Levosimendan ­ a valuable player in the treatment of a right-sided heart failure

A 66 year-old obese man, suffering from type 2 diabetes, high blood pressure, chronic nephropathy in stage 4, permanent atrial fibrillation accompanied by bradycardia was admitted to a cardiology ward with the signs and symptoms of acute right-sided heart failure. A standard therapy was used including combined diuretics therapy. In spite of the applied methods and pharmaceuticals, no significant reduction of the body weight neither improvement in cardiovascular capacity or renal parameters were observed. Due to the ineffectiveness of the standard combined pharmacotherapy applied in the case of the acute circulatory failure, the resistance to diuretics was recognized and as a result of the above, infusion of levosimendan was decided to be applied. This therapy resulted in rich diuresis, significant loss in body weight and considerable improvement in cardiovascular capacity which allowed to continue further diagnostics and appropriate invasive treatment. The article describes current knowledge on the place of levosimendan and its application in the treatment of an right-sided heart failure.

[Niewydolnosc serca - problem medyczny, ekonomiczny i spoleczny].

Heart failure has accompanied mankind since the dawn of time. The first mentions of the disease, which today we describe as heart failure, come from ancient times. Epidemiology of symptomatic heart failure is well known , especially in Europe. Heart failure affects approximately 2% of the adult population in Europe. The article presents: definition, epidemiology and prognosis of patients with heart failure. The article presents current methods of pharmacotherapy and treatment of heart failure. An important element in the management of patients with heart failure is medical rehabilitation and the prevention of cardiovascular diseases, according to the ESC guidelines. The topic also discussed in the article is the analysis of socio-economic costs of heart failure. The article concludes that: heart failure is a medical problem, because despite the introduction of new treatment methods, it is a disease that is still characterized by poor prognosis; heart failure is an economic problem because its treatment is expensive and absorbs 2% of all costs of healthcare; heart failure is a social problem because it is a disorder affecting mainly elderly people, leading to a significant reduction in their ability to live independently, which results in their exclusion from social life.

Pulmonary vascular resistance as a potential marker of reactive pulmonary hypertension reduction following sildenafil therapy in patients disqualified from orthotopic heart transplantation.

PURPOSE: We sought to determine the predictors of restoration of heart transplantation (HTx) candidacy in patients with systolic heart failure (HF) and reactive fixed pulmonary hypertension (RFPH) defined as pulmonary vascular resistance (PVR) > 2.5 Wood units (WU), transpulmonary gradient (TPG) > 12 mmHg or ≤2.5 WU with systolic arterial pressure ≤85 mmHg during vasoreactivity test, following sildenafil therapy. MATERIAL AND METHODS: Between 2007 and 2018 1136 patients were evaluated at our department as candidates for HTx. Thirty-five of them, who presented with systolic HF and were not eligible for HTx due to RFPH, were included in the study (31 men aged 55.1 ± 7.4 years). In all the patients sildenafil was introduced and up-titrated to a maximal tolerated dose in addition to optimal medical therapy. Patients were assessed at 3-6 months intervals. RESULTS: During median 11 months (interquartile range 6-18 months) reduction of RFPH enabling qualification for HTx was observed in 62.9% patients. Higher baseline PVR (OR 0.32; 95% CI (0.14-0.74) p < 0.001), pulmonary artery systolic pressure (PASP) (OR 0.94, 95% CI (0.88-0.99) p = 0.05), mean artery pulmonary pressure (mPAP) (OR 0.87, 95% CI (0.77-0.98) p = 0.02) and TPG (OR 082, 95% CI (0.70-0.96) p = 0.003) were negative predictors of RFPH reduction with sildenafil therapy. In multivariable analysis, lower PVR (p = 0.02) was identified as an independent predictor of RFPH reduction following sildenafil therapy. CONCLUSION: Sildenafil therapy can support PH reduction in systolic HF patients uneligible for HTx due to RFPH. Lower baseline PVR was identified as an independent predictor of PH reversibility with sildenafil enabling restoration of HTx candidacy.

Evaluation of left ventricular systolic and diastolic function in patients with atrioventricular re-entrant tachycardia treated by radiofrequency current ablation.

