Utility of combining multiple parameters of 123I-IMP SPECT and voxel-based morphometry MRI using a multiparametric scoring system for differentiating dementia with Lewy bodies from Alzheimer's disease.

BACKGROUND: Brain magnetic resonance imaging voxel-based morphometry (VBM) and perfusion single-photon emission computed tomography (SPECT) are useful for differentiating dementia with Lewy bodies (DLB) from Alzheimer's disease (AD). PURPOSE: To determine whether combining multiple parameters of VBM and SPECT using a multiparametric scoring system (MSS) improves diagnostic accuracy in differentiating DLB from AD. MATERIAL AND METHODS: In total, 23 patients with DLB and 57 patients with AD underwent imaging using a voxel-based specific regional analysis system for AD (VSRAD), an easy Z-score imaging system, and a Z-Graph using three-dimensional stereotactic surface projection. The cutoff values were determined using the receiver operating characteristic curve to differentiate DLB from AD for all parameters. Patients were scored 1 (DLB) or 0 (AD) for each statistically significant parameter, according to a threshold. The total score was determined for each case to obtain a cutoff value for the MSS. RESULTS: The mean Z-scores in the medial temporal lobes using the VSRAD were significantly lower in patients with DLB than in those with AD. Each Z-score of the summed Z-scores in all four segmented regions of the occipital lobes using the Z-Graph was significantly higher in patients with DLB than in those with AD. Among the five parameters, the highest accuracy was 80% for the Z-score of the summed Z-scores in the left medial occipital lobe. For the MSS, a cutoff value of four improved the diagnostic accuracy to 82%. CONCLUSION: MSS was more accurate than any single parameter of VBM or SPECT in differentiating DLB from AD.

Proper use of fentanyl facilitates anesthesia during pulmonary vein isolation.

Although intraoperative anesthetic management of extensive encircling pulmonary vein isolation (PVI) is essential for the safe performance of this procedure, there is no standardized approach for the use of sedation and analgesia. Therefore, the present study aimed to clarify the optimal fentanyl dosage and timing of administration for the anesthetic management during PVI. A total of 364 patients with atrial fibrillation (AF) who underwent PVI at our institution between June 2017 and October 2020 were recruited. All patients were anesthetized with propofol for induction and maintenance under controlled ventilation via the supraglottic airway without neuromuscular blocking drugs. Among them, 234 patients received less frequent injections (Group 1) and 130 received a scheduled injection of 50 mg of fentanyl (Group 2) in addition to propofol during PVI. We compared the total and additional propofol doses, frequency of additional propofol, and procedure time between the two groups. The mean patient age was 67.2 years, and 69% were male. The total propofol dose was significantly lower in Group 2 than in Group 1 (17.0 ± 5.2 mg/kg vs. 19.0 ± 5.5 mg/kg, p < 0.01). The loading dose and frequency of additional propofol were also significantly lower in Group 2 than in Group 1. The procedure time was significantly shorter in Group 2 than in Group 1 (119 ± 36 min vs. 132 ± 31 min, p < 0.01). During PVI, proper use of fentanyl decreased the propofol dose, additional propofol frequency, and procedure time.

Effect of heart rate on left ventricular longitudinal myocardial function in type 2 diabetes mellitus.

BACKGROUND: Left ventricular (LV) longitudinal myocardial dysfunction is considered a marker of preclinical LV dysfunction in patients with type 2 diabetes mellitus (T2DM). High heart rate (HR) is associated with cardiovascular outcomes, but the effect of HR on LV longitudinal myocardial function in T2DM patients is uncertain. METHODS: We studied 192 T2DM patients with preserved LV ejection fraction (LVEF), and 81 age-, sex-, and LVEF-matched healthy volunteers. HR was measured as the average HR during echocardiography, and high HR was defined as resting HR ≥ 70 beats/minute. LV longitudinal myocardial function was assessed as global longitudinal strain (GLS). The predefined cutoff for subclinical LV dysfunction was set at GLS < 18%. RESULTS: GLS in T2DM patients with high HR was significantly lower than that in T2DM patients with low HR (16.3% ± 4.2% vs. 17.8% ± 2.8%; P = 0.03), whereas GLS in normal subjects with high and low HR was similar (20.3 ± 1.7% vs. 20.3 ± 2.0%; P = 0.99). Multivariable logistic regression analysis showed that high HR (odds ratio: 1.04; 95% confidence interval: 1.01-1.07; P = 0.01) was independently associated with GLS < 18% in T2DM patients as well as HbA1c, T2DM duration, LVEF, body mass index, and mitral inflow E and mitral e' annular velocity ratio. One sequential logistic model evaluating the associations between GLS < 18% and clinical variables in T2DM patients showed an improvement with the addition of LVEF and E/e' (P < 0.001) and a further improvement with the addition of high HR (P < 0.001). CONCLUSION: Compared with normal subjects, resting HR was associated with LV longitudinal myocardial function in asymptomatic T2DM patients with preserved LVEF. Our findings provide new insights on the management of T2DM patients.

