Cardiopulmonary Exercise Test Parameters at Three Months After Alcohol Septal Ablation in Hypertrophic Obstructive Cardiomyopathy Are Associated With Late Clinical Outcome.

BACKGROUND: Alcohol septal ablation (ASA) is an established interventional treatment for hypertrophic obstructive cardiomyopathy (HOCM) patients with drug refractory symptoms. This study investigated the prognostic value of cardiopulmonary exercise test (CPET) in relation to the late clinical outcome. METHODS: Twenty-one (21) HOCM patients underwent CPET before and 3 months after ASA and were followed yearly thereafter. Clinical success was considered to be a decrease of ≥1 (New York Heart Association or Canadian Cardiovascular Society) functional class. Cardiopulmonary exercise test parameters [maximal oxygen uptake (PeakVO2), % predicted VO2 (PeakVO2%), oxygen uptake at anaerobic threshold (AT), maximal workload (W), % predicted W (W%), ventilation (VE), % predicted VE (VE%), ventilation to maximal carbon dioxide production slope (VE/VCO2), % predicted maximal heart rate (HR%), and maximal systolic blood pressure (SBP)] were compared before and 3 months after ASA. RESULTS: After follow-up of 29 ± 13 months, 16 patients had a good clinical results (clinical responders), while five did not improve (clinical non-responders). The CPET parameters did not change in non-responders, while clinical responders showed significant improvement in VO2, VO2%, W, VE/VCO2, VE, VE%, as well as an increase in HR% and SBP at 3 months. CONCLUSIONS: The data confirmed a good association between the improvement in CPET parameters and the clinical results 3 months after ASA. This may therefore serve as an early marker of HOCM-ASA treatment success.

Intraoperative TTE inferior vena cava monitoring in elderly orthopaedic patients with cardiac disease and spinal-induced hypotension.

Objective To address the role of transthoracic echocardiography in inferior vena cava (IVC) monitoring in the management of haemodynamically unstable elderly patients subjected to lower limb orthopaedic surgery under spinal anesthesia. Possible implications in the postoperative care unit (PACU) length of stay (LOS) are investigated. Methods 41 elderly patients with cardiac diseases were recruited. Patients experiencing intraoperative haemodynamic instability (diastolic blood pressure ≤ 60 mmHg) were divided into two groups according to right atrial pressure (RAP), (RAP < 5 mmHg and RAP between 5 and 10 mmHg) as measured by inferior vena cava collapsibility index (IVCCI). Haemodynamic instability was treated with normal saline infused at a constant rate supplemented by phenylephrine (PHE) infusions titrated to normal blood pressure values. Intraoperatively comparisons of peak PHE infusion rates and all episodes of hypotension, including in the PACU, were recorded among groups. The patients' PACU LOS and associated factors were assessed. Results The intraoperative peak PHE infusion rate and the incidence of haemodynamic instability in the postoperative period were significantly higher in patients with RAP < 5 mmHg. The total PHE consumption was also higher in patients with RAP < 5 mmHg postoperatively. The primary risk factor for a prolonged stay in PACU, as determined by multiple regression analysis was RAP. Conclusions Patients with high dynamic collapsibility of the IVC may require aggressive treatment to restore their haemodynamic status. Additionally, intraoperative levels of RAP, as measured by IVCCI, can act as a predictor for increased LOS in the PACU.

Impact of continuous positive airway pressure treatment on myocardial performance in patients with obstructive sleep apnea. A conventional and tissue Doppler echocardiographic study.