UNLABELLED: Little is known about the long-term influence of radiofrequency current ablation (RFCA) on left ventricular (LV) systolic and diastolic function in patients with atrioventricular re-entrant tachycardia (AVRT). METHOD: The study group consisted of 65 patients (33 M, mean age 39 +/- 11 y) with WPW syndrome and recurrent episodes of AVRT without any concomitant diseases. The control group consisted of 50 age-matched healthy volunteers. In both study and control groups transthorasic echocardiography (TTE) and Doppler were performed in order to assess LV systolic and diastolic function. In WPW patients TTE was followed by electrophysiology study and RFCA. TTE was repeated in 6-months time in the study group. RESULTS: At 6-month follow-up a decrease in LV end-systolic diameters (1.77 +/- 0.22 vs. 1.67 +/- 0.22 cm/m2, P < 0.001) and volumes (20 +/- 6 vs. 17 +/- 5 ml, P < 0.001) and an increase in LV FS (33 +/- 6 vs. 37 +/- 5%, P < 0.001), EF (54 +/- 6 vs. 60 +/- 5%, P < 0.001), IVS (44 +/- 13 vs. 49 +/- 14%, P < 0.05) and LV PW thickening (58 +/- 19 vs. 62 +/- 16%, P < 0.05) was found. Doppler analysis revealed an increase in E wave (78 +/- 17 vs. 82 +/- 14 cm/s, P < 0.001), E/A ratio (1.14 +/- 0.37 vs. 1.33 +/- 0.24, P < 0.001) and a decrease in A wave (68 +/- 19 vs. 63 +/- 12 cm/s, P < 0.05), DT (219 +/- 33 vs. 180 +/- 20 ms, P < 0.001 ), IVRT (105 +/- 13 vs. 88 +/- 13 ms, P < 0.001), AR (26 +/- 8 vs. 18 +/- 12 cm/s, P < 0.001 ) and difference between duration of AR and A waves (5 +/- 24 vs. -12 +/- 21 ms, P < 0.001). No significant differences in regard to LV systolic and diastolic variables were found between patients and controls post RFCA. CONCLUSION: RFCA of accessory pathway in patients with WPW syndrome and AVRT is associated with improvement of LV systolic and diastolic function.

Myocardial perfusion scintigraphy - interpretation of gated imaging. Part 2.

The first part of the review describes the basic aspects of interpreting myocardial perfusion defects in single photon emission computed tomography (SPECT) scintigraphy. It also presents indications for invasive diagnostics based on stress perfusion defects. This article provides basic information concerning the interpretation of gated SPECT imaging, including such parameters as left ventricular wall motion and thickening as well as left ventricular wall systolic and diastolic function. Gated examination combined with the assessment of myocardial perfusion reduces the rate of false positives results of myocardial perfusion scintigraphy in perfusion tests, additionally providing data on left ventricular systolic and diastolic function.

Doppler predictors of inducibility of atrial fibrillation in patients with WPW syndrome and atrioventricular re-entrant tachycardia.

BACKGROUND: Atrial fibrillation (AF) in patients with Wolff-Parkinson-White syndrome (WPW) may induce complex ventricular arrhythmias resulting in sudden cardiac death. It is essential to find an effective non-invasive diagnostic method allowing to select patients at risk of life-threatening arrhythmias. Our objective was to examine Doppler predictors of AF in patients with WPW and atrioventricular re-entrant tachycardia (AVRT). MATERIAL AND METHODS: 65 patients with WPW and AVRT (33 men, mean age 39 +/- 11 y) were prospectively studied. In all patients TTE was performed with measurements of left ventricle (LV) diameters, volumes and parameters of systolic and diastolic function. TTE was followed by invasive electrophysiology study (EPS) and radiofrequency current ablation of accessory pathway.AF lasting at least 30 s was induced in 29 (44.6%) patients during EPS. Reduction of right upper pulmonary vein (RUPV) systolic velocity (P < 0.005) and systolic to diastolic velocity ratio (P < 0.005) and increase in atrial reversal velocity (P < 0.05) of RUPV flow and difference between duration of RUPV atrial reversal flow and A wave of mitral profile (P < 0.05) were associated with increased risk of AF in patients with WPW syndrome and AVRT. Systolic and atrial reversal velocities were identified as independent predictors of AF in those patients. CONCLUSIONS: Systolic and atrial reversal right upper pulmonary vein flow velocities have been shown to be independent predictors of AF inducibility in patients with Wolff-Parkinson-White syndrome and atrioventricular re-entrant tachycardia.