Hemodynamic changes during transcatheter atrial septal defect closure predict midterm heart failure deterioration in adults.

OBJECTIVES: To investigate whether hemodynamic changes during balloon occlusion test (BOT) predict future heart failure (HF) deterioration after transcatheter atrial septal defect closure (tASD-closure). BACKGROUND: Midterm HF deterioration can sometimes occur after tASD-closure in adults. Whether hemodynamic changes during tASD-closure can help identify patients at risk is unknown. METHODS: This prospective observational study enrolled 86 consecutive adult patients who underwent tASD-closure. Hemodynamic parameters, including pulmonary capillary wedge pressure (PCWP), were measured at baseline, during BOT, and after tASD-closure. The changes in PCWP during BOT and after tASD-closure were defined as ΔPCWP (Occ-Pre) and ΔPCWP (Post-Pre), respectively. Clinical parameters were evaluated before tASD-closure and during the 3-month follow-up. We assessed the occurrence of HF deterioration (HF requiring hospitalization or additional diuretics) during a 2-year follow-up period and categorized patients into HF (+) and HF (-) groups accordingly. The aforementioned parameters were compared between groups. RESULTS: Midterm HF deterioration occurred in 12 patients (13.9%). Compared to the HF (-) group, the HF (+) group presented a significantly higher ΔPCWP (Occ-Pre) (9.5 ± 4.4 mmHg vs. 3.0 ± 3.3 mmHg; p < 0.001) and ΔPCWP (Post-Pre) (4.0 ± 2.8 mmHg vs. 0.6 ± 1.8 mmHg; p = 0.004). Receiver operating characteristic curve analysis showed that the ΔPCWP (Occ-Pre) cutoff value of 5.5 mmHg had excellent ability to predict HF deterioration (Area under the curve 0.886 [0.779-0.993], p < 0.001; sensitivity 0.917, specificity 0.824). CONCLUSIONS: Increases in PCWP during BOT predict midterm HF deterioration after tASD-closure. Close surveillance may be needed in patients with a ΔPCWP (Occ-Pre) >5 mmHg.

Impact of diabetes mellitus on left ventricular longitudinal function of patients with non-ischemic dilated cardiomyopathy.

BACKGROUND: Left ventricular (LV) longitudinal dysfunction has been identified in type 2 diabetes mellitus (T2DM) patients with preserved LV ejection fraction (LVEF). However, the impact of T2DM on LV longitudinal function or the association of LV longitudinal function with outcome for dilated cardiomyopathy (DCM) remains unclear. METHODS: We retrospectively studied 206 patients with non-ischemic DCM, mean age of 59 ± 17 years and LVEF of 31 ± 8% (all < 45%). All patients underwent a standard echocardiographic examination, and LV longitudinal function was assessed in terms of global longitudinal strain (GLS). Long-term outcomes were assessed, with a median follow-up period of 6.2 years, as primary endpoints of death from or hospitalization for deteriorating heart failure. RESULTS: GLS of DCM patients with T2DM (n = 55) was significantly lower than that in DCM patients without T2DM (n = 151) in spite of similar conventional LV function (7.0 ± 2.0% vs. 7.8 ± 2.2%, p = 0.03). Kaplan-Meier curves indicated that long-term outcomes for DCM patients without T2DM were better than for those with T2DM (log-rank p = 0.001). Subdividing the two groups into four with by using the median value of GLS (7.9%) showed long-term outcome was worst for DCM patients with T2DM and low GLS. Cox proportional hazards analyses demonstrated an independent association of T2DM, GLS and left atrial volume index with long-term outcome. Moreover, multiple regression analysis for the association of GLS showed that T2DM was the independent determinant parameter for GLS as well as for LVEF and left atrial volume index. CONCLUSION: Management of DCM patients with T2DM may be improved by using GLS guidance.

