Impact of Heart Rate on Flow Measurements in Aortic Regurgitation.

BACKGROUND: Flow measurements using cardiac magnetic resonance imaging (CMRI) enable quantification of the stroke volume, regurgitant volume (RV) and regurgitant fraction (RF) in patients with aortic regurgitation (AR). These variables are used to assess the severity of the valve disease and for the timing of surgery. The aim of the study was to investigate the impact of an increased heart rate on measurement of the RV and RF in patients with AR. METHODS: Among 13 patients with known moderate or severe AR, regurgitant flow measurements, using phase-contrast cine magnetic resonance imaging, were obtained in the ascending aorta. Flow measurements were obtained at rest and at increased heart rates after intravenous administration of atropine. RESULTS: The mean heart rate was 61 beats per min at rest and 91 beats per min after atropine administration. The RV and RF were 52 ml and 35% at rest, respectively, and 34 ml (p <0.001) and 30% (p = 0.065) at increased heart rate, respectively. CONCLUSIONS: An increased heart rate leads to a decreased RV. The RF is more stable and may therefore be preferable for severity grading in AR.

The role of advanced echocardiography and cardiovascular magnetic resonance in the assessment of myocardial function in Marfan syndrome-An update.

Cardiovascular assessment of patients with Marfan syndrome has normally focused on the aortic root and vascular manifestations of the disease due to the high risk of aortic dissection. Although primary myocardial impairment has long been suspected in these patients, the evidence has been controversial. Advanced echocardiography and cardiovascular magnetic resonance imaging have proven to be effective, accurate, and more sensitive in the detection of subtle cardiac dysfunction. The application of these techniques to Marfan syndrome over the last 10 years has made significant progress in demonstrating the presence of primary myocardial impairment in these patients, but further work is still required to obtain confirmatory molecular, pathophysiological, and prognostic clinical data. Phenotypic expression of the disease has prognostic value, also suggesting potential effective medical therapy.

Alterations in heart rate variability during everyday life are linked to insulin resistance. A role of dominating sympathetic over parasympathetic nerve activity?

AIMS: To evaluate the role of the autonomic nervous system (ANS) in the development of insulin resistance (IR) and assess the relationship between IR and activity of ANS using power spectrum analysis of heart rate variability (HRV). SUBJECTS AND METHODS: Twenty-three healthy first-degree relatives of patients with type 2 diabetes (R) and 24 control subjects without family history of diabetes (C) group-matched for age, BMI and sex were included. Insulin sensitivity (M value) was assessed by hyperinsulinemic (56 mU/m(2)/min) euglycemic clamp. Activity of the ANS was assessed using power spectrum analysis of HRV in long-term recordings, i.e., 24-h ECG monitoring, and in short-term recordings during manoeuvres activating the ANS. Computed tomography was performed to estimate the amount and distribution of abdominal adipose tissue. RESULTS: Insulin sensitivity (M value, mg/kg lbm/min) did not differ significantly between the R and C groups. Total spectral power (Ptot) and very low-frequency (PVLF) power was lower in R than C during 24 h ECG-recordings (p = 0.02 and p = 0.03). The best fit multiple variable linear regression model (r(2) = 0.37, p < 0.001 for model) indicated that body composition (BMI) and long-term low to high frequency (LF/HF) power ratio (std ß = -0.46, p = 0.001 and std ß = -0.28, p = 0.003, respectively) were significantly and independently associated with the M value. CONCLUSION: Altered heart rate variability, assessed by power spectrum analysis, during everyday life is linked to insulin resistance. The data suggest that an increased ratio of sympathetic to parasympathetic nerve activity, occurring via both inherited and acquired mechanisms, could potentially contribute to the development of type 2 diabetes.

Laparoscopic repair of paraesophageal hernia with anterior gastropexy: a multicenter study.