Interpreting myocardial perfusion scintigraphy using single-photon emission computed tomography. Part 1.

This article discusses the protocol for myocardial perfusion scintigraphy performed with single-photon emission computed tomography (SPECT). Indications for SPECT are listed with consideration given to the results of the increasingly more common angio-CT examinations of the coronary arteries (multislice computed tomography). The paper also presents basic information about interpreting the results, including the scores of left ventricle myocardial perfusion using the 17-segment polar map, and explains the concept of total perfusion deficit.

Predominant location of coronary artery atherosclerosis in the left anterior descending artery. The impact of septal perforators and the myocardial bridging effect.

INTRODUCTION: Coronary artery atherosclerosis presents characteristic patterns of plaque distribution despite systemic exposure to risk factors. We hypothesized that local hemodynamic forces induced by the systolic compression of intramuscular septal perforators could be involved in atherosclerotic processes in the left anterior descending artery (LAD) adjacent to the septal perforators' origin. Therefore we studied the spatial distribution of atherosclerosis in coronary arteries, especially in relation to the septal perforators' origin. MATERIAL AND METHODS: 64-slice computed tomography angiography was performed in 309 consecutive patients (92 male and 217 female) with a mean age of 59.9 years. Spatial plaque distribution in the LAD was analyzed in relation to the septal perforators' origin. Additionally, plaque distribution throughout the coronary artery tree is discussed. RESULTS: The coronary calcium score (CCS) was positive in 164 patients (53.1%). In subjects with a CCS > 0, calcifications were more frequent in the LAD (n = 150, 91.5%) compared with the right coronary artery (RCA) (n = 94, 57.3%), circumflex branch (CX) (n = 76, 46.3%) or the left main stem (n = 42, 25.6%) (p < 0.001). Total CCS was higher in the LAD at 46.1 (IQR: 104.2) and RCA at 34.1 (IQR: 90.7) than in the CX at 16.8 (IQR: 61.3) (p = 0.007). In patients with calcifications restricted to a single vessel (n = 54), the most frequently affected artery was the LAD (n = 42, 77.8%). In patients with lesions limited to the LAD, the plaque was located mostly (n = 37, 88.1%) adjacent to the septal perforators' origin. CONCLUSIONS: We demonstrated that coronary calcifications are most frequently located in the LAD in proximity to the septal branch origin. A possible explanation for this phenomenon could be the dynamic compression of the tunneled septal branches, which may result in disturbed blood flow in the adjacent LAD segment (milking effect).

The impact of a previous history of ischaemic episodes on the occurrence of left ventricular free wall rupture in the setting of myocardial infarction.

BACKGROUND: Ischaemic episodes preceding myocardial infarction (MI) are one of the defence mechanisms protecting the body from the consequences of sudden ischaemia. Left ventricular free wall rupture (LVFWR) is a rare complication of MI but leading, in a majority of patients, to sudden cardiac death. AIM: To assess the impact of a previous history of ischaemic episodes (IEs) on the occurrence of LVFWR in patients with acute MI (AMI) managed by percutaneous coronary intervention (PCI). METHODS: The study population consisted of 270 patients who had died during hospitalisation for AMI. All the patients were managed by PCI. The study group (the LVFWR group) consisted of 49 patients who developed LVFWR during hospitalisation and the control group (the non-LVFWR group) consisted of the remaining 221 patients who had died from causes other than LVFWR. In all the patients with LVFWR the rupture was confirmed by autopsy. The data on AMI was obtained from history or medical records. The data on IEs was obtained on the basis of the symptoms that were reported by the patients in the past that directly preceded the most recent AMI or on the basis of medical records. RESULTS: Compared to the non-LVFWR group the LVFWR group was characterised by an older age (70.3 ± 3.4 vs. 65.2 ± 9.9 years, p 〈 0.001) and a higher percentage of females (75.0% vs. 60.2%, p 〈 0.001). The LVFWR group was also characterised by a higher percentage of IEs in the past (61.2% vs. 40.2%, p = 0.003), a lower percentage of patients with a history of MI (14.2% vs. 33.4%, p = 0.004), a higher percentage of patients with multivessel coronary artery disease (77.5% vs. 61.5%, p = 0.03), a longer interval from the onset of symptoms to PCI (9.0 ± 5.5 vs. 4.5 ± 3.2 h, p 〈 0.001) and a lower percentage of patients with IEs in the past but without an MI (6.1% vs. 23.9%, p 〈 0.001). Our study showed that independent risk factors for LVFWR in the setting of AMI were: older age (OR 1.1, 95% CI 1.02-1.19), male sex (OR 0.2, 95% CI 0.07-0.52) and a longer interval between the onset of symptoms and PCI (OR 1.25, 95% CI 1.07-1.47). CONCLUSIONS: A previous history of IEs in patients without a previous history of AMI was a protective factor against the development of LVFWR in the setting of AMI.

