Left atrial function and atrial natriuretic factor/cyclic guanosine monophosphate changes in DDD and VVI pacing modes.

Left atrial systolic function and the plasma of atrial natriuretic factor (ANF) and cyclic guanosine monophosphate (cGMP) were investigated as possible markers for the development of pacemaker syndrome during VVI pacing. Patients who developed pacemaker syndrome during VVI pacing had a significant decrease in left atrial emptying fraction and a substantial increase in ANF and cGMP plasma levels.

Evaluation of left ventricular diastolic function in patients with non-Q-wave myocardial infarction and its correlation with underlying coronary artery disease.

Left ventricular diastolic function was studied by Doppler echocardiography in 35 patients with non-Q-wave myocardial infarction, on the third and tenth day of hospitalization and six weeks after hospitalization and was correlated with electrocardiogram, serum enzyme values, and angiographic data. Normal diastolic function on the first echocardiographic study predicted (p = 0.0001) the existence of no or single-vessel disease, and excluded (p = 0.005) the presence of 3-vessel or left main disease, whereas an abnormal study on either the second or third echocardiographic discriminated (p = 0.0001), with higher sensitivity (80.97%, 92.31%, respectively), patients with 3-vessel or left main vessel disease.

Evaluation of serial QT dispersion in patients with first non-Q-wave myocardial infarction: relation to the severity of underlying coronary artery disease.

BACKGROUND: Increased QT dispersion (QTD) has been correlated with ventricular arrhythmias. Recent reports suggest that it may serve as a marker of the severity of underlying coronary artery disease (CAD). HYPOTHESIS: The aim of this study was to examine in-hospital changes of QTD and their possible correlation with the severity of underlying CAD in patients with first non-Q-wave myocardial infarction. METHODS: In 62 patients we estimated QTD, precordial QTD, as well as their values corrected for heart rate on Days 3 and 7 after admission. The severity of underlying ischemic burden was estimated by means of the number of diseased vessels as well as by the jeopardy score. RESULTS: On Day 3, patients with jeopardy score > or = 6 exhibited greater QTD, corrected QTD, precordial QTD, and corrected precordial QTD (p = 0.001, p = 0.003, p = 0.02, p = 0.036, respectively); patients with multivessel disease had greater QTD (p = 0.007). On Day 7, patients with jeopardy score > or = 6 and multivessel disease exhibited greater QTD, corrected QTD, precordial QTD, and corrected precordial QTD (p < 0.001 for all). Multiple regression analysis revealed a jeopardy score of > or = 6 as the most significant independent predictor for QTD variables. From Days 3 to 7, only patients with none or one diseased vessel orjeopardy score < 6 had shortened QTD (p = 0.01 and p = 0.015, respectively) and corrected QTD (p < 0.001 for both). CONCLUSIONS: In patients with first non-Q-wave myocardial infarction, QTD variables and their in-hospital changes reflect the severity of underlying CAD.

Thirty one-year durability of a Starr-Edwards aortic prosthesis.

We report the case of a 57-year old man who was admitted to our department because of worsening dyspnea - orthopnea and whose aortic valve had been replaced 31 years previously, with a Starr-Edwards caged-ball prosthesis. His symptoms' deterioration was due to a recent myocardial infarction which in combination with the chronic mitral regurgitation of rheumatic origin led to heart failure. As assessed by echocardiography the mechanical prosthesis did not show signs of significant dysfunction and except for mild regurgitation, it had a good performance. Despite some valve related complications, such as the recurrent thromboembolic events that our patient had, his Starr Edwards aortic prosthesis demonstrated an excellent long term durability and reliability.

Emergency bedside echocardiography as a tool for early detection and clinical decision making in cases of suspected pulmonary embolism--a case report.

Massive pulmonary embolism (PE) constitutes the most unexpected cause of death in necropsy. Consequently, prompt diagnosis and treatment is considered imperative. This article reports the case of a 37-year-old man who presented with cardiogenic shock due to PE as detected with bedside echocardiography in the emergency department. The authors wish to emphasize the usefulness of emergency bedside echo-Doppler for a prompt diagnosis and treatment of this life threatening condition.

Incidence of inferior vena cava thrombosis detected by transthoracic echocardiography in the immediate postoperative period after adult cardiac and general surgery.