BACKGROUND: The approach to repair of paraesophageal hernias (PEHs) is controversial. Recent data suggest that mesh repair leads to recurrence rates similar to non-mesh approaches, while subjecting patients to mesh-associated complications. Routine fundoplication during PEH repair has been favored despite significant dysphagia rates. We present our multicenter prospective data on laparoscopic PEH repairs using a modified Boerema anterior gastropexy without fundoplication. METHODS: We prospectively followed patients after modified Boerema PEH repair at three institutions. Patient demographics, perioperative data, and postoperative outcomes were evaluated. Subjective and objective outcomes were assessed via clinical assessment, follow-up questioning, endoscopy, and radiographic swallow studies. RESULTS: A total of 101 patients were followed a mean of 10.8 (median, 12) months. We encountered 9 (8.9%) intraoperative complications and 13 (12.9%) postoperative complications. There was no mortality. Reflux symptoms were absent in 71 patients (70.3%) postoperatively. Of the remaining subjects, 8 (7.9%) had mild intermittent reflux without the need for proton pump inhibitors (PPI), 12 (11.9%) had moderate reflux necessitating PPI as needed, and 10 (9.9%) had reflux requiring daily PPI. Our recurrence rate, assessed at postoperative endoscopy/barium swallow, was 16.8%. Of these, 10 (9.9%) were small segmental recurrences and 7 (6.9%) were large recurrences. CONCLUSION: Herein, we demonstrate a favorable recurrence rate while avoiding the potential major complications associated with mesh hiatoplasty. Our data tend to support a tailored approach to incorporation of fundoplication during PEH repair. Postoperative acid reflux was absent in most of our patients, and pharmacotherapy alone was sufficient for those experiencing reflux symptoms.

Peroral endoscopic myotomy (POEM) for nutcracker esophagus. Three cases with 12 months follow-up.

INTRODUCTION: Peroral endoscopic myotomy (POEM) has been introduced as a new treatment of achalasia, and studies are emerging on POEM treatment of other esophageal motility disorders. The effects of medical treatment, botox injections and dilatations are often limited in patients with severe nutcracker esophagus (NE). We therefore decided to perform POEM in three patients with severe NE. MATERIAL AND METHODS: Informed consent was provided. POEM was performed under general anesthesia on the distal esophagus and upper stomach. At 3 months, 6 months and 1 year postoperatively all patients had clinical follow-up, barium swallow and high-resolution manometry. RESULTS: All patients displayed marked improvement with a significant reduction in Eckardt score at follow-up after 1 year, from 10, 10 and 11 to 3, 1 and 1, respectively. During follow-up, the patients were diagnosed with increased reflux index and one patient was diagnosed with gastroparesis. CONCLUSION: Considering our results, treating severe NE with POEM has to be considered in the future; however, further studies have to confirm this.

Serum apolipoproteins, apoB/apoA-I ratio and objectively measured physical activity in elderly.

OBJECTIVES: Several studies have suggested that subjectively reported physical activity is associated with favorable apolipoproteins and apoB/apoA-I ratio but this association has not been studied much in elderly, and seldom with objective methods. The specific aim of the current study was to increase our understanding of the association between objectively measured physical activity, and apolipoproteins and apoB/apoA-I ratio in elderly subjects. DESIGN: In a long-term follow-up of coronary artery bypass graft surgery patients, a total of 89 subjects (55-88 years old) were recruited. Peak oxygen uptake was measured by ergospirometry and physical activity by accelerometry. Subjects were divided into two groups based on their activity levels (i.e. more or less than 30 minutes of moderate activity per day). RESULTS: Only 26% (23/89) of participants achieved the recommended 30 min/day of moderate intensity activity. Objectively measured physical activity was associated with higher apolipoprotein A-I levels and smaller apoB/apoAI ratio and lower body mass index, whereas no significant association with apolipoprotein B was observed. CONCLUSION: The significant association of objectively measured physical activity with favorable apolipoprotein A-I levels and a apoB/apoA-I ratio stresses the importance of being physically active.

Heart sounds are altered by open cardiac surgery.

