Ventricular and atrial functions assessed by speckle-tracking echocardiography in patients with human immunodeficiency virus.

PURPOSE: Antiretroviral therapy (ART) has dramatically changed the clinical manifestation of human immunodeficiency virus (HIV) associated cardiomyopathy from severe left ventricular (LV) systolic dysfunction to a pattern of subclinical cardiac dysfunction. The aim of this study was to evaluate by speckle tracking echocardiography (STE) LV, right ventricular (RV), and biatrial functions in HIV-infected patients under different ART combinations. METHODS: We consecutively included 128 HIV-infected patients (mean age 44.2 ± 10.1 years, 110 males) and 100 controls (mean age 42.1 ± 9.4 years, 83 males). Ventricular and atrial functions were assessed by both conventional and STE. RESULTS: Although there was not any significant difference in conventional echocardiographic variables, HIV-infected patients had significantly lower LV global longitudinal strain (GLS), RV GLS, left atrial (LA) reservoir and conduit strain, and right atrial conduit strain. HIV patients receiving integrase strand transfer inhibitors and protease inhibitors (PI) had significantly lower LV GLS and LA conduit strain, while patients receiving non-nucleoside reverse transcriptase inhibitors and PI had significantly lower RV GLS than controls. CD4 count at the time of echocardiography was strongly correlated with LV GLS (r = .619, P < .001) and RV GLS (r = .606, P < .001). CONCLUSION: Biventricular and atrial functions are subclinically impaired in HIV-infected patients. ART regimen may also affect myocardial functions.

Evaluation of right ventricular dyssynchrony in patients with acute inferior myocardial infarction and its relation with mortality.

PURPOSE: The aim of this study was to evaluate right ventricle (RV) dyssynchrony and its relation with mortality using speckle-tracking echocardiography (STE) in patients with acute inferior myocardial infarction (IMI). METHODS: One hundred and fifty-eight consecutive patients with acute IMI treated with primary percutaneous coronary intervention, and 44 healthy subjects were included. RV myocardial involvement (RVMI) was defined as an elevation >1 mm in V1 or V4R and/or the presence of a culprit lesion at the proximal portion of the first RV marginal branch after reviewing coronary angiography. Patients were followed for 3 years to determine the cardiovascular mortality. RESULTS: Overall, 70 patients with IMI had RVMI. IMI patients had significantly higher RV peak systolic longitudinal strain dyssynchrony (PLSSD) index, lower peak longitudinal systolic strain (PLSS), longer time to PLSS, and time to PLSS differences compared to healthy controls while the patients with RVMI had significantly worse values compared to patients without RVMI and healthy controls. Twenty-seven patients (17.1%) died within 2 years. RVMI was more prevalent in mortality group, and they had significantly higher RV PSSD index, whereas they had lower RV free wall PLSS and longer time to PLSS differences. Receiver operating characteristics (ROC) analysis revealed that a RV PLSSD index > 65 ms predicted mortality with a sensitivity of 88.9% and specificity of 71.8% in IMI patients. CONCLUSIONS: Intra- and inter-ventricular dyssynhcrony may develop in patients with acute IMI, especially in those with RV involvement, which might have a negative effect on the prognosis of these patients.

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.

"Main Vessel-Oriented" Treatment Strategy Versus "Open Side Branch" Treatment Strategy in Acute Coronary Syndrome Patients With Culprit Bifurcation Lesions.

Percutaneous coronary intervention of bifurcation lesions is associated with an increased risk of complications in patients with acute coronary syndrome (ACS). The study aimed to evaluate the in-hospital outcomes of patients with ACS with culprit bifurcation lesions who were treated with either a "main vessel-oriented" (MVO) treatment strategy or an "open side branch" (OSB) treatment strategy. This retrospective study included 575 consecutive patients with ACS. "MVO" and "OSB" treatment strategies were defined as primary/urgent percutaneous coronary intervention procedures performed by either totally ignoring the side branch (SB) or trying to maintain both main vessel and SB open with thrombolysis in myocardial infarction 3 flow. Procedural success and major cardiac/cerebrovascular events during hospitalization were noted. MVO and OSB treatment strategies were performed on 384 and 191 patients, respectively. The procedural success rate was significantly higher in the OSB treatment strategy whereas major cardiac/cerebrovascular events rates were similar except for the contrast-induced nephropathy rate being slightly higher in OSB treatment strategy. Subgroup analysis revealed a significantly higher procedural success rate in OSB treatment strategy if the SB was located within the bifurcation core, especially in those where the diameter of SB was ≥2 mm. In conclusion, our results suggest a better procedural result with SB protection attempts in patients with ACS with a culprit bifurcation lesion if the SB is originating within the bifurcation core and its diameter is ≥2 mm. MVO treatment strategy may be preferred in most cases with minor SBs located distant to the bifurcation core because of the similar procedural success.