INTRODUCTION: Obstructive sleep apnea (OSA) is a highly prevalent condition related to several cardiovascular complications. We assessed the effects of continuous positive airway pressure (CPAP) treatment on myocardial performance and various somatometric parameters in patients with severe OSA receiving CPAP. MATERIALS AND METHODS: This is a prospective longitudinal study of 44 patients aged 55.8 ± 10.6 years (79.5 % men), with newly diagnosed moderate and severe OSA (apnea-hypopnea index ≥15 with polysomnographic evaluation). All patients enrolled received CPAP therapy. The study protocol included a complete conventional and tissue Doppler echocardiographic study at baseline and 12 months after CPAP treatment. RESULTS: Among patients enrolled, 31 completed the prespecified study protocol. After CPAP therapy, a decrease in pulmonary artery systolic pressure (p < 0.001), right ventricular (RV) diameter (p = 0.012), inferior vena cava diameter (p = 0.005), and RV wall thickness (p = 0.006) was observed. In addition, tricuspid annular plane systolic excursion values (p = 0.048) and tissue E/A ratio at the tricuspid annulus (p = 0.01) were significantly increased. Moreover, a reduction in left ventricular (LV) mass was observed (p < 0.001). With respect to somatometric parameters, body mass index and waist diameter (p < 0.001 for both) were reduced. Importantly, the improvement in apnea-hypopnea index was associated with the improvement in pulmonary artery systolic pressure, independently from confounders such as age, gender, and the reduction in body mass index. DISCUSSION: CPAP therapy in OSA patients was found to improve right heart chambers remodeling and performance as well as somatometric characteristics. The impact of CPAP on LV performance seems less pronounced.

Churg-Strauss syndrome masquerading as an acute coronary syndrome.

Churg-Strauss Syndrome (CSS) is a rare vasculitis with multiorgan involvement. Cardiac manifestations are common causing serious complications. We report a case of CSS masquerading as a non-ST elevation myocardial infarction with heart failure. CSS should be considered in the differential diagnosis of an acute coronary syndrome(ACS)with normal coronary arteries when history of asthma, peripheral eosinophilia and multisystemic involvement is present.

Transthoracic echocardiography for the diagnosis of left ventricular thrombosis in the postoperative care unit.

INTRODUCTION: Transthoracic echocardiography (TTE) is a reliable, noninvasive imaging method that is useful in the evaluation of cardiovascular thrombosis. We conducted a retrospective study of all the echocardiograms from patients in the postoperative care unit to assess the role of TTE in thrombus identification in the left ventricle. METHODS: This retrospective database evaluation included all echocardiograms during a 14-month period. The echocardiographic examination protocol included the subcostal four-chamber view, the apical four-chamber view, the apical two-chamber view and the parasternal view, along the long and short axes in both spontaneously and mechanically ventilated patients. All echocardiograms were obtained within the 48 hours immediately following surgery. RESULTS: In total, 160 postoperative echocardiograms were obtained from 160 patients and resulted in the detection of five cases of left ventricular thrombosis. Subgroup analysis showed that 21 and 35 of the 160 patients examined had either dilated or ischemic cardiomyopathy, respectively. In these patients, preoperative echocardiograms had been obtained recently prior to surgery and were negative for left ventricular thrombus. In three of 35 patients with ischemic cardiomyopathy and two of 21 patients with dilated cardiomyopathy, thrombus was identified in the left ventricle. The thrombi were mobile, uncalcified and pedunculated and were located in the apex of the left ventricle. In addition, no clinical consequences of the left ventricular thrombi were recorded. CONCLUSIONS: Low-flow conditions in heart chambers due to ischemic or dilated cardiomyopathy in conjunction with the hypercoagulability caused by perioperative prothrombotic factors may lead to thrombotic events in the left ventricle.

Effects of darbepoetin alpha on right and left ventricular systolic and diastolic function in anemic patients with chronic heart failure secondary to ischemic or idiopathic dilated cardiomyopathy.

BACKGROUND: Anemia is a frequent condition in chronic heart failure (CHF) that affects adversely long-term cardiac outcomes. We sought to investigate the effects of recombinant human erythropoietin analogue darbepoetin alpha on left (LV) and right ventricular (RV) function and neurohormonal activation in patients with CHF and anemia. METHODS: Thirty-two CHF patients (New York Heart Association class II-III, LV ejection fraction [EF] <40%, hemoglobin level <12.5 g/dL, serum creatinine level <2.5 mg/dL) were randomized (2:1) to receive either a 3-month darbepoetin alpha regimen at 1.5 microg/kg every 20 days plus oral iron (n = 21) or placebo plus oral iron (n = 11). Echocardiographic indices of LV systolic and diastolic function and RV function, plasma B-type natriuretic peptide (BNP) and 6-minute walked distance were assessed at baseline and posttreatment. RESULTS: Regarding LV function, only treatment with darbepoetin alpha caused a significant improvement in LVEF (F = 22.001, P < .001), end-systolic wall stress (F = 4.934, P = .034), mitral annulus systolic displacement (F = 6.710, P < .015), isovolumic relaxation time (F = 4.909, P = .035), and E/e ratio (F = 7.833, P = .009). The RV systolic pressure (F = 7.715, P = .009) as well as tricuspid annulus systolic displacement and RVEF (F = 9.264, P = .005) were significantly improved only in the darbepoetin alpha group. Darbepoetin alpha had also alpha beneficial effect on New York Heart Association class (F = 14.586, P = .001), plasma BNP (F = 14.781, P = .001), and 6-minute walk test (F = 19.926, P < .001), whereas these parameters did not significantly change in the placebo-treated patients. CONCLUSION: Darbepoetin alpha improves both LV and RV performance and exercise capacity and counteracts neurohormonal activation in CHF patients with anemia. The drug effects on LV diastolic function, RV function, and LV end-systolic wall stress, in particular, are novel findings, with a potential important contribution to patients' symptomatic improvement.

