Effect of ultra-endurance exercise on left ventricular performance and plasma cytokines in healthy trained men.

The purpose of this study was to investigate the effect of ultra-endurance exercise on left ventricular (LV) performance and plasma concentration of interleukin (IL)-6, IL-10, IL-18 and tumour necrosis factor alpha (TNF-α) as well as to examine the relationships between exercise-induced changes in plasma cytokines and those in echocardiographic indices of LV function in ultra-marathon runners. Nine healthy trained men (mean age 30±1.0 years) participated in a 100-km ultra-marathon. Heart rate, blood pressure, ejection fraction (EF), fractional shortening (FS), ratio of early (E) to late (A) mitral inflow peak velocities (E/A), ratio of early (E') to late (A') diastolic mitral annulus peak velocities (E'/A') and E-wave deceleration time (DT) were obtained by echocardiography before, immediately after and in the 90th minute of the recovery period. Blood samples were taken before each echocardiographic evaluation. The ultra-endurance exercise caused significant increases in plasma IL-6, IL-10, IL-18 and TNF-α. Echocardiography revealed significant decreases in both E and the E/A ratio immediately after exercise, without any significant changes in EF, FS, DT or the E/E' ratio. At the 90th minute of the recovery period, plasma TNF-α and the E/A ratio did not differ significantly from the pre-exercise values, whereas FS was significantly lower than before and immediately after exercise. The increases in plasma TNF-α correlated with changes in FS (r=0.73) and DT (r=-0.73). It is concluded that ultra-endurance exercise causes alterations in LV diastolic function. The present data suggest that TNF-α might be involved in this effect.

Factors related to the early and late success of direct current cardioversion of chronic nonrheumatic atrial fibrillation: An echocardiographic study.

OBJECTIVES: To assess factors related to the success of restoration and one-year maintenance of sinus rhythm in chronic (more than 48 h) nonrheumatic atrial fibrillation (AF). METHODS AND RESULTS: One hundred and fifty consecutive patients aged 62+/-9 years with AF lasting 123+/-254 days were evaluated clinically with transthoracic and transesophageal echocardiography before elective direct current cardioversion. Heart chamber dimensions and left ventricular ejection fraction were measured. The presence of left atrial thrombi and spontaneous echocardiographic contrast as well as flow velocities in the left atrial appendage were assessed. The first cardioversion was followed by standardized two-step antiarrhythmic treatment including a second cardioversion, if necessary. Twenty patients (13%) spontaneously reverted to sinus rhythm (S) during anticoagulation preceding cardioversion, 81 (54%) were successfully cardioverted (Y), and in 49 (33%) cardioversion failed initially (N). No differences were noted between the two latter groups. However, S patients had smaller left atria measured in the short and long axes (42+/-4 mm, P=0.05, and 53+/-7 mm, P=0.005, respectively) than both the Y (45+/-4 and 61+/-8 mm) and the N patients (46+/-4 and 61+/-8 mm). One-year follow-up was obtained in 95 patients: 64 (67%) were in sinus rhythm while 31 (33%) had AF. Again, no initial differences predicting the maintenance of sinus rhythm were found. CONCLUSIONS: Spontaneous reversion of AF seems more likely with smaller left atria. Echocardiography, including trans-esophageal echocardiography, is unlikely to identify patients in whom attempts to restore and maintain sinus rhythm will fail or succeed.

CN3OP: an active regimen in patients with relapsed/refractory Hodgkin's lymphoma.