Evaluation of Arterial Stiffness Parameters and the Growth Differentiation Factor-15 Level in Patients with Premature Myocardial Infarction.

BACKGROUND: Myocardial infarction (MI) is increasing at a younger age. Growth differentiation factor-15 (GDF-15) has been implicated in several key mechanisms of atherogenesis. Arterial stiffness parameters, including pulse wave velocity (PWV) and the augmentation index (AIx), can indicate the presence or progression of atherosclerosis. The aim of this study is to evaluate the GDF-15 level and arterial stiffness parameters in patients with premature MI. METHOD: Thirty patients aged ≤45 years (mean age: 39 ± 5 years, 23 male) who recovered from a MI and 15 age and sex-matched subjects were consecutively included. The serum GDF-15 concentration levels and arterial stiffness parameters of the patients and controls were measured. RESULTS: GDF-15 levels were significantly higher in patients with premature MI, while there were no significant differences in PWV and AIx between the groups. The GDF-15 level was correlated negatively with high-density lipoprotein (HDL) cholesterol and positively with uric acid levels. Both GDF-15 (p = 0.046, odds ratio: 1.092, 95% confidence interval: 1.003-1.196) and HDL cholesterol (p = 0.037, odds ratio: 0.925, 95% confidence interval: 0.859-0.995) were found as independent factors associated with premature MI. CONCLUSIONS: GDF-15 could be a risk factor for premature MI. Further studies are needed to elucidate the central role of GDF-15 in the pathophysiology of early atherosclerosis and MI in the young population.

The Impact of Cystic Fibrosis- and Noncystic Fibrosis-Bronchiectasis on Pulmonary Artery Wall Thickness and Right Heart Functions Assessed by Speckle-Tracking Echocardiography.

BACKGROUND: Right heart functions are affected in patients with bronchiectasis as a result of pulmonary hypertension induced by chronic hypoxemia. Pulmonary artery wall thickness has recently been introduced as a sign of intensive and prolonged inflammation. The aim of this study was to analyze right ventricular and right atrial functions and to mea-sure pulmonary artery wall thickness in patients with cystic fibrosis-bronch iecta sis in comparison to those with noncystic fibrosis-bronchiectasis and healthy individuals. METHODS: We studied 36 patients with cystic fibrosis-bronchiectasis, 34 patients with noncystic fibrosis-bronchiectasis, and 32 age- and sex-matched control subjects. Lung function tests were performed. All subjects underwent comprehensive echocardiographic evaluation including conventional, tissue Doppler, speckle-tracking, and pulmonary artery wall thickness measurements. RESULTS: Right ventricular global longitudinal strain and global longitudinal right atrial strain during ventricular systole decreased in cystic fibrosis-bronchiectasis group compared with noncystic fibrosis-bronchiectasis and control groups (P <.001, both). Conversely, pulmonary artery wall thickness was increased in cystic fibrosis-bronchiectasis group in comparison to other groups (P <.001). Moreover, right ventricular global longitudinal strain was lower and pulmonary artery wall thickness was higher in patients with airflow obstruction (P <.001 and P =.025, respectively) than in those without. Only right ventricular global longitudinal strain was significantly correlated with pulmonary function test parameters. The negative effect of cystic fibrosis on right ventricular and right atrial functions was independent of age, gender, and disease duration. CONCLUSION: Our study showed that right ventricular and right atrial functions were deteriorated and pulmonary artery wall was thickened in cystic fibrosis-bronchiectasis patients more than noncystic fibrosis-bronchiectasis patients. Right ventricular global longitudinal strain detected subclinical right ventricular dysfunction and was associated with the severity of pulmonary disease.

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.

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.

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.

Bleeding risk with concomitant use of tirofiban and third-generation P2Y12 receptor antagonists in patients with acute myocardial infarction: A real-life data.