Exercise-induced changes in E/E' ratio in patients with suspected coronary artery disease.

OBJECTIVES: Ischemia affects the left ventricular (LV) diastolic function earlier than the systolic function. The ratio of the early diastolic transmitral velocity to the early diastolic tissue velocity (E/E') measured by tissue Doppler echocardiography allows a reliable assessment of the diastolic function. We investigated whether exercise-induced changes in E/E' ratio may help in the detection of coronary artery disease (CAD). METHODS: The study population consisted of 114 patients undergoing coronary angiography. Patients with impaired LV ejection fraction, earlier myocardial infarction, arterial hypertension greater than stage I, or LV hypertrophy were excluded. Patients underwent a treadmill exercise test combined with an echocardiogram at baseline and within the first minute after exercise. RESULTS: Coronary angiography showed a stenosis more than 70% in 72 (63%) patients (CAD group), the remaining 42 formed the non-CAD group. The two groups did not differ regarding age, sex, LV dimensions, and function. At baseline, the E/E' lateral and septal ratios and their average did not differ between the two groups. The exercise-induced changes of the E/E' ratios were higher in the CAD group (change of E/E' average: 1.9+/-3.3 vs. -1.1+/-2.3, P<0.001). In the CAD group, 78% showed an exercise-induced increase of E/E' average compared with 24% in the non-CAD group (P<0.001). In multivariate analysis, the association between an increase of E/E' average and the presence of obstructive CAD was independent of traditional risk factors, exercise test result or exercise-induced wall motion abnormalities (odds ratio=8.1, P<0.001). CONCLUSION: Exercise-induced changes in E/E' ratio may offer significant assistance in the detection of CAD.

Cardiovascular ultrasonography detection of embolic sources in trauma.

Venous thromboembolism (deep vein thrombosis and pulmonary embolism) and bone cement implantation syndrome are major sources of embolic events in trauma patients. In these patients, embolic events due to venous thromboembolism and bone cement implantation syndrome have been detected with cardiac and vascular ultrasonography in the emergency setting, during the perioperative period, and in the intensive care unit. This article discusses the ultrasonography modalities and imaging findings of embolic events related to venous thromboembolism and bone cement implantation syndrome. The aim is to present a short review with exceptional illustrations that can enable physicians to identify sources of emboli in trauma patients with cardiovascular ultrasonography.

Ultrasound in cardiac trauma.

In the perioperative period, the emergency department or the intensive care unit accurate assessment of variable chest pain requires meticulous knowledge, diagnostic skills, and suitable usage of various diagnostic modalities. In addition, in polytrauma patients, cardiac injury including aortic dissection, pulmonary embolism, acute myocardial infarction, and pericardial effusion should be immediately revealed and treated. In these patients, arrhythmias, mainly tachycardia, cardiac murmurs, or hypotension must alert physicians to suspect cardiovascular trauma, which would potentially be life threatening. Ultrasound of the heart using transthoracic and transesophageal echocardiography are valuable diagnostic tools that can be used interchangeably in conjunction with other modalities such as the electrocardiogram and computed tomography for the diagnosis of cardiovascular abnormalities in trauma patients. Although ultrasound of the heart is often underused in the setting of trauma, it does have the advantages of being easily accessible, noninvasive, and rapid bedside assessment tool. This review article aims to analyze the potential cardiac injuries in trauma patients, and to provide an elaborate description of the role of echocardiography for their accurate diagnosis.

Effects of levosimendan on right ventricular function in patients with advanced heart failure.