Venous thromboembolism is an important complication after general and cardiac surgery. Using transthoracic echocardiography, this study assessed the incidence of inferior vena cava (IVC) thrombosis among a total of 395 and 289 cardiac surgical and major surgical patients in the immediate postoperative period after cardiac and major surgery, respectively. All transthoracic echocardiography was performed by a specialist intensivist within 24 hours after surgery with special emphasis on using the subcostal view in the supine position to visualise the IVC. Of the 395 cardiac surgical patients studied, the IVC was successfully visualised using the subcostal view in 315 patients (79.8%) and eight of these patients (2.5%) had a partially obstructive thrombosis in the IVC. In 250 out of 289 (85%) general surgical patients, the IVC was also clearly visualised, but only one patient (0.4%) had an IVC thrombosis (2.5 vs 0.4%, P <0.05). In summary, visualisation of the IVC was feasible in most patients in the immediate postoperative period after both adult cardiac and major surgery. IVC thrombosis appeared to be more common after adult cardiac surgery than general surgery. A large prospective cohort study is needed to define the risk factors for IVC thrombus and whether early thromboprophylaxis can reduce the incidence of IVC thrombus after adult cardiac surgery.

Evaluation of left atrial longitudinal function in patients with hypertrophic cardiomyopathy: a tissue Doppler imaging and two-dimensional strain study.

OBJECTIVE: We sought to quantify left atrial longitudinal function by tissue Doppler (TDI) and two-dimensional (2D) strain in patients with hypertrophic cardiomyopathy (HCM). DESIGN: Case-control study. SETTING: Tertiary university hospital. PATIENTS: 43 consecutive patients with familial HCM, aged 49 (SD 18) years, along with 21 patients with non-HCM left ventricular hypertrophy (LVH, aged 52 (12) years) and 27 healthy volunteers (aged 42 (13) years). INTERVENTIONS: Subjects were studied by both TDI and 2D left atrial strain during all three atrial phases (reservoir, conduit, contractile), as well as by left ventricular systolic strain; total atrial deformation (TAD) was defined as the sum of maximum positive and maximum negative strain during a cardiac cycle. MAIN OUTCOME MEASURES: Left atrial longitudinal function. RESULTS: Both TDI and 2D atrial strain and TAD were significantly reduced in HCM, compared to the other two groups in all atrial phases (p<0.001 in most cases); left ventricular systolic strain was also significantly reduced in HCM (p<0.001). Adding 2D contractile atrial strain to a model of conventional echo measurements (including left atrial diameter and volume index, interventricular septal thickness and E/A ratio and E/e' ratios) increased its prognostic value in differentiating HCM from non-HCM LVH (p value of the change <0.001), while addition of TDI atrial strain or left ventricular strain did not. A cut-off for 2D contractile strain of -10.82% discriminated HCM from non-HCM LVH with a sensitivity of 82% and a specificity of 81%. Intra-observer and inter-observer variabilities for atrial strain in HCM were 16% and 17.5% for TDI and 8% and 9.5% for 2D, respectively. Processing time per case in HCM was 12.5 (2.6) minutes for TDI versus 3.8 (1.2) minutes for 2D strain (p<0.001). CONCLUSION: Left atrial longitudinal function is reduced in HCM compared to non-HCM LVH and healthy controls. In addition, 2D atrial strain has an additive value in differentiating HCM from non-HCM LVH and it is more reproducible and less time consuming than TDI strain.

Effects of serial levosimendan infusions on left ventricular performance and plasma biomarkers of myocardial injury and neurohormonal and immune activation in patients with advanced heart failure.

BACKGROUND: Levosimendan is a novel inodilator that improves central haemodynamics and symptoms of patients with decompensated chronic heart failure. The role, however, of repeated levosimendan infusions in the management of these patients has not yet been properly assessed. PURPOSE: This randomised placebo-controlled trial investigated the effects of serial levosimendan infusions on cardiac geometry and function, and on biomarkers of myocardial injury and neurohormonal and immune activation (troponin T, N-terminal B-type natriuretic pro-peptide (NT-proBNP), C reactive protein (CRP) and interleukin (IL) 6) in patients with advanced heart failure. METHODS: 25 patients with decompensated chronic heart failure were randomised (2:1) to receive five serial 24-h infusions (every 3 weeks) of either levosimendan (n = 17) or placebo (n = 8), and were evaluated echocardiographically and biochemically before and after each drug infusion and 30 days after the final infusion. RESULTS: Following treatment, cardiac end-systolic and end-diastolic dimension and volume indices were significantly reduced only in the levosimendan-treated patients (p<0.01). A significant decrease in NT-proBNP (p<0.01), high-sensitivity CRP (p<0.01) and plasma IL6 (p = 0.05) was also observed in the levosimendan group, whereas these markers remained unchanged in the placebo group; similar changes were observed after each drug infusion. Although the number of patients with a positive troponin T (>or=0.01 ng/ml) was not different between the two groups at baseline, it was significantly higher in the placebo-treated group during the final evaluation (p<0.05). CONCLUSION: Serial levosimendan treatments improved left ventricular performance and modulated neurohormonal and immune activation beneficially in patients with advanced heart failure, without increasing myocardial injury.