Positive effect of dapagliflozin on left ventricular longitudinal function for type 2 diabetic mellitus patients with chronic heart failure.

BACKGROUND: The effect of sodium glucose cotransporter type 2 (SGLT2) inhibitor on left ventricular (LV) longitudinal myocardial function in type 2 diabetes mellitus (T2DM) patients with heart failure (HF) has remained unclear. METHODS: We analyzed data from our previous prospective multicenter study, in which we investigated the effect of the SGLT2 inhibitor dapagliflozin on LV diastolic functional parameters of T2DM patients with stable HF at five institutions in Japan. Echocardiography was performed at baseline and 6 months after administration of dapagliflozin. LV diastolic function was defined as the ratio of mitral inflow E to mitral e' annular velocities (E/e'). LV longitudinal myocardial function was assessed as global longitudinal strain (GLS), which in turn was determined as the averaged peak longitudinal strain from standard LV apical views. RESULTS: E/e' significantly decreased from 9.3 to 8.5 cm/s 6 months after administration of dapagliflozin (p = 0.020) as previously described, while GLS showed significant improvement from 15.5 ± 3.5% to 16.9 ± 4.1% (p < 0.01) 6 months after administration of dapagliflozin. Furthermore, improvement of GLS in HF with preserved ejection fraction patients was more significant from 17.0 ± 1.9% to 18.7 ± 2.0% (p < 0.001), compared to that in HF with mid-range ejection fraction and HF with reduced ejection fraction patients from 14.4 ± 2.4% to 15.5 ± 1.8% (p = 0.06) and from 8.1 ± 1.5% to 7.8 ± 2.1% (p = 0.44), respectively. It was noteworthy that multiple regression analysis showed that the change in GLS after administration of dapagliflozin was the only independent determinant parameters for the change in E/e' after administration of dapagliflozin. CONCLUSION: Dapagliflozin was found to be associated with improvement of LV longitudinal myocardial function, which led to further improvement of LV diastolic function of T2DM patients with stable HF. GLS-guided management may thus lead to improved management of T2DM patients with stable HF.

Effectiveness of a 3D mapping benchmark for ablation in patients with atrioventricular nodal reentrant tachycardia.

BACKGROUND: Avoiding excessively fast junctional rhythm (JR) during slow pathway (SP) modification for atrioventricular nodal reentrant tachycardia (AVNRT) helps prevent serious atrioventricular block. This study investigated the usefulness of a predictive ablation point that lies near the boundary line between appropriate and excessively fast JRs with three-dimensional (3D) electroanatomical mapping in AVNRT patients. METHODS: Participants were 141 consecutive patients with common AVNRT who received anatomical ablation to an antegrade SP at our institution between August 2013 and December 2019. Patients were divided into two groups: Group A, treated using a location marker that predicts successful ablation sites in a 3D mapping system, and Group B, treated prior to the development of this marker and therefore without it. RESULTS: The average age was 61.9 ± 16.9 years, and 41.1% of patients were male. Excessively fast JRs appeared less frequently in Group A than in Group B, though this difference did not reach significance. The distance from the His bundle to the successful ablation point was significantly longer in Group A than in Group B (13.4 ± 4.5 vs 10.8 ± 4.4 mm, P < .01). The number of ablations near the successful ablation point was significantly lower in Group A (6.5 ± 5.2 vs 11.4 ± 9.9, P < .01), and a greater number of accelerated JRs at the successful ablation point were observed in Group A (46.9 ± 29.2 vs 32.8 ± 19.2, P < .01). CONCLUSION: Using our benchmark for a predictive successful ablation point in 3D mapping simplifies and improves common AVNRT ablation procedures.

The feasibility of leadless pacemaker implantation for superelderly patients.