Right ventricular (RV) dysfunction frequently complicates advanced left ventricular heart failure and contributes to an unfavorable prognosis. Levosimendan is a novel inodilator that beneficially affects hemodynamics and left ventricular systolic and diastolic function in patients with advanced heart failure. However, its effects on RV function have not yet been properly assessed in these patients. In this randomized trial, the impact of levosimendan or placebo on various echocardiographic parameters of RV systolic and diastolic function was investigated in 54 patients with advanced heart failure due to left ventricular systolic dysfunction. Tissue Doppler imaging maximal systolic tricuspid annular velocity (S wave) increased significantly only in the levosimendan group (8.2 +/- 3.2 vs 9.0 +/- 3.0 cm/s, p <0.03). Tissue Doppler imaging RV early diastolic velocity (E wave) and the ratio of early to late diastolic velocities (E/A) also increased significantly after levosimendan administration (p <0.01 and p <0.05, respectively). Systolic pulmonary arterial pressure decreased significantly (54 +/- 11 vs 43 +/- 11 mm Hg, p <0.01) in the levosimendan-treated patients. Levosimendan beneficially modulated neurohormonal and inflammatory status by decreasing B-type natriuretic peptide levels (p <0.05) and by altering the ratio of interleukin-6 to interleukin-10 in favor of the latter (p <0.05). In conclusion, levosimendan could offer further therapeutic advantages in patients with advanced heart failure by improving systolic and diastolic RV function.

Pleural effusion causing cardiac tamponade: report of two cases and review of the literature.

We report on two patients who developed large left-sided pleural effusions in association with hemodynamic compromise. In both cases transthoracic echocardiography demonstrated left ventricular diastolic collapse confirming our clinical suspicion of cardiac tamponade. Large-volume thoracentesis in the first case and thoracotomy with drainage of the pleural collection in the second case resulted in immediate hemodynamic improvement. Our report shows that large pleural effusions can result in impaired cardiac filling and a tamponade-like physiology. Thoracentesis in this setting can lead to rapid improvement of the hemodynamic profile.

Effects of levosimendan on markers of left ventricular diastolic function and neurohormonal activation in patients with advanced heart failure.

In this randomized, placebo-controlled study, it was found that a 24-hour levosimendan infusion improves echocardiographic markers of abnormal left ventricular diastolic function (transmitral flow patterns and mitral annulus velocities, as assessed by transthoracic pulse-wave Doppler and tissue Doppler imaging, respectively) and reduces substances of excessive neurohormonal activation (plasma B-type natriuretic peptide and interleukin-6) in patients with advanced heart failure. Moreover, levosimendan-treated patients had fewer events and longer progression-free survival during a 5-month follow-up compared with those who received placebo. Thus, levosimendan seems to be effective in improving left ventricular diastolic function and reducing neurohormonal activation in patients with severe heart failure.

Detection of high-burden coronary artery disease by exercise-induced changes of the E/E' ratio.

To investigate whether exercise-induced changes of the E/E' average ratio can detect high-burden coronary artery disease (CAD) in patients with chest pain and normal left ventricular (LV) systolic function. The study population consisted of 359 patients admitted for chest pain (59.8 ± 9.8 years, 75% male). Patients underwent exercise echocardiography, scintigraphy and coronary angiography. The average of the lateral and septal ratios of early diastolic transmitral velocity to early diastolic tissue velocity (E/E') at baseline and immediately after exercise was calculated. Exercise induced wall motion abnormalities were also calculated. Coronary angiography showed flow limiting CAD in 238 patients (66%). The exercise-induced changes of E/E' average ratio had a sensitivity of 87.3% and a specificity of 75.2% for detection of flow limiting CAD, whereas myocardial scintigraphy showed 79.2% sensitivity and 80.1% specificity and exercise induced wall motion abnormalities had a sensitivity of 74.3% and a specificity of 66.9%. Likelihood ratio chi square showed an incremental value of the exercise-induced changes of E/E' average ratio over regional perfusion technique (from 121.37 to 194.15, P < 0.001) and over wall motion abnormalities (from 57.03 to 146.50, P < 0.001). The exercise-induced change of the E/E' average ratio detects flow limiting CAD in patients with chest pain and normal LV systolic function showing an incremental value over regional perfusion technique and wall motion abnormalities.