Tissue Doppler echocardiography contribution to the diagnosis of upper extremities venous thrombosis.

We present the case of a 35-year-old man with a history of beta-thalassemia complicated with heart failure who was admitted to our department because of right arm painful swelling. A transthoracic echo-Doppler study revealed a mass within the right jugular vein (RJV) lumen and absence of flow within the right subclavian vein (RSV). Subsequently, color tissue Doppler echocardiography clearly demonstrated the intraluminal mass by means of its different color hues as compared with the surrounding vessel wall, further enforcing the suspicion of upper extremity vein thrombosis (UEVT). It is emphasized that tissue Doppler echocardiography, a safe and reproducible method, can contribute to the diagnosis of UEVT.

Ruptured aneurysm of the sinus of Valsalva associated with an atrial septal aneurysm.

Aneurysm of the sinus of Valsalva (ASV) is a rare cardiac disease that may be acquired or congenital. It is usually an asymptomatic condition; however, when it ruptures, symptoms appear and the condition deteriorates rapidly. Atrial septal aneurysm (ASA) is a localized "saccular" deformity of the interatrial septum that is associated with cerebrovascular events of embolic origin. We will report on a case of a 69-year-old woman who was referred to our department because of congestive heart failure. Echocardiographic evaluation, both transthoracic and transesophageal, disclosed a ruptured aneurysm of the right sinus of Valsalva into the right atrium (RA), which was associated with an aneurysm of the atrial septum.

Effects of a preload increase on ventricular filling in coronary artery disease.

This study was conducted to investigate the effects of a preload increase on ventricular filling dynamics in 50 coronary artery disease patients both before and immediately after leg elevation. Mitral and tricuspid peak E and A velocities and the mitral E/A velocity ratio increased after leg elevation whereas isovolumic relaxation time and mitral deceleration time decreased. The increase in tricuspid peak A velocity after leg elevation was related to the positivity of the exercise stress test (p = 0.01). The increase in mitral peak A velocity was related to the history of old myocardial infarction (p = 0.006).

Effect of different AV delays on left ventricular diastolic function and ANF levels in DDD paced hypertensive patients during daily activity and exercise.

Fifteen hypertensive patients (13 men) with left ventricular hypertrophy, mean age 69 6 5 years, having complete heart block and paced in the DDD mode, were studied by two-dimensional and Doppler echo in 100 and 200 ms atrioventricular delays. ANF plasma levels were measured at rest and at peak exercise, during pacing with the two different atrioventricular delays. ANF plasma levels were significantly higher at pacing with long atrioventricular delays (200 ms), at rest (152.47 6 12.38 pg/mL vs 119 6 12.38 pg/mL, P, 0.001) and at exercise (180.93 6 11.51 vs 123.67 6 16.24 pg/mL, P, 0.0001). ANF plasma levels were significantly increased at exercise, compared to those at rest during pacing with the two different atrioventricular delays, but we found a more pronounced increase of ANF levels (from 152.47 6 10.49 pg/mL to 180.93 6 11.51 pg/mL), when the atrioventricular delays was set to 200 ms (P, 0.0001). A significant decrease of isovolumic relaxation time (from 123.33 6 20.5 to 105.33 6 11.06 ms, P, 0.001) was observed, during pacing with the short atrioventricular delays. Moreover, the peak early (E) to peak atrial (A) velocity ratio (E/A) was declined (from 0.89 6 0.7 to 0.57 6 0.18, P, 0.05). We also noticed that patients with small left ventricles exhibit greater increase in ANF plasma levels during DDD pacing with long atrioventricular delays (r 5 20.792, P 5 0.000). In conclusion, left ventricular diastolic function of our patients seems to be improved during DDD pacing with short (100 ms) atrioventricular delays, as it was expressed by echocardiographic and hormonal measurements.