BACKGROUND AND OBJECTIVE: Patients have reported that they perceive their own heart sounds differently after open cardiac surgery than before the surgery. The present study was designed to investigate whether changes in heart sounds can be quantitatively measured. METHOD: Heart sounds were recorded from 57 patients undergoing coronary artery bypass graft (CABG) surgery and from a control group of 10 subjects. The so-called Hjorth descriptors and the main frequency peak were compared before and after surgery to determine whether the characteristics of the heart sounds had changed. RESULTS: At a group level, the first heart sound was found to be significantly different after CABG surgery. Generally, the heart sounds shifted toward a lower frequency after surgery in the CABG group. No significant changes were found in the control group. CONCLUSIONS: Heart sounds are altered after CABG surgery. The changes are objectively quantifiable and may also be subjectively perceived by the patients.

Central neuronal mechanisms of gastric electrical stimulation in diabetic gastroparesis.

OBJECTIVE: The mechanisms underlying symptom improvement in gastric electrical stimulation (GES) are not fully understood. Modulation of the central nervous system excitability may be involved. The objective of the study was to investigate the central effects of GES, including the possible modulation of the visceral sensory nervous system. MATERIAL AND METHODS: A gastric electrical stimulator was implanted in seven diabetic patients with medically refractory gastroparesis. A double-blinded protocol was used to investigate the patients at baseline and one month after recovery with the stimulator turned on and off (1-month periods). The following assessments were carried out: mechanical, thermal and electrical stimulations with sensory recordings in the esophagus and duodenum, and standardized, self-administered, daily symptom questionnaires. RESULTS: No difference was found between baseline and the on- and off periods in overall gut pain thresholds across all stimulus modalities in the esophagus (p=0.63), duodenum (p=0.19) or esophagus and duodenum combined (p=0.76). No difference in the sensory response to mechanical stimulation was found in the esophagus before (all p>0.31) and after (all p>0.43) smooth muscle relaxation with butylscopolamine. Similar findings were observed in the duodenum. No differences were found in thermal sensitivity (esophagus (p=0.67) and duodenum (p=0.17)), sensory response to electrical stimulation (esophagus (p=0.57) and duodenum (p=0.52)) or induced somatic referred pain areas (esophagus (p=0.75) and duodenum (p=0.51)). No difference was seen in the induced somatic referred pain areas or self-reported symptoms. CONCLUSIONS: No evidence was found for GES-induced modulation of the visceral sensory system and central excitability. However, GES has been proven to modulate the central nervous system in animal studies, necessitating further human experiments in order unambiguously to establish the possible central effects of GES.

Separating the left cardiac ventricle from the atrium in short axis MR images using the equation of the atrioventricular plane.

Short axis (SA) images obtained from cardiac magnetic resonance imaging are used to advantage in the calculation of important clinical parameters such as the ejection fraction and stroke volume (SV). A prerequisite for these calculations is the separation of the left ventricle and the left atrium. When only using the information seen in the SA images this separation can be a source of error due to the through-plane motion of the basal part of the left ventricle. In this study a method is proposed where the separation of the left ventricle and the atrium is performed by identifying the intersections of the atrioventricular plane in the SA images. The equation of the atrioventricular plane was determined in both systole and diastole using long axis and four chamber image views. Stroke volumes were measured in 20 patients using SA images where the endocardium had been delineated. The SV obtained using the new method was compared with quantitative flow measurements and the conventional technique for calculation of SV from SA images, respectively. The agreement of SV was, according to Bland-Altman analysis, 2.0 ml (95% CI -12.0 to 15.9 ml) in comparison with the flow measurements and 2.2 ml (95% CI -9.2 to 13.6 ml) compared to the conventional method. Inter- and intra-observer variability, when using the new proposed method, was small. This study shows that the identification of the left atrioventricular plane in SA images can be used in the separation of the left atrium and ventricle.

[Overweight and gastro-oesophageal reflux disease].

The increase in the prevalence of obesity is paralleled by an increase in gastro-oesophageal reflux disease (GERD), and several mechanisms link GERD and obesity, so weight loss is a cornerstone in the treatment of GERD. Sustained weight loss often requires surgery, and fundoplication is the first surgical choice among normal weight patients with reflux; however, reflux complications increase with increasing BMI. Therefore, patients with obesity and GERD should be treated with gastric bypass surgery. The aim of this article is to discuss the relationship between overweight and GERD and outline treatment options of this disease.

Effect of Vitamin D supplementation on body composition and cardiorespiratory fitness in overweight men-a randomized controlled trial.