Does the method of heart transplantation affect left ventricular filling?

BACKGROUND: For over 40 years now orthotopic heart transplantation (OHT) has been the treatment of choice in patients with advanced heart failure. For many years patients undergoing OHT have been treated with the classical approach involving anastomosis of the donor atria with the recipient atria resulting in a heart in which the atria are enlarged. An alternative method for OHT is the bicaval anastomosis technique, which involves connecting both of the donor's venae cavae with the recipient's venae cavae. AIM: To assess left ventricular (LV) filling in patients undergoing OHT using the classical (biatrial) versus bicaval approach. METHODS: We analysed 60 patients who had undergone OHT between 1 and 36 months before. Myocardial biopsy at echocardiography revealed grade 0 or 1A rejection in all the patients. All the patients were also in NYHA functional class I. The patients were divided in two groups: patients who had undergone biatrial anastomosis (Group 1, n = 40) and patients who had undergone bicaval OHT (Group 2, n = 20). In order to render the results independent of pre-OHT blood pressure values in the pulmonary circulation we assessed the values of right ventricular systolic pressure (RVSP), mean pulmonary artery pressure (PAP) and transpulmonary gradient (TPG) in all the patients before OHT. We assessed the following echocardiographic parameters: peak early filling velocity (E-wave), peak atrial filling velocity (A-wave), E-wave deceleration time, early diastolic mitral valve ring motion velocity (E'), E/E', isovolumetric relaxation time of the LV, duration of the A-wave, right atrial area and left atrial area, LV mass, LV mass index, LV end-diastolic and end-systolic dimension, and the severity of tricuspid regurgitation (TR). RESULTS: The values of RVSP, PAP and TPG in the study groups before OHT did not differ significantly. The values of E (86.5 ± 12.5 vs. 67.3 ± 8.5; p < 0.001), E' (11.9 ± 1.1 vs. 10.9 ± 0.9; p = 0.003) and E/E' (7.4 ± 1.5 vs. 6.1 ± 0.85; p = 0.006) differed between the groups and were significantly higher in the group undergoing surgery using the biatrial approach. The duration of the A-wave was significantly longer in the group undergoing surgery using the bicaval approach (129.0 ± 5.1 vs. 136.7 ± 10.0; p = 0.001). There were no significant differences in the other parameters of LV filling. Right atrial area was significantly lower in the group undergoing surgery using the bicaval approach (19.2 ± 3.0 vs. 14.0 ± 2.0; p < 0.001). LV size, LV mass and LV mass index did not differ significantly between the groups. The lack of TR was more commonly observed in the group undergoing surgery using the bicaval approach at the limit of p = 0.05. Pacemaker implantation was required in 12 (30%) patients from the group undergoing surgery using the classical method and 2 (10%) patients from the group undergoing OHT using the bicaval approach (p = 0.04). CONCLUSIONS: Certain echocardiographic parameters suggest a better LV filling in patients undergoing OHT using the bicaval approach. Preservation of the right atrial geometry in patients undergoing OHT using the bicaval approach plays an important role in LV filling.

Predictors of successful iatrogenic pseudoaneurysm compression dressing repair.

BACKGROUND: Complications to femoral artery puncture may result in formation of a pseudoaneurysm (PSA). We investigated whether PSA obliteration may be achieved by compression dressing repair (CDR) and sought to determine the predictors of successful CDR. METHODS: Sixty two patients (30 male, mean age 61.0 +/- 12.8) with femoral PSAs due to cardiac catheterization were included in the study. In all patients, duplex ultrasound followed by CDR was performed to evaluate PSA morphology and flow velocities in the PSA neck. RESULTS: Forty six (74.2%) patients did not respond to CDR. Predictors of successful CDR were forward [0.18 (0.07-0.47), p = 0.0004] and reverse [0.08 (0.02-0.33), p = 0.0006] flow velocities in the PSA neck. The forward velocity was identified as an independent predictor of CDR outcome (p = 0.02). CONCLUSIONS: Compression dressing repair may serve as an alternative method of femoral pseudoaneurysm management in patients with low forward and reverse velocities of the flow in pseudoaneurysm neck. The forward velocity is an independent predictor of compression dressing repair result.