OBJECTIVE: Combination of dual antiplatelet therapy (DAPT) with glycoprotein (GP) IIb/IIIa inhibitors can increase bleeding risk. In this study, we aimed to investigate bleeding complications of different DAPTs with concomitant tirofiban use in patients with acute coronary syndrome (ACS). METHODS: This retrospective study included 224 consecutive ACS patients (mean age 56.6±11.1 years, 193 men) who were given conventional dose of tirofiban (25 µg/kg per 3 minutes followed by an infusion of 0.15 µg/kg/min for 24 hours) in addition to DAPT (300 mg aspirin followed by 100 mg/day + 600 mg clopidogrel followed by 75 mg/day or 180 mg ticagrelor followed by 90 mg twice daily or 60 mg prasugrel followed by 10 mg/day). Any intra-hospital bleeding complications were noted. RESULTS: Of the 224 patients, 115 were given ticagrelor and 32 were given prasugrel. Mean hemoglobin fall was similar between the patients taking ticagrelor/prasugrel and those taking clopidogrel. Ten patients taking ticagrelor and one patient taking prasugrel had hemoglobin fall ≥3 g/dL versus two patients in clopidogrel group (p=0.228). Gastrointestinal bleeding (two patients taking ticagrelor), hematoma at access site (three patients taking ticagrelor), and cardiac tamponade (two patients taking ticagrelor) rates were also similar. Creatinine levels were associated with hemoglobin fall ≥3 g/dL (p=0.032, Odds ratio 2.189, 95% confidence interval 1.070-4.479). There was no relation between hemoglobin fall ≥3 g/dL and antiplatelet agent, age, sex, hypertension, or diabetes. CONCLUSION: Tirofiban may be given to patients receiving ticagrelor or prasugrel with a bleeding rate similar to clopidogrel. Close monitoring for bleeding risk is recommended, especially in patients with higher creatinine levels.

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.

Apical transverse motion as surrogate parameter to determine regional left ventricular function inhomogeneities: a new, integrative approach to left ventricular asynchrony assessment.

AIMS: Left ventricular (LV) asynchrony assessment is mostly based on delays between regional myocardial velocity peaks. Regional function is barely considered. We propose apical transverse motion (ATM) as a new parameter integrating both temporal and functional information, which was tested in different conduction delays. METHODS AND RESULTS: We examined 67 patients, 11 patients with post-infarct ischaemic left bundle branch blocks (iLBBB) and 25 patients with non-ischaemic left bundle branch block (nLBBB), 12 patients with right bundle branch block (RBBB), and 19 normal healthy volunteers (NORM). Longitudinal colour tissue Doppler data were used to calculate the total transverse apex motion (ATM), the transverse motion in the four-chamber view plane alone (ATM(4CV)) as well as regional myocardial deformation and conventional LV asynchrony parameters. Median ATM was 1.8 mm in NORM, 1.5 mm in RBBB (P = 0.999), 2.4 mm in iLBBB (P = 0.183), and 4.3 mm in nLBBB (P < 0.001 vs. NORM and RSB). ATM(4CV) behaved similarly, showed a good correlation with regional deformation data, and distinguished well between NORM and LBBB (AUC = 0.87). CONCLUSION: Apical transverse motion is a new and simple parameter integrating information on both regional and temporal function inhomogeneities of the LV. It has a potential role in assessing LV asynchrony in the clinical context.

The evaluation of ventricular functions by speckle tracking echocardiography in preeclamptic patients.

Preeclampsia is a maternal disorder of pregnancy characterized by concomitant increase in preload and afterload with end organ dysfunction. The aim of our study is to evaluate left ventricular (LV) and right ventricular (RV) functions with speckle tracking echocardiography in preeclamptic patients. Fifty-five preeclamptic (mean age: 30.7 ± 5.9 years) and 35 healthy pregnant women (mean age: 28.8 ± 5.7 years) of the same race, similar age and gestational week were consecutively included. The diagnosis of preeclampsia was based on the criteria proposed by the American College of Obstetricians and Gynecologists. LV and RV functions were assessed by both conventional and speckle tracking echocardiography after the 30th gestational week and at the postpartum 6th months. The preeclamptic patients had significantly larger left atrium, thicker interventricular septum, higher systolic pulmonary artery pressure and mitral E/e' ratio compared to controls during pregnancy while LV ejection fraction was similar. Preeclamptic patients had significantly lower LV and RV global longitudinal strain (GLS) during pregnancy compared to controls (- 18.0 ± 2.6% vs. - 19.8 ± 2.1% p = 0.001 and - 26.7 ± 3.3% vs. 28.9 ± 3.3% p = 0.002, respectively). In the postpartum period, while LVGLS values of preeclamptic patients increased significantly (- 18.0 ± 2.6% vs. - 20.4 ± 2.4% p < 0.001) and became similar to those of controls at the sixth month, the RVGLS decreased significantly (- 26.7 ± 3.3% vs. - 25.8 ± 2.7% p = 0.003) making the difference in RVGLS between the preeclamptic patients and controls more prominent. Preeclampsia may impair LV and RV function. Long-term follow up with larger sample is needed to determine the clinical relevance of the observed changes in strain.