PURPOSE: Several observational studies have shown an association between vitamin D deficiency and non-skeletal major health issues including impaired cardiorespiratory fitness and adiposity. Only a few studies have examined the impact of vitamin D supplementation on these conditions and the results are ambiguous. The aim of this study was to examine the effect of vitamin D supplementation on body composition and cardiorespiratory fitness in overweight/obese men with vitamin D deficiency. METHODS: This study was a prospective, placebo controlled, double blinded, randomized trial with a study period of 6 months. Forty overweight/obese men (BMI > 25 kg/m2) with vitamin D deficiency (25(OH)D ≤ 55 nmol/L) were randomized to receive either 2000 IU Cholecalciferol drops or the equivalent amount of drops of placebo. At baseline and follow up body composition and cardiorespiratory fitness were measured and blood samples were obtained. Body composition was measured using bioelectrical impedance analysis (BIA) and cardiorespiratory fitness using cardiopulmonary exercise test (CPET). The primary outcomes were changes in percentage body fat and in maximum oxygen uptake (VO2max). RESULTS: No statistically significant difference between the placebo and the intervention group regarding changes in percentage body fat (p = 0.54) and VO2max (p = 0.90) was observed. Moreover, there was no statistically significant difference between the groups concerning changes in BMI (p = 0.26), maximum load (p = 0.89) and oxygen uptake at anaerobic threshold (AT) (p = 0.14). CONCLUSIONS: We conclude that treatment with 2000 IU/d vitamin D for 6 months does not impact body composition or maximum oxygen uptake in overweight/obese men with vitamin D deficiency.

Early Assessment of Cost-effectiveness of Gastric Electrical Stimulation for Diabetic Nausea and Vomiting.

BACKGROUND/AIMS: Recurrent nausea and/or vomiting are common complications of diabetes mellitus. The conditions severely impact the quality of life of patients and often cause repeated admissions to hospital incurring significant healthcare costs. If standard treatment fails, gastric electrical stimulation (GES) may be offered in selected cases, as a minimally invasive, but expensive, therapeutic option. Our aims are to evaluate the clinical effect and the cost-utility of GES as a treatment for severe diabetic recurrent nausea and/or vomiting. METHODS: Among 33 diabetes patients implanted with GES because of recurrent nausea and/or vomiting, 30 were available for evaluation. The effect of treatment was assessed prospectively using symptom-diaries and the SF-36 questionnaires at baseline, after 6 and 12 months, and thereafter yearly. The number of days in hospital due to symptoms related to gastrointestinal dysfunction was calculated using hospital records 12 months prior to and 12 months after implantation. RESULTS: The surgical procedures were performed without mortality or major complications. Six months after surgery 78% of the respondents had at least 50% reduction in time with nausea and 48% had at least 50% reduction in days with vomiting. Symptom relief persisted at follow-up after at least 4 years. Quality adjusted life years improved after GES, which was cost-effective after 24 months. CONCLUSIONS: GES reduces symptoms and improves quality of life in diabetes patients with recurrent nausea and/or vomiting. The procedure is supposed as cost-effective over a 2-year time horizon.

[Concurrent achalasia and severe obesity].

Achalasia is a rare oesophageal motility disorder which classically is not associated with obesity. We present the case of a 50-year-old woman who underwent gastric bypass and afterwards was diagnosed with achalasia. Following, she was treated successfully with peroral endoscopic myotomy (POEM). A thorough medical history revealed that symptoms of achalasia had been present for 25 years and were the cause of inappropriate eating habits and consequently morbid obesity. This case story illustrates the importance of being aware of simultaneous occurrence of achalasia and morbid obesity. Furthermore, it demonstrates that POEM is safe and effective for symptomatic relief of achalasia after previous gastric bypass.

[Treatment of acute cholecystitis in a third-trimester pregnant women]. / Behandling af akut kolecystitis hos gravide i tredje trimester.