RADIal versus femoral approach for percutaneous coronary interventions in patients with Acute Myocardial Infarction (RADIAMI): A prospective, randomized, single-center clinical trial.

BACKGROUND: The transradial approach for percutaneous coronary intervention (PCI) seems to be superior to transfemoral. The safety and efficacy of transradial approach for PCI in acute myocardial infarction is not well-established. METHODS: Hundred patients with acute myocardial infarction qualified to PCI were randomly assigned to transradial (group I; n = 50) and transfemoral (group II; n = 50) approaches. RESULTS: PCI was successful for almost all patients, except one from group II. There were no significant differences between groups in X-ray exposition, volume of contrast and total procedure duration. Small but significant elongation of door to stent time in group I was caused mostly by a longer time between beginning of procedure and arterial sheath introduction. Major bleeding complications occurred in three patients from group I and seven from group II. There were no significant differences observed between the two groups. Time to ambulation in group I was significantly shorter then in group II (22.6 +/- 10.3 h vs. 34.7 +/- 34.6 h; p = 0.003). CONCLUSIONS: The transradial approach for PCI in acute myocardial infarction has the same efficacy as transfemoral. There are no differences in total procedure duration, X-ray exposition or volume of contrast between the two approaches. A longer time from the patient's admission to the individual stages of the PCI procedure in group I was mostly due to the longer times of the initial stages of the procedure. The use of transradial approach reduces the time to ambulation and allows rehabilitation to begin sooner. In both groups, bleeding complications occurred rarely.

Is depression a problem in patients with chronic heart failure?

Depression is a common psychiatric disorder, characterized by a persistent lowering of mood, loss of interest in routine activities and diminished ability to experience pleasure. There are several depression classification systems and diagnostic tools based on clinical symptoms, i.e. the International Classification of Diseases (ICD-10), the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV), the Hamilton Depression Rating Scale, the Montgomery-Asberg Scale and Beck's Depression Inventory. Depression frequently occurs in patients with heart failure, as similar pathophysiological mechanisms of neurohormonal activation, arrhythmia, inflammation and hypercoagulation are present in both these diseases. Prognosis in patients with depression is also affected by insufficient cooperation between a patient and his doctor as regards the lifestyle and medication intake of a patient. Depression is usually accompanied by remission and relapse periods which might be related to the current heart failure status of a patient and despite intensive medical treatment they may recur. Depression is often difficult to diagnose or even left undiagnosed and thus untreated, because its symptoms: fatigue, apathy and decreased exercise tolerance, are common in the general population. Furthermore, safety and efficacy of antidepressant therapy in patients with cardiovascular diseases are not well established. Evidence from clinical trials evaluating the influence of depression behavioral and pharmacological treatment on morbidity and mortality in patients with heart failure is also limited. Taking into account that depression affects prognosis in patients with variety of disorders and common pathological mechanisms present both in depression and heart failure, screening tests for depression should be considered not only in patients with diagnosed heart failure but also those at risk of heart failure development.

The comparison of contrast echocardiography and tissue Doppler imaging for evaluation of reperfused myocardium in patients with acute anterior myocardial infarction.

BACKGROUND: Prediction of functional myocardial recovery post acute myocardial infarction should be based not only on flow patency of the infarct related artery (IRA) but also on the quality of microcirculation in at-risk segments. Myocardial blush grade (MBG) is a method of perfusion assessment which has an established value in prediction of both ventricular remodelling and prognosis. However, its invasive character encourages the search for other methods able to reflect myocardial recovery following successful reperfusion. Echocardiography is an imaging modality which has the potential to assess, noninvasively, myocardial perfusion and, quantitatively, the loss of contractile function. The aim of this study was to compare the values of myocardial contrast echocardiography (MCE), MBG and tissue Doppler imaging (TDI) in the assessment of microcirculation in patients with first acute myocardial infarction of the anterior wall. METHODS: The study group consisted of 39 patients (15 female and 24 male, mean age 58.8 +/- 12.2 years) with first anterior infarction within 6 hours of chest pain onset. All patients underwent angioplasty of the anterior descending artery (LAD). Myocardial blush grade was assessed directly after angioplasty, whereas MCE using SonoView contrast accompanied by TDI study was performed 4 days thereafter. RESULTS: Neither of the quantitative MCE parameters showed significant correlation with perfusion assessed by MBG. Significant negative correlation of MBG was found with maximal systolic strain ( e) (R = -0.51, p = 0.003) and post systolic shortening (R = -0.49, p = 0.007) in infarcted segments, but this was not the case with the unaffected segments. CONCLUSIONS: Use of MCE in the assessment of myocardial perfusion in myocardial infarction is limited, as shown by poor correlation with MBG. The presence of impaired contractile function by TDI corresponds better with myocardial perfusion than MCE does.