BACKGROUND: The safety and efficacy of the leadless pacemaker (LP) have been confirmed in previous reports, yet studies on LPs in superelderly patients are limited. METHODS AND RESULTS: A total of 62 patients aged over 85 years old were implanted with single-chamber pacemakers due to symptomatic bradyarrhythmia at Sakakibara Heart Institute from May 2014 through July 2019. We divided them into two groups, a transvenous (TV) single-chamber pacemaker group (35 patients) and an LP group (27 patients), and compared the groups. Mean participant age was 90.3 ± 3.8 y.o., 41.9% were male, and mean participant body mass index (BMI) was 21.3 kg/m2 . The LP group contained a significantly larger proportion of patients with dementia than the TV group did (63% vs. 37.1%, P = .04). The complication-free rate tended to be lower in the LP group in spite of the higher frequency of dementia (88.6% vs. 92.6%, P = .68). At implantation, the pacing threshold was significantly higher in the LP group than in the TV group (1.30 ± 0.91 V vs. 0.71 ± 0.23 V, P < .01), but over the first 3 months after the operation the pacing threshold in the LP group gradually improved (0.82 ± 0.2 V vs. 1.05 ± 1.02 V, P = .16). The procedure time and time from operation to discharge were also shorter in the LP group. CONCLUSIONS: LP implantation appears to be safe and is accordingly becoming the cornerstone for Japanese superelderly patients indicated for single-chamber pacemakers, even for those with small bodies and dementia. However, careful procedures and long follow-ups are needed until a greater volume of data is reported.

A safe and simple approach to avoid fast junctional rhythm during ablation in patients with atrioventricular nodal reentrant tachycardia.

INTRODUCTION: Fast junctional rhythm (JR) during slow pathway modification for atrioventricular nodal reentrant tachycardia (AVNRT) is a predictor of serious atrioventricular block. This study investigated the boundary to avoid fast JR during ablation with three-dimensional (3D) electroanatomical mapping in AVNRT patients. METHODS AND RESULTS: Participants were 129 consecutive patients with common AVNRT who received anatomical ablation to an antegrade slow pathway at our institution between August 2013 and March 2019. Successfully ablated sites with JR were evaluated in terms of distances and angles in the left and right anterior oblique views (LAO and RAO, respectively) to the proximal His bundle (His) site using 3D mapping. We divided JR by heart rate: JR1 ≥150 bpm and JR2 <150 bpm. Average age was 61 ± 16 years; 41.1% of patients were male. The distance from the most proximal His to the JR1 and JR2 site was not significantly different (11.9 ± 4.4 vs 10.7 ± 4.5 mm, P = .24). JR1 predominantly appeared closer to the left ventricle than JR2 in LAO (110.5 ± 19.1° vs 77.5 ± 18.6°, P < .01), and was more posterior from the proximal His in RAO (30.8% vs 6.8%, P < .01). The vertical line drawn down from the proximal His in the LAO view was a good indicator of JR1 appearance (sensitivity and specificity 84.6% and 81.6%, respectively). CONCLUSION: The vertical line drawn down from the proximal His in the LAO view can be employed as a boundary to avoid fast JR during ablation in AVNRT.

Association of glycemic variability with left ventricular diastolic function in type 2 diabetes mellitus.

BACKGROUND: Type 2 diabetes mellitus (T2DM) is a major cause of heart failure (HF) with preserved ejection fraction (HFpEF), usually presenting as left ventricular (LV) diastolic dysfunction. Thus, LV diastolic function should be considered a crucial marker of a preclinical form of DM-related cardiac dysfunction. However, the impact of glycemic variability (GV) on LV diastolic function in such patients remains unclear. METHODS: We studied 100 asymptomatic T2DM patients with preserved LV ejection fraction (LVEF) without coronary artery disease (age: 60 ± 14 years, female: 45%). GV was evaluated as standard deviation of blood glucose level using continuous glucose monitoring system for at least 72 consecutive hours. LV diastolic function was defined as mitral inflow E and mitral e' annular velocities (E/e'), and > 14 was determined as abnormal. RESULTS: E/e' in patients with high GV (≥ 35.9 mg/dL) was significantly higher than that in patients with low GV (11.3 ± 3.9 vs. 9.8 ± 2.8, p = 0.03) despite similar age, gender-distribution, and hemoglobin A1c (HbA1c). Multivariate logistic regression analysis showed that GV ≥ 35.9 mg/dL (odds ratio: 3.67; 95% confidence interval: 1.02-13.22; p < 0.05) was an independently associated factor, as was age, of E/e' > 14. In sequential logistic models for the associations of LV diastolic dysfunction, one model based on clinical variables including age, gender and hypertension was not improved by addition of HbA1c (p = 0.67) but was improved by addition of high GV (p = 0.04). CONCLUSION: Since HFpEF is a syndrome caused by diverse agents, reducing GV may represent a potential new therapeutic strategy for the prevention of the development of HFpEF in T2DM patients.