Prognostic utility of anemia and pro-B-type natriuretic peptide in patients with nonischemic dilated cardiomyopathy and normal renal function.

BACKGROUND: Idiopathic dilated cardiomyopathy frequently coexists with anemia and high plasma NT proBNP levels. However, the prognostic impact of these features on the disease course is uncertain, especially in patients with normal renal function. METHODS: Forty-seven patients with idiopathic dilated cardiomyopathy with sinus rhythm and normal renal function were prospectively followed for a mean 25+/-18 months period. Clinical end points were death (sudden cardiac death and deaths because of worsening heart failure) and cardiac transplantation. Prognostic impact of NT proBNP levels, anemia, echocardiographic and clinical parameters on the clinical end points was evaluated with Kaplan-Meier survival analysis. Cut-off values of hemoglobin and plasma NT proBNP levels for predicting end points were determined by receiver operating curve analysis. RESULTS: Twenty-eight patients (59.6%) suffered clinical end points. The patients who suffered clinical end points were anemic (P=0.002), had lower systolic (P<0.003) and diastolic (P<0.0001) blood pressures, and higher NYHA functional classes (P=0.005), lower left ventricle ejection fractions (P=0.003), higher E/A ratios (P=0.001), shorter E-wave deceleration times (P=0.001), isovolumetric relaxation times (P=0.05) and pulmonary acceleration times (P=0.004), and higher plasma NT proBNP levels (P<0.0001). Anemic patients had more clinical end points (P=0.002). In univariate analysis the prognostic predictors of life expectancy were log NT proBNP, anemia, NYHA functional class, systolic blood pressure, left ventricle ejection fraction, and E-wave deceleration time. However, multivariate analysis revealed only plasma NT proBNP as independent predictor of clinical end points. CONCLUSION: Tracking plasma NT proBNP levels is a useful strategy during routine follow-ups of patients with nonischemic dilated cardiomyopathy. Its predictive value for prognosis needs more evaluation in larger controlled studies. In addition, the importance of anemia in those patients needs more study.

The influence of dipper and nondipper blood pressure patterns on left ventricular functions in hypertensive patients: a tissue Doppler study.

OBJECTIVES: We investigated the effect of dipper and non-dipper blood pressure patterns on left ventricular diastolic filling parameters in hypertensive patients. STUDY DESIGN: Fifty-five hypertensive patients (37 women, 18 men; mean age 55+/-10 years) were evaluated with echocardiography and ambulatory 24-hour blood pressure monitoring. All the patients received antihypertensive drug therapy for at least three months prior to the evaluations. Tissue Doppler-derived systolic and diastolic parameters were compared. RESULTS: Dipper and nondipper blood pressure patterns were found in 22 patients (40%) and 33 patients (60%), respectively. Both groups had similar left ventricular systolic and diastolic diameters. Dipper patients had significantly lower values for left atrial diameter (p<0.0001), interventricular septum (p=0.001) and posterior wall (p=0.012) thickness, left ventricular mass (p=0.017) and mass index (p=0.021). Both groups had similar mitral E and A waves, E/A ratio, E-wave deceleration time, isovolumetric relaxation time, and tissue Doppler-derived A' wave. Dipper patients had a significantly lower E/E' ratio (10.8+/-3.4 vs. 14.1+/-3.6; p=0.002) and significantly higher systolic (S') (p=0.05) and early diastolic (E') (p=0.027) tissue velocities. Based on the E/E' ratios being <15 or = or >15, the frequency of dipper hypertension was significantly higher in patients with E/E' <15 (48.8% vs. 9.1%; p=0.019). The frequency of dippers was also higher among patients having an E/E' ratio of <8, compared to those having an E/E' ratio of = or >8 to <15 (90% vs. 35.3%; p=0.019). CONCLUSION: Nondipper blood pressure pattern may be associated with increased left ventricular mass, impaired left ventricular systolic and diastolic dysfunction, and higher left ventricular filling pressures.