Long-term prognosis and risk factors for cardiac adverse events in patients with chronic systolic heart failure due to hypertension.

OBJECTIVES: The long-term prognosis and predictors of adverse cardiac events in hypertension-related chronic systolic heart failure (CHF) remain uncertain. Therefore, we sought to determine the major adverse cardiac events (MACE) in this group of patients. PATIENTS AND METHODS: One hundred and thirty two patients (83% males, age 48.6 +/- 8.2 years) in NYHA class II and III with hypertension-related chronic CHF were prospectively evaluated for three years. Hypertension was defined as blood pressure > or = 140/90 mmHg documented clinically twice for at least 5 years before the onset of CHF symptoms. All patients underwent coronary angiography to exclude coronary artery disease as a cause of CHF. Analysis of predictors of MACE (death, urgent heart transplantation and re-admission to the hospital due to CHF progression) during the 3 years of follow up was performed. RESULTS: After follow up the frequency of MACE was 41.7%. The independent predictors of MACE occurrence were as follows: the symptoms of depression [hazard ratio (HR) 2.58 (95% CI 1.44-4.63, p < 0.01)], end-diastolic diameter of the right ventricular (EDDRV) [HR 1.07 (95% CI 1.02-1.12, p < 0.01)] and D-dimers [HR 2.24 (95% CI 1.08-4.67, p < 0.05)]. To define optimal prognostic accuracy of EDDRV and D-dimers the receiver operating characteristics curve analysis was performed. The cut-off for EDDRV was 28 mm (sensitivity 50%, specificity 67.6%, area under curve [AUC] 0.64, p < 0.01) and for D-dimers 0.23 microg/ml, (sensitivity 58%, specificity 64.2%, AUC 0.62, p < 0.05). CONCLUSIONS: In analysed group the symptoms of depression, higher baseline right ventricular diastolic diameter and higher baseline D-dimers level were independent predictors of MACE.

Left ventricular systolic and diastolic function in patients with atrioventricular nodal re-entrant tachycardia treated by radiofrequency current ablation.

BACKGROUND: The impact of radiofrequency current ablation (RFCA) on left ventricular (LV) systolic and diastolic function in patients with atrioventricular nodal re-entrant tachycardia (AVNRT) is not well established yet. METHODS: The study group consisted of 25 patients (18 W, mean age 43 +/- 11) with recurrent episodes of AVRT without any concomitant diseases. The control group was formed of 25 healthy volunteers. In both study and control groups, transthorasic echocardiography (TTE) and Doppler were performed in order to assess LV systolic and diastolic function. In AVNRT syndrome patients, TTE was followed by electrophysiology study and RFCA. TTE was repeated after six months in the study group. RESULTS: Significant differences were found between the study and control groups with regard to LV systolic (FS--fractional shortening: 37 +/- 4 vs. 42 +/- 6%, p = 0.001; ESV--end-systolic volume: 19 +/- 4 vs. 17 +/- 4 ml/m(2), p = 0.03; EF--ejection fraction: 55 +/- 5 vs. 62 +/- 4%, p = 0.001) and diastolic function (E wave: 69 +/- 17 vs. 84 +/- 15 cm/s, p = 0.002; E/A: 1.09 +/- +/- 0.42 vs. 1.38 +/- 0.27, p = 0.005; DT--duration difference between A and AR waves: 7 +/- 29 vs. -28 +/- 13 ms, p = 0.001; DT--deceleration time of E wave: 223 +/- 34 vs. 177 +/- 27 ms, p = 0.001; IVRT--isovolumic relaxation time: 105 +/- 15 vs. 86 +/- 11 ms, p = 0.001; E/A while Valsalva manoeuvre: 0.93 +/- 0.35 vs. 1.25 +/- 0.16, p = 0.001; AR--atrial reversal velocity: 27 +/- 7 vs. 14 +/- 11 cm/s, p = 0.001) variables. In 6-month follow-up decrease in LVESV (19 +/- 4 vs. 17 +/- 4 ml, p < 0.03) and increase in EF (55 +/- 5 vs. 62 +/- 4%, p < 0.001) was noted. Doppler analysis showed an increase in E wave (69 +/- 17 vs. 79 +/- 20 cm/s, p < 0.02), E/A ratio (1.09 +/- 0.42 vs. 1.30 +/- 0.27, p < 0.006) and decrease in A wave (68 +/- 13 vs. 63 +/- 10 cm/s, p < 0.02), DT (223 +/- 34 vs. 179 +/- 22 ms, p < 0.001), IVRT (105 +/- 15 vs. 89 +/- 11 ms, p < 0.001) and DT (7 +/- 29 vs. -13 +/- 28 ms, p < 0.001). CONCLUSIONS: Successful RFCA of slow atrioventricular conduction pathway in patients with AVNRT and AVRT results in improvement of LV systolic and diastolic function.