Association of Relatively Short Posterior Mitral Leaflet With Mitral Regurgitation in Patients With Atrial Fibrillation.

BACKGROUND: The underlying mechanism of mitral regurgitation (MR) in atrial fibrillation (AF) is an isolated annulus dilation caused by left atrial (LA) remodeling. However, the association of mitral valve (MV) geometry with MR in AF patients remains unclear.Methods and Results:We studied 96 AF patients with preserved left ventricular ejection fraction (LVEF). MV geometry was evaluated with 3-dimensional transesophageal echocardiography (3D-TEE). Mitral annulus area of the MR group (n=11, ≥ moderate) was significantly larger (10.6±1.8 vs. 8.2±1.5 cm2, P<0.0001), and relative posterior mitral leaflet (PML) area (PML area / mitral annulus area) was significantly smaller (0.51±0.06 vs. 0.57±0.01, P=0.002) than in the non-MR group (n=85,

"An imprisoned heart" arrested by pillory of calcified ring surrounding both ventricles: An extremely rare case of constrictive pericarditis.

We report the case of a 63-year-old man who was admitted to our hospital due to progressive dyspnea and leg edema. Echocardiography and cardiac computed tomography revealed localized severe pericardial calcification surrounding the basal segments of both ventricles, which caused pericardial constriction. Right heart catheter examination confirmed typical hemodynamic findings of constrictive pericarditis and subsequently led to the definite diagnosis of constrictive pericarditis. We experienced a rare case of localized constrictive pericarditis caused by the thickened and calcified pericardial ring. Non-invasive and invasive multimodality evaluations should be encouraged for accurate diagnosis and better management of these cases.

Combined assessment of left atrial volume parameters for predicting recurrence of atrial fibrillation following pulmonary vein isolation in patients with paroxysmal atrial fibrillation.

OBJECTIVES: Our aim was to test the hypothesis that comprehensive simplified left atrial (LA) assessment derived from routine echocardiography may be more useful than assessment of LA volume alone for predicting atrial fibrillation (AF) recurrence after pulmonary vein isolation (PVI). METHODS: We studied 156 patients with paroxysmal AF (PAF) who had undergone PVI. Echocardiography was performed within two days before PVI. Maximum (Max-LAVi) and minimum LA volume index (Min-LAVi) were calculated with the biplane modified Simpson's method, and then normalized to the body surface area. On the basis of previous findings, the predefined cutoff value of Max-LAVi for AF recurrence was set at Max-LAVi ≥ 34 mL/m2 . ΔLA volume index (ΔLAVi) was also calculated as Max-LAVi minus Min-LAVi. The follow-up period after PVI was 24 months. RESULTS: AF recurrence was observed in 35 patients. Multivariate logistic regression analysis showed that ΔLAVi (odds ratio [OR]: 1.131; 95% confidence interval [CI]: 1.057-1.221; P < 0.001) was an independent predictor of AF recurrence. Sequential logistic regression models for predicting AF recurrence revealed that a model based on clinical variables including age, gender and AF duration (χ2  = 1.65) was improved by the addition of Max-LAVi ≥ 34 mL/m2 (χ2  = 13.8; P < 0.001), and further improved by the addition of ΔLAVi (χ2  = 18.2; P = 0.036). Of note is that only 1.02 ± 0.10 minutes per patient was needed to obtain a comprehensive LA assessment that included Max-LAVi, Min-LAVi, and ΔLAVi. CONCLUSION: This easy-to-use comprehensive simplified LA approach from routine echocardiography may well have clinical implications for better management of PAF patients.