This case report describes a 35-year-old female with acute cholecystitis 36 weeks into her pregnancy. Laparoscopic cholecystectomy was assessed not to be possible. An ultrasonic guided percutaneous transhepatic gall bladder drainage was performed resulting in immediate pain relief. The patient was discharged two days later, and the drain sat in place until a caesarian section was per--formed. A post-surgery cholangiography demonstrated stones in the gall bladder but no stones in the common bile duct. An uneventful laparoscopic cholecystectomy was carried out three months after surgery. The case report demonstrates that percutaneous transhepatic gall bladder drainage is a safe procedure to be considered in women with cholecystitis in which cholecystectomy is not possible or assumed to be associated with an unacceptable high risk.

Parasympathetic dysfunction in hypertrophic cardiomyopathy assessed by heart rate variability: comparison between short-term and 24-h measurements.

In this study, we evaluate cardiac autonomic function in hypertrophic cardiomyopathy (HCM) by assessing heart rate variability (HRV), comparing a short-term laboratory method with an ambulatory (24-h) method, in patients with and without beta-blockade. Reduced HRV is a risk factor for adverse events in some cardiac diseases, but is not a proven risk indicator in HCM. Analysis of HRV has been based on either short- or long-term electrocardiographic recordings and previous studies in HCM have shown conflicting results. There is no consensus on which method to prefer, and we evaluate, for the first time, both short- and long-term analyses in patients with HCM. Long- and short-term HRV analyses were performed in 43 patients with HCM. They were divided in two groups, 22 patients on beta-blockade and 21 non-treated patients. As controls, 121 healthy subjects were used. Young patients without beta-blockade showed a reduction in HRV parameters reflecting parasympathetic function, both in the short- and long-term registrations, which was attenuated by beta-blockade. Parasympathetic autonomic regulation was found to be impaired in young patients with HCM. This may be of clinical relevance as abnormal autonomic function might be a substrate for malignant dysrhythmias. The impairment was attenuated by beta-blockade, which might indicate a clinically useful effect. We also show that short- and long-term methods yield similar results, suggesting that a short-term registration might be sufficient to assess HRV in patients with HCM.

Intrahepatic fat content correlates with soluble CD163 in relation to weight loss induced by Roux-en-Y gastric bypass.

OBJECTIVE: Soluble CD163 (sCD163) is a new marker of obesity-related metabolic complications. sCD163 and CD163 mRNA were investigated in relation to the fat distribution at baseline and 12 months after Roux-en-Y gastric bypass (RYGB). METHODS: Thirty-one obese subjects (BMI: 42.3 ± 4.7 kg/m(2)) were enrolled. Subcutaneous (SAT) and visceral adipose tissue (VAT) volume were determined by MRI, intrahepatic lipid content (IHL) by MR-spectroscopy, and body composition by DXA. Fasting blood samples and adipose tissue samples were obtained, and ELISA and RT-PCR were performed. RESULTS: RYGB-induced weight loss (36 ± 11 kg) was accompanied by a significant reduction in sCD163 (2.1 ± 0.8 mg/l vs. 1.7 ± 0.7 mg/l), SAT, VAT, and IHL (all, P < 0.001). At baseline, sCD163 was associated with VAT (r = 0.40, P < 0.05) but not with SAT or IHL. Moreover, CD163 mRNA was significantly upregulated in VAT compared with SAT at baseline (P < 0.05) and significantly downregulated in SAT after RYGB (P < 0.001). ΔsCD163 was significantly associated with ΔIHL after RYGB compared with baseline (r = 0.40, P < 0.05). CONCLUSIONS: RYGB-induced weight loss results in a reduction of sCD163 and CD163 mRNA. The association between ΔsCD163 and ΔIHL may reflect a reduction in sCD163-producing Kupffer cells in the liver. Moreover, sCD163 may be a marker of "unhealthy" fat distribution in obese subjects.

Holter ECG monitoring in patients with perceived electrical hypersensitivity.