The influence of atrioventricular and atrioventricular nodal re-entrant tachycardia on left ventricular systolic and diastolic function.

BACKGROUND: Incessant tachycardia may result in left ventricular (LV) systolic dysfunction. Little is known about the influence of atrioventricular tachycardia (AVRT) and atrioventricular nodal re-entrant tachycardia (AVNRT) on LV systolic and diastolic function. The aim of the study was to assess LV systolic and diastolic function and factors affecting LV systolic and diastolic performance in patients with AVRT and AVNRT. MATERIAL: The study group included 90 patients (40 male, 50 female, mean age 40 +/- 12 years) with symptomatic narrow-QRS tachycardia. After an invasive electrophysiology study (EPS) had been performed, these were divided into two groups: one (AVNRT) of 25 patients with AVNRT and the other (WPW) of 65 patients with AVRT. The control group consisted of 50 healthy volunteers (23 male, 27 female, mean age 39 +/- 13 years). In all three groups transthoracic echocardiography was performed in order to assess LV systolic and diastolic function. RESULTS: LV fractional shortening (FS) (WPW: 32 +/- 6%, AVNRT: 36 +/- 4%, p < 0.005) and ejection fraction (EF) (WPW: 54 +/- 7%, AVNRT: 55 +/- 5%, p < 0.001) were significantly decreased in the study groups compared to the control group (FS: 40 +/- 5%, EF: 62 +/- 4%). FS was significantly increased in the AVNRT compared to the WPW patients (p < 0.005). LV diastolic dysfunction was found in 20 (80%) of the AVNRT and 55 (83%) of the WPW group and in none of the patients from the control group. A positive correlation was found between diastolic dysfunction and the scale of recurrence of AVRT (R = 0.67, p < 0.05) and AVNRT (R = 0.52, p < 0.05). CONCLUSIONS: AVNRT and AVRT may lead to development of LV systolic and diastolic dysfunction. LV diastolic dysfunction is related to the frequency of AVRT or AVNRT recurrence. (Cardiol J 2007; 14: 160-166).

[Effect of elevated bilirubin levels on the long-term outcome in patients with chronic heart failure due to hypertension]. / Wplyw stqienia bilirubiny na rokowanie odlegle u pacjentów z przewlekla skurczowa niewydolnoscia serca w przebiegu choroby nadcisnieniowej.

OBJECTIVES: The aim of the study was to evaluate the occurence of death and major adverse cardiac events (MACE) in patients with normal (group A) and elevated (group B) plasma bilirubin levels. PATIENTS AND METHODS: We evaluated 124 patients (83% males, mean age 50.1 +/- 7.7 yrs) in New York Heart Association class II and III with hypertension-related chronic heart failure. We assessed the occurence of death and MACE (death, urgent heart transplantation and readmission to hospital). RESULTS: Groups A and B comprised 77 and 47 patients respectively. The independent predictors of death in group B were: N-terminal pro-brain natriuretic peptide (NT-proBNP) level (per 100 pg/ml difference; 95% CI: 1.29-4.76; p = 0.005) and physical component summary score (per 10 point difference; 95% CI: 0.66-0.99; p = 0.03). The independent predictors of MACE in group B were: age (per 10 yrs; 95% CI: 0.1-1.8; p = 0.04), NT-proBNP level (per 100 pg/ml difference; 95% CI: 1.02-3.69; p = 0.04) and the symptoms of depression (95% CI: 1.02-2.5; p = 0.01). The independent predictors of MACE in group A were: NT-proBNP level (per 100 pg/ml difference; 95% CI: 1.31-5.32; p = 0.006) and mental component summary (per 10 point difference; 95% CI: 0.85-0.98; p = 0.01). In a two-year follow-up the death rate was 5.2% in group A, and 23.4% in group B (p = 0.002) and frequency of MACE 18.2% and 42.6% in group A and B (p = 0.003), respectively. CONCLUSIONS: Elevated bilirubin levels are associated with higher incidence of death and MACE during a two-year follow-up in patients with hypertension-related chronic heart failure. Thus, it may be used as a simple prognostic factor in such of patients.

Assessment of right ventriclar function by tissue Doppler in relation to plasma NT-proBNP concentration in patients with dilated cardiomyopathy.

BACKGROUND: Impairment of right ventricular function is a common finding in patients with dilated cardiomyopathy (DCM). The aim of the study was to assess the function of the right ventricle by tissue Doppler imaging (TDI) in relation to NT-proBNP concentration in patients with DCM. METHODS: 29 patients with DCM were studied. Group I (n = 21) constituted of subjects with a NT-proBNP concentration > 500 pg/ml and group II (n = 8) constituted of patients with NT-proBNP < 500 pg/ml. In all patients the TDI parameters for the free-wall of the right ventricle were analysed: velocity of myocardium (VEL), strain (epsilon) and strain rate (SR). RESULTS: There were no significant differences between the two groups with respect to clinical characteristics, parameters of global and regional left ventricular systolic function or between indicators of global right ventricular function. In group I the maximal values of e in the apical and medial segments of the right ventricular free wall were significantly lower than in group II (-17 +/- 10 vs. -29 +/- 7%; p = 0.0168 and -13 +/- 6 vs. -25 +/- 5%; p = 0.0023 respectively). Moreover, in group I the maximal SR in the apical and medial segments of the right ventricular free wall were significantly lower than in group II (1.56 +/- 0.6 epsilon(-1) vs. -1.071 +/- 0.5 epsilon(-1); p = 0.0358 and -0.99 +/- 0.38 epsilon(-1) vs. -1.55 +/- 0.37 epsilon(-1); p = 0.0044 respectively). CONCLUSIONS: Impairment of right ventricular function is most visible in the apical and medial segments. The maximal values of e and SR for the right ventricle free wall are lower in patients with DCM and NT-proBNP > 500 pg/ml. (Cardiol J 2007; 14: 167-173).

Triple-site biventricular pacing in patients undergoing cardiac resynchronization therapy: a feasibility study.

AIMS: To evaluate implantation safety and efficiency of triple-site (double left-single right) cardiac resynchronization therapy (CRT) and to assess the outcome of this procedure. METHODS AND RESULTS: Twenty-six patients with New York Heart Association (NYHA) class III-IV, left ventricular ejection fraction (EF) < or = 35%, and QRS > or = 120 ms underwent triple-site CRT. Procedural course and complications were analysed. NYHA class, QRS duration, echocardiographic parameters, peak oxygen consumption (VO(2)max), and 6 min walking distance (6MWD) were assessed at baseline and after 3 months. Responders were defined by survival, by no re-hospitalization for heart failure, and by >10% EF, VO(2)max, and 6MWD increase. Implantation was successful in 22 patients (84.6%). Procedure duration (199.1 min) and fluoroscopy time (38.7 min) were higher than in standard procedures. Two clinically silent coronary sinus dissections occurred intra-operatively; one phrenic nerve stimulation and one pocket infection were observed during follow-up. After 3 months of CRT, a significant reduction (P < 0.05) of NYHA class, increment of VO(2)max, 6MWD, EF, and improvement of indices of dyssynchrony were observed. Response rate in the studied group was 95.4%. CONCLUSION: Triple-site resynchronization appears to be a safe and efficient treatment method, with high response rate. Further studies are needed to evaluate the role of this pacing mode in CRT.