Impact of dapagliflozin on left ventricular diastolic function of patients with type 2 diabetic mellitus with chronic heart failure.

BACKGROUND: The objective of this study was to investigate the impact of sodium glucose cotransporter type 2 (SGLT2) inhibitors on left ventricular (LV) diastolic function of type 2 diabetes mellitus (T2DM) patients with heart failure (HF). METHODS: This trial was a prospective multicenter study of 58 T2DM patients with stable HF at five institutions in Japan. Patients who had been taking at least one antidiabetic drugs other than SGLT2 inhibitors started the administration of 5 mg/day of dapagliflozin. The physical examinations, blood tests, and echocardiography were performed at baseline and 6 months after administration of dapagliflozin. The primary endpoint was defined as a change in mitral inflow E and mitral e' annular velocities (E/e') between baseline and 6 months after the administration of dapagliflozin. The secondary end points consisted of a change in brain natriuretic peptide (BNP), LV mass index (LVMI) and left atrial volume index (LAVI). RESULTS: E/e' significantly decreased from 9.3 to 8.5 cm/s (p = 0.020) 6 months after administration of dapagliflozin. LAVI and LVMI significantly decreased from 31 to 26 mL/m2 (p = 0.001), and from 75.0 to 67.0 g/m2 (p < 0.001), respectively, 6 months after administration of dapagliflozin. No significant change was observed in BNP (from 27.9 to 28.9 pg/mL; p = 0.132) 6 months after administration of dapagliflozin, except for a significant decrease from 168.8 to 114.3 pg/mL (p = 0.012) in patients with BNP ≥ 100 pg/mL. CONCLUSION: This prospective multicenter trial showed the beneficial effect of SGLT2 inhibitors on LV diastolic functional parameters for T2DM patients with HF. Our findings may thus offer a new insight into the management of T2DM patients. Trial registration UMIN000019789, Registered 28 September 2014, Date of registration: 11/14/2015, Date of enrolment of the first participant to the trial: 6/15/2016, Date of enrolment of the last participant to the trial: 12/9/2017.

Baseline Global Longitudinal Strain as a Predictor of Left Ventricular Dysfunction and Hospitalization for Heart Failure of Patients With Malignant Lymphoma After Anthracycline Therapy.

BACKGROUND: Our aim was to investigate the baseline clinical and echocardiographic parameters for predicting left ventricular (LV) dysfunction after anthracycline chemotherapy and heart failure (HF) hospitalization in a single cancer disease. Methods and Results: We studied 73 patients with malignant lymphoma and preserved LV ejection fraction (LVEF). Echocardiography was performed before and after anthracycline chemotherapy. Global longitudinal strain (GLS) was determined from 3 standard apical views. LV dysfunction after anthracycline chemotherapy was defined according to the current definition of cancer therapeutics-related cardiac dysfunction. Long-term (50-month) unfavorable outcome was prespecified as hospitalization for HF. A total of 10 patients had LV dysfunction after anthracycline chemotherapy. Multivariate logistic regression analysis showed that baseline GLS was the only independent predictor of this dysfunction. Receiver-operating characteristic curve analysis identified the optimal GLS cutoff for predicting LV dysfunction after anthracycline chemotherapy as ≤19% (P=0.008). Furthermore, the Kaplan-Meier curve indicated that fewer patients with GLS >19% were hospitalized for HF than among those with GLS ≤19% (log-rank P=0.02). For sequential logistic models, a model based on baseline clinical variables (χ2=2.9) was improved by the addition of baseline LVEF (χ2=9.0; P=0.01), and further improved by the addition of baseline GLS (χ2=13.1, P=0.04). CONCLUSIONS: Watchful observation or early therapeutic intervention with established cardioprotective medications may be necessary for patients with malignant lymphoma and preserved LVEF but with abnormal GLS.

The first case of "locked-in leaflet" after transcatheter aortic valve replacement in a patient with bicuspid aortic stenosis.

This case report is about an 85-year-old woman with bicuspid aortic stenosis (AS). Although preoperative multimodality imaging showed challenging anatomical aspects, transcatheter aortic valve replacement (TAVR) was selected to be performed as a less invasive alternative treatment approach, owing to her comorbidity. Postoperative transesophageal echocardiography and multidetector-row computed tomography revealed the presence of "locked-in leaflet" caused by stent distortion due to pinching by calcified native leaflets, with nodular calcification preventing the full expansion of the valve, which resulted in moderate perivalvular leakage. This is the first reported case of bicuspid AS treated with TAVR that eventually resulted in "locked-in leaflet."

Echocardiography during preload stress for evaluation of right ventricular contractile reserve and exercise capacity in pulmonary hypertension.

OBJECTIVES: Pulmonary hypertension (PH) is characterized by marked and sustained elevation of pulmonary vascular resistance and pulmonary artery pressure, and subsequent right-sided heart failure. Right ventricular (RV) function and exercise capacity have been recognized as important prognostic factors for PH. Our aim was to investigate RV contractile reserve and exercise capacity during a leg-positive pressure (LPP) maneuver. METHODS: The study population comprised 43 PH patients and 17 normal controls. All patients underwent echocardiography at rest and during LPP stress. Exercise capacity was assessed by 6-minute walk distance for PH patients. RV relative wall thickness was calculated from dividing by RV free wall thickness by basal RV linear dimensions at end-diastole. RV function was calculated by averaging peak speckle-tracking longitudinal strain from the RV free wall. RV contractile reserve was assessed as the difference in RV free wall strain at rest and during LPP stress. Changes in left ventricular stroke volume (ΔSV) during LPP stress were also calculated. RESULTS: ΔSV and RV contractile reserve of PH patients were significantly lower than of controls (3.6 ± 6.0 mL vs 8.5 ± 2.3 mL, and 8.2 ± 11.9% vs 14.5 ± 6.6%; both P < 0.01). RV contractile reserve of PH patients with ΔSV <3.3 mL was significantly lower than of PH patients with ΔSV >3.3 mL (3.9 ± 13.2% vs 12.3 ± 8.9%; P = 0.02). ΔSV had also significant correlation with 6-minute walk distance (r = 0.42, P = 0.006). Multivariate regression analysis showed that RV relative wall thickness was an independent determinant parameter of ΔSV during LPP stress for PH patients (ß = 3.2, P = 0.003). CONCLUSIONS: Preload stress echocardiography in response to LPP maneuver, a noninvasive and easy-to-use procedure for routine clinical use, proved to be useful for the assessment of RV contractile reserve and exercise capacity of PH patients.

Left ventricular dispersion as a parameter for augmented left ventricular stroke volume in patients with atrial septal defect following transcatheter closure.

OBJECTIVES: The closure of atrial septal defect (ASD) results in normalized left ventricular (LV) and right ventricular (RV) geometry, and can increase LV stroke volume (LVSV), but the parameters associated with this increase after the closure of ASD remain uncertain. METHODS: Seventy ASD patients, who underwent transcatheter closure, were studied. Their mean age was 57.80 ± 16.88 years, 42 (60%) were female, and LV ejection fraction (LVEF) was 66.76% ± 7.91% (all ≥55%). Transthoracic echocardiography was performed before and 3 months after the procedure. Global longitudinal strain (GLS) was determined as the average peak speckle tracking strain of 18 segments from the 3 standard apical views, LV dispersion was defined as standard deviation of time-to-peak strain from the same views, and RV systolic function was calculated by averaging the 3-regional peak speckle tracking longitudinal strains from the RV free wall. A significant relative increase in LVSV between before and 3 months after the closure was defined as ∆LVSV ≥15%. Twenty age-, gender-, and LVEF-matched controls served as the control group. RESULTS: Global longitudinal strain (GLS) and RV free wall strain were similar for ASD patients and controls, but LV dispersion in ASD patients was significantly larger. Global longitudinal strain (GLS) remained unchanged after transcatheter closure, whereas RV free wall strain and LV dispersion decreased significantly. An important finding of the multivariate logistic regression analysis showed that ∆LV dispersion was the only independent determinant of increased LVSV after the closure (OR 1.023; 95% CI 1.001-1.046; P < .01). CONCLUSIONS: The assessment of LV dispersion may well have clinical implications for better management of ASD patients after transcatheter closure.