Earlier studies have indicated that patients claiming to be sensitive to electromagnetic fields, so-called electrical hypersensitivity (EHS), have a dysbalance of the autonomic nervous system (ANS) regulation. This paper focuses on a possible dysbalance in the ANS among EHS patients by the use of long-term monitoring of electrocardiogram (ECG) in both a patient and a matched control group. At the same time, the environmental power frequency magnetic field was recorded for both groups in order to see if there was any difference in exposure between the groups. ECG, heart rate (HR) and heart rate variability (HRV) as well as the magnetic field exposure were monitored for 24 h. Fourteen patients with perceived EHS symptoms were selected from the University Hospital, Umeå, Sweden. Symptoms indicating autonomic nervous dysregulation were not part of the inclusion criteria of the patient group. Age and sex matched healthy subjects were used as controls. No differences were found between the groups regarding magnetic field exposure or the mean HR for 24 h. The HRV analyses showed that the high-frequency (HF) component did not have the expected increase with sleep onset and during nighttime in the EHS group. When separating the sleeping and awake time even less differences between the two conditions in the EHS patients, both for the low-frequency and HF components in the HRV spectrum, were seen. EHS patients had a disturbed pattern of circadian rhythms of HRV and showed a relatively 'flat' representation of hourly-recorded spectral power of the HF component of HRV.

[Cardiac tamponade after laparoscopic operation for a traumatic].

Cardiac tamponade is a rare complication of diaphragmatic hernia repair. We report a case of a 79-year-old female, who underwent a laparoscopic procedure with mesh implantation. Tackers were used to secure the mesh to the diaphragm. Nine hours after surgery the patient died from circulatory collapse. Autopsy showed perforation of the pericardium and the right coronary artery by a tacker. A review of the literature reveals nine earlier reported cases. In three of these cases the complication resulted in death. Rapid diagnosis and intervention can decrease mortality. To avoid further incidents it is necessary to consider alternatives to tacks.

Flow and peak velocity measurements in patients with aortic valve stenosis using phase contrast MR accelerated with k-t BLAST.

OBJECTIVE: To investigate the accuracy of velocity measurements in patients with aortic valve stenosis using phase contrast (PC) imaging accelerated with SENSE (Sensitivity Encoding) and k-t BLAST (Broad-use Linear Acquisition Speed-up Technique). METHODS: Accelerated quantitative breath hold PC measurements, using SENSE and k-t BLAST, were performed in twelve patients whose aortic valve stenosis had been initially diagnosed using echocardiography. Stroke volume (SV) and peak velocity measurements were performed on each subject in three adjacent slices using both accelerating methods. RESULTS: The peak velocities measured with PC MRI using SENSE were -8.0±9.5% lower (p<0.01) compared to the peak velocities measured with k-t BLAST and the correlation was r=0.83. The stroke volumes when using SENSE were slightly higher 0.4±17.1 ml compared to the SV obtained using k-t BLAST but the difference was not significant (p>0.05). CONCLUSIONS: In this study higher peak velocities were measured in patients with aortic stenosis when combining k-t BLAST with PC MRI compared to PC MRI using SENSE. A probable explanation of this difference is the higher temporal resolution achieved in the k-t BLAST measurement. There was, however, no significant difference between calculated SV based on PC MRI using SENSE and k-t BLAST, respectively.

Atrial function after epicardial microwave ablation in patients with atrial fibrillation.

OBJECTIVES: To study epicardial microwave ablation of concomitant atrial fibrillation and its effects on heart rhythm and atrial function during follow-up. DESIGN: The study included 20 open-heart surgery patients with concomitant atrial fibrillation. Transthoracic echocardiography with flow and tissue Doppler recordings was performed preoperatively and at 6 months postoperatively. Blood samples were obtained preoperatively and postoperatively for analysis of atrial natriuretic peptide (ANP), brain natriuretic peptide (BNP), and amino terminal precursor of brain natriuretic peptide (NT-proBNP). RESULTS: Fourteen of 19 patients (74%) were in sinus rhythm with no antiarrhythmic drugs at 12 months. All patients in sinus rhythm had preserved left and right atrial-filling waves through atrioventricular valves during atrial contraction. Tissue velocity echocardiography on patients in sinus rhythm showed preserved atrial wall velocities, atrial strain, and atrial strain rate. Levels of natriuretic peptides tended to decrease in patients with stable sinus rhythm at one year compared to patients in atrial fibrillation. CONCLUSIONS: Epicardial microwave ablation results in sinus rhythm in a majority of patients and seems to preserve atrial mechanical function.