Patients with recurrent or refractory Hodgkin's and non-Hodgkin's lymphoma are increasingly being treated with high-dose therapy and hematopoietic cell transplantation. As minimal disease status at the time of transplant has been a repeatedly proven significant prognostic factor for long-term survival, effective initial cytoreduction is an important step in the process. Modern chemotherapy programs for Hodgkin's lymphoma include virtually all active agents and little is left for effective salvage. Mitoxantrone is an active agent in lymphoma that is not generally used in first-line treatment. The aim of this study was to determine toxicity and response rate to CN3OP (fractionated mitoxantrone 6 mg/m2 on days 1, 2, and 3, combined with standard dose cyclophosphamide, vincristine, and prednisone) in 44 patients with relapsed or refractory lymphoma. Most of patients had advanced disease and one or more extranodal sites at relapse. Median response duration to immediate past therapy was four months, and one third of patients had not responded to prior treatment. A median of 4 cycles of CN3OP were given per patient for a total of 173 cycles. Grade III-IV neutropenia occured in 53% of cycles, Grade I-III mucositis in 24%, and Grade I-III infection in 17% of cycles. Of 34 evaluable patients with Hodgkin's lymphoma 12 (35%) achieved complete remission (CR) and 15 (44%) partial remission (PR) for an overall response rate of 79%. Two of five evaluable non-Hodgkin's lymphoma patients responded with PR. Median overall survival and event free survival in the entire group was 29 months and 11 months respectively. At this time 16 patients have died; 12 of lymphoma, two of unknown cause and two of other causes. Complete response to CN3OP correlated with survival. CN3OP is an effective and safe regimen for cytoreduction in Hodgkin's lymphoma patients pretreated with doxorubicin/alkylator/etoposide-containing primary therapies.

Transoesophageal echocardiography for definitive diagnosis of haemodynamically significant pulmonary embolism.

Transesophageal echocardiographic evaluation of right and left pulmonary arteries, up to the origin of their lobar branches, was prospectively performed with a single plane probe in 32 consecutive patients (18 M, 14 F, aged 55.5 +/- 14.6, from 32 to 80 years) with clinical or echocardiographic suspicion of pulmonary embolism, who met transthoracic echocardiographic criteria of right ventricular overload. Transoesophageal echocardiography showed unequivocal (20 patients) or suspected (three patients) intraluminar thrombi in 88.5% of 26 patients with haemodynamically significant acute or chronic pulmonary embolism, confirmed with reference methods. The sensitivity of the unequivocal transoesophageal echocardiographic diagnosis was 80% for acute and 73% for chronic haemodynamically significant pulmonary embolism. No false-positive results were found (specificity 100%). Additionally, in three cases, transoesophageal echocardiography disclosed the cause of the right ventricular overload revealing a previously undiagnosed atrial septal defect or Ebstein anomaly. Direct visualization of proximal pulmonary arterial thrombi by transoesophageal echocardiography emerges as a useful new method of prompt and definite diagnosis of haemodynamically important pulmonary embolism.

[Giant cell arteritis--presentation of 3 cases]. / Olbrzymiokomórkowe zapalenie Tetnicy skroniowej--omówienie 3 przypadków.

Three patients with giant cell arteritis (GCA) observed recently in our department are described. One of them demonstrated clinical picture of polymyalgia rheumatica, the other two presented with clinical symptoms of GCA. This presentation seems to be very helpful for correct diagnosis in cases with difficult recognition.

A comparison between the automatized impedance cardiography and pulsed-wave Doppler echocardiography methods for measurements of stroke volume (SV) and systolic time intervals (STI).

Stroke volume (SV) and systolic time intervals (STI) were measured automatically using impedance cardiography signals (ICG) and compared with those obtained by pulsed-wave Doppler echocardiography using the apex approach. The comparison was made in 9 healthy male subjects, mean age 24.9 +/- 12.2 years, using recordings of 10 heart cycles simultaneously obtained by the two methods. During measurements the subjects rested in the supine position. There were no differences between mean values of SV determined by the two methods as well as between mean values of ejection time (ET) (p > 0.8 and p > 0.9, respectively). The pre-ejection period (PEP) estimated by ICG was 22 ms longer than that determined by echocardiography (p < 0.001). The relationship between SV values measured by impedance cardiography (SVA) vs those calculated by echocardiography (SVE) