantly different from the controls and significantly increased after the closure. But LA S, SR and LV S, SR results decreased in 1 month after the closure. SLV in ASD patients was significantly correlated with echocardiographic findings and the invasively measured defect size. CONCLUSION: LA and LV S and SR are not significantly affected in ASD patients. However, correction of the long-standing volume overload by percutaneous closure causes an early increase in LA and LV longitudinal deformation that correlates with the magnitude of the atrial septal defect. But this increase decreased in 1 month after closure.

The value of plasma D-dimer level on admission in predicting no-reflow after primary percutaneous coronary intervention and long-term prognosis in patients with acute ST segment elevation myocardial infarction.

D-dimer is a final product of fibrin degradation and gives an indirect estimation of the thrombotic burden. We aimed to investigate the value of plasma D-dimer levels on admission in predicting no-reflow after primary percutaneous coronary intervention (p-PCI) and long-term prognosis in patients with ST segment elevation myocardial infarction (STEMI). We retrospectively involved 569 patients treated with p-PCI for acute STEMIs. We prospectively followed up the patients for a median duration of 38 months. Angiographic no-reflow was defined as postprocedural thrombolysis in myocardial infarction (TIMI) flow grade <3 or TIMI 3 with a myocardial blush grade <2. Electrocardiographic no-reflow was defined as ST-segment resolution <70%. The primary clinical end points were mortality and major adverse cardiovascular events (MACE). The incidences of angiographic and electrocardiographic no-reflow were 31 and 39% respectively. At multivariable analysis, D-dimer was found to be an independent predictor of both angiographic (p < 0.001), and electrocardiographic (p < 0.001) no-reflow. Both mortality (from Q1 to Q4, 5.7, 6.4, 11.3 and 34.1%, respectively, p < 0.001) and MACE (from Q1 to Q4, 17.9, 29.3, 36.9 and 52.2%, respectively, p < 0.001) rates at long-term follow-up were highest in patients with admission D-dimer levels in the highest quartile (Q4), compared to the rates in other quartiles. However, Cox proportional hazard model revealed that high D-dimer on admission (Q4) was not an independent predictor of mortality or MACE. In contrast, electrocardiographic no-reflow was independently predictive of both mortality [Hazard ratio (HR) 2.88, 95% confidence interval (CI) 1.04-8.58, p = 0.041] and MACE [HR 1.90, 95% CI 1.32-4.71, p = 0.042]. In conclusion, plasma D-dimer level on admission independently predicts no-reflow after p-PCI. However, D-dimer has no independent prognostic value in patients with STEMI.

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.

Effect of increased severity of mitral regurgitation and preprocedural right ventricular systolic dysfunction on biventricular and left atrial mechanical functions following percutaneous mitral balloon valvuloplasty.

BACKGROUND: Severe mitral stenosis (MS) may impair left atrial (LA) pump function, and increase LA and pulmonary venous pressure resulting in right ventricular (RV) systolic dysfunction. The aim of this study was to evaluate biventricular and LA function after percutaneous mitral balloon valvuloplasty (PMBV) by tissue Doppler (TDI) and speckle tracking echocardiography (STE). METHODS: Twenty-eight consecutive patients with severe symptomatic rheumatic MS (11 men, mean age: 39 ± 7 years) who were referred for PMBV were included in the study. In addition to conventional echocardiography, all patients underwent TDI and two-dimensional (2D) (STE) to assess left ventricular (LV), LA, and RV function before and 3 months after PMBV. Severity of mitral regurgitation (MR) was graded by the ratio of MR jet area to LA area (JA/LAA) method and any postprocedural progression of the JA/LAA ratio was defined as worsening of MR. Peak systolic velocity of tricuspid lateral annulus (RVs) <11.5 cm/sec was accepted as RV dysfunction. RESULTS: Left atrial diameter and area were decreased, while LV dimensions were unchanged following the valvuloplasty. PMBV improved STE-based LV mechanical indices, LA reservoir and conduit function, and RV free wall basal longitudinal strain (LS) and displacement. Increased severity of MR was detected in 6 patients, and PMBV did not improve the STE-based RV or LV function in these patients, while LA reservoir and conduit function were both improved independent of MR worsening. There was significant improvement in RVs and RV basal LS in the 15 patients with preprocedural RV systolic dysfunction, while the improvement in patients with normal preprocedural RV function was not significant. CONCLUSION: Percutaneous mitral balloon valvuloplasty may improve both LA and biventricular function in patients with severe symptomatic MS. Both TDI and STE are useful to determine biventricular and LA function after PMBV. Although the number of patients was insufficient, worsening of MR after PMBV may limit the improvement in RV and LV function, while preprocedural RV dysfunction does not seem to limit the improvement in RV function and pulmonary artery systolic pressure. Large scale follow-up studies are required to see whether the changes observed in cardiac mechanics are persistent.

Time course of right ventricular remodeling after percutaneous atrial septal defect closure: assessment of regional deformation properties with two-dimensional strain and strain rate imaging.

BACKGROUND: Quantitative assessment of the right ventricular (RV) function in atrial septal defect (ASD) patients before and after closure remains difficult. The aim of this study was to assess the regional RV function in ASD patients, to evaluate the extent and time course of RV remodeling following ASD closure, and to investigate whether any regional difference exists in RV remodeling. METHODS: Twenty patients with ASD and 20 age-matched controls were included. All underwent standard echocardiography and two-dimensional strain (S) and strain rate (SR) imaging by speckle tracking before, and 24 hours and 1 month after the defect closure. RESULTS: Right ventricular S was higher in ASD patients except apical lateral segment S, which was lower when compared with controls. There was no difference in RV SR between ASD patients and controls. RV septal S and SR, and lateral SR decreased in 24 hours after the procedure and remained the same at 1 month. RV lateral basal and mid S decreased and apical S increased in 24 hours after the closure. All 3 segments showed some more increase at 1 month. RV apical S showed strong correlations with systolic pulmonary artery pressure and global RV systolic function indices. CONCLUSIONS: Chronic volume overload in ASD patients causes alterations in RV deformation. Percutaneous closure results in rapid remodeling and normalization of RV deformation. The major geometrical and deformational changes are completed in 24 hours. Lateral wall S seems to reflect the RV deformational changes due to volume loading and unloading better than SR in ASD patients.

Soluble CD40 ligand release in patients with stable coronary artery disease during elective stent implantation: effect of drug-eluting stent over bare metal stent.

OBJECTIVES: We aimed to determine the effect of drug-eluting stent (DES) implantation on soluble CD40 ligand (sCD40L) levels in patients with stable coronary artery disease undergoing stent replacement. STUDY DESIGN: Eighty-nine consecutive patients (33 women, 56 men; mean age 61±10 years) with stable coronary artery disease undergoing stent replacement were recruited. Pre- and post-procedural blood samples were collected for sCD40L analysis, and differences in plasma levels were calculated and expressed as delta sCD40L. Total size and length of implanted stents and pre- and post-dilatation procedures were recorded for each patient, for possible impact on sCD40L release. Patients were followed for one year following procedures for possible adverse cardiac events such as death, myocardial infarction and revascularization. RESULTS: Forty-nine patients received bare metal stent (BMS) and 40 patients received DES. There were no differences between BMS- and DES-implanted patients in terms of age, stent size and length, and delta sCD40L plasma levels. Delta sCD40L was correlated only with total implanted stent length (r=0.374, p<0.001). Delta sCD40L levels were divided into quartiles for better determination of the procedural parameters that are effective on biomarker release. Total stent length (p=0.008), stent size (p=0.038) and pre-dilatation procedure (p=0.034) were the statistically differing parameters between delta sCD40L quartiles. Although statistically non-significant, all three adverse events were observed in patients with the highest quartile (p=0.179). CONCLUSION: Procedural sCD40L release did not differ between DES- and BMS-implanted stable coronary artery disease patients. Total implanted stent length, stent size and pre-dilatation procedure were the influential parameters on procedural sCD40L release.

Evaluation of cardiac electromechanics in patients with newly diagnosed hypertension.

OBJECTIVES: This study aimed to investigate the relationship between subclinical left ventricular (LV) systolic dysfunction and ECG parameters in newly diagnosed hypertension patients. METHODS: In this cross-sectional study, adults diagnosed with hypertension based on 24-h ambulatory blood pressure monitor recordings were included. The patients were classified into two groups based on the presence of subclinical LV systolic dysfunction according to LV global longitudinal strain (LVGLS). Findings were compared between the two groups. RESULTS: A total of 244 patients (female, 55.7%) were included. Based on LVGLS, 82 (33.6%) patients had subclinical LV systolic dysfunction. The proportion of early repolarization pattern (ERP) on ECG was significantly higher in patients with subclinical LV systolic dysfunction than in patients with normal LV systolic function [24 (28.6%) vs. 8 (5%), P < 0.001]. PR and corrected QT intervals were also significantly longer in patients with subclinical LV systolic dysfunction than in patients with normal LV systolic function [median (interquartile range), 148 (132-158) vs. 141 (127-152), P = 0.036 and 443 (427-459) vs. 431 (411-455), P = 0.007, respectively]. According to multivariate regression analysis ERP, early (E) wave velocity/late (A) wave velocity (E/A), and LV mass index were independently associated with subclinical LV systolic dysfunction. CONCLUSION: In newly diagnosed hypertension patients, the ERP on admission ECG could be a sign of subclinical systolic dysfunction.

Intracoronary bolus-only compared with intravenous bolus plus infusion of tirofiban application in patients with ST-elevation myocardial infarction undergoing primary percutaneous coronary intervention.

OBJECTIVES: The aim of this pilot study was to compare intracoronary bolus-only with standard intravenous bolus plus maintenance infusion of tirofiban with respect to improvement in myocardial reperfusion after primary percutaneous coronary intervention (p-PCI). BACKGROUND: Changes in clinical practice may obviate the need for a maintenance infusion of small molecule glycoprotein IIb/IIIa inhibitors in current practice. METHODS: Forty-nine patients undergoing p-PCI were randomized to either intracoronary bolus-only (n = 25) or intravenous bolus plus infusion (n = 24) of tirofiban. The primary end point was coronary hemodynamic indices of microvascular perfusion measured 4-5 days after p-PCI. The secondary end points were ST segment resolution at 90 min, the corrected TIMI frame count and myocardial blush grade. At 6 months, echocardiography and technetium-99m single-photon-emission computed tomography were performed. RESULTS: Microvascular perfusion did not differ significantly between the two treatment groups: index of microvascular resistance (27 ± 13 vs. 35 ± 15 U, P = 0.08) and coronary flow reserve (2.2 ± 0.7 vs. 1.9 ± 0.6, P = 0.25). The corrected TIMI frame counts assessed in the first (P = 0.13) and the second (P = 0.09) catheterization or the myocardial blush grades evaluated immediately (P = 0.23) and 4-5 days after MI (P = 1.00) were not significantly different between the two groups. At 6 months, there was no difference between the two groups in infarct size, left ventricular volumes, or ejection fraction. CONCLUSIONS: The standard intravenous bolus plus maintenance infusion of tirofiban in p-PCI is not superior to intracoronary bolus-only administration with respect to microvascular perfusion. Further, adequately powered randomized trials are warranted to evaluate the clinical outcomes associated with this strategy.

Intraventricular and papillary muscle dyssynchrony is related to the diastolic phase of functional mitral regurgitation in patients with non-ischemic dilated cardiomyopathy.

BACKGROUND AND AIM OF THE STUDY: Functional mitral regurgitation (FMR) is commonly encountered in patients with heart failure, and is associated with an adverse prognosis. It is hypothesized that left ventricular (LV) and papillary muscle systolic dyssynchrony causes diastolic mitral regurgitation (DMR) in non-ischemic dilated cardiomyopathy (DC) patients. METHODS: A total of 77 patients with non-ischemic DC was enrolled, of whom 25 were without DMR (group I) and 52 with DMR (group II). Mitral valve apparatus measurements were calculated using two-dimensional echocardiography, while LV/papillary muscle (Pap-index) systolic dyssynchrony parameters were calculated using tissue Doppler echocardiography. RESULTS: The FMR volumes were similar between the two groups (19.4 +/- 10.6 and 22.4 +/- 11.1 ml/beat in groups I and II, respectively). Both groups had similar mitral valves, as assessed by the geometry of the mitral valve apparatus parameters, including tent area, mitral annulus diameter, and tethering distance. However, the maximal intraventricular mechanical delay (MIMD; p < 0.001), peak (+/- SD) myocardial sustained systolic velocity (Ts-SD; p < 0.001) and Pap-index (p < 0.001) were each significantly increased in group II. Strong correlations were apparent between DMR and dyssynchrony parameters [(Ts-SD; r = 0.74, p < 0.001), MIMD (r = 0.78, p < 0.001) and Pap-index (r = 0.78, p < 0.001)]. Linear regression analysis revealed the MIMD (OR 2.94, 95% CI 2.7-6.6, p < 0.001), Ts-SD (OR 3.6, 95% CI 1.2-3.5, p < 0.001) and Pap-index (OR 2.2, 95% CI 1.27-1.35, p = 0.001) to be independent predictors of DMR. CONCLUSION: In patients with non-ischemic DC, DMR may serve as a useful indicator of mechanical LV/papillary muscle dyssynchrony, especially when used in combination with the other echocardiographic parameters.

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.

In-hospital prognostic value of admission plasma B-type natriuretic peptide levels in patients undergoing primary angioplasty for acute ST-elevation myocardial infarction.

OBJECTIVES: We assessed in-hospital prognostic value of admission plasma B-type natriuretic peptide (BNP) levels in patients undergoing primary percutaneous coronary intervention (p-PCI) for acute ST-elevation myocardial infarction (STEMI). STUDY DESIGN: In a retrospective design, we evaluated 992 patients (801 males, 191 females; mean age 56 ± 12 years) treated with p-PCI for STEMI. The patients were divided into two groups according to the admission BNP levels, taking the cut-off value of BNP as 100 pg/ml; i.e, ≥ 100 pg/ml (n=334, 33.7%) and <100 pg/ml (n=658, 66.3%). Postprocedural angiographic and clinical in-hospital results were recorded. RESULTS: No-reflow (24% vs. 9%), heart failure (32.3% vs. 5.5%) and death (15.6% vs. 1.7%) were significantly more common in patients with BNP ≥ 100 pg/ml (p<0.001). In multivariate analysis, elevated baseline BNP level was identified as an independent predictor of no-reflow (OR=1.83; 95% CI 1.22-2.74, p=0.003), acute heart failure (OR=2.67; 95% CI 1.55-4.58, p<0.001), and in-hospital mortality (OR=3.28; 95% CI 1.51-7.14, p=0.003). In receiver operating characteristic curve analysis, the area under the curve and sensitivity/specificity of the cut-off value of BNP (100 pg/ml) for prediction of clinical endpoints were 0.741 and 58.6%/70.3% for no-reflow, 0.822 and 75%/73.3% for heart failure, and 0.833 and 82.5%/69.4% for death, respectively (p<0.001 for all). CONCLUSION: Elevated admission BNP level is an independent predictor of angiographic no-reflow, acute heart failure, and mortality in STEMI patients during in-hospital period, suggesting that it might be incorporated into traditional risk scoring systems to improve early risk stratification.

Primary angioplasty in a high-volume tertiary center in Turkey: in-hospital clinical outcomes of 1625 patients.

OBJECTIVES: We evaluated in-hospital results of primary percutaneous coronary intervention (PCI) in a high-volume tertiary center. STUDY DESIGN: We retrospectively evaluated 1625 patients (1323 males, 302 females; mean age 56.0 ± 11.6 years) who underwent primary PCI for acute ST-elevation myocardial infarction between January 2006 and April 2008. All coronary angiography procedures were performed using the femoral artery route. In-hospital clinical and angiographic results were recorded. RESULTS: On admission, 23% of the patients had diabetes mellitus, 49.6% had anterior myocardial infarction, and 4.9% had cardiogenic shock. The mean duration of pain was 171.2 ± 121.2 minutes, and the mean door-to-balloon time was 31.6 ± 7.2 minutes. Infarct-related artery was the left anterior descending artery in 49.7%, multivessel disease was present in 40.9%, TIMI 2/3 flow was present in 23.6%, and high-grade thrombus was observed in 66.8%. Primary PCI involved balloon dilatation (5.7%) and stent implantation (94.3%). The incidence of angiographic no-reflow was 11.9%. The mean hospital stay was 5.2 ± 3.3 days. All-cause mortality occurred in 71 patients (4.4%). Other in-hospital events were reinfarction (1.4%), target vessel revascularization (1.9%), hemorrhagic/ischemic stroke (0.6%), stent thrombosis (1.2%), major bleeding (3.8%), blood transfusion (4.8%), heart failure (10.5%), atrial fibrillation (4%), and ventricular tachycardia (3.9%). CONCLUSION: Primary PCI is an effective method in achieving complete revascularization of the infarct-related artery. Successful in-hospital results not only depend on the experience and equipment of the center, but also on how rapidly reperfusion is achieved.

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.

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.

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.

Assessment of atrial electromechanical delay by tissue Doppler echocardiography in patients with nonischemic dilated cardiomyopathy.

BACKGROUND: Atrial electromechanical delay (AEMD) calculated from tissue Doppler imaging (TDI) echocardiography can be an alternative to invasive electrophysiologic studies. We investigated whether the AEMD obtained from TDI is prolonged in patients with nonischemic dilated cardiomyopathy (DCM). METHODS: Fifty-five patients with nonischemic DCM (23 men/32 women; age, 43.9 +/- 14.8 years) and 55 controls (20 men/35 women; age, 41.3 +/- 13.4 years) were included in this study. Atrial electromechanical delay (the time interval from the onset of P wave on electrocardiogram to the beginning of late diastolic wave [Am wave] on TDI) was calculated from the lateral and septal mitral annulus, and lateral tricuspid annulus (PA lateral, PA septum, and PA tricuspid, respectively). P-wave dispersion was calculated from the 12-lead electrocardiogram. RESULTS: PA lateral and PA septum duration were significantly longer in patients with nonischemic DCM than the controls (78.4 +/- 19.7 versus 53.8 +/- 6.6 and 55.2 +/- 16.3 versus 40.5 +/- 6.2, P < .0001 for both; respectively). However, PA tricuspid duration was statistically similar between the 2 groups (36.4 +/- 10.9 versus 37.2 +/- 5.7, P > or = .05). P-wave dispersion was significantly higher in nonischemic DCM patients than the controls (53.0 +/- 14.4 versus 37.5 +/- 5.5, P < .0001). PA lateral was correlated with the left atrial maximal volume (r = 0.64, P < .0001), P-wave dispersion (r = 0.65, P < .0001), and log B-type natriuretic peptide (NT proBNP) (r = 0.63, P < .0001). There was a statistically significant and negative correlation between the PA lateral and left ventricular ejection fraction (r = -0.63, P < .0001) and E-wave deceleration time (r = -0.34, P < .0001). Multivariate analysis revealed that left atrial maximal volume and log NT proBNP were the independent predictors of PA lateral (P < .0001 and P = .003, respectively). CONCLUSION: The AEMD was significantly prolonged in patients with nonischemic DCM. Left atrial enlargement and log NT proBNP were the independent predictors of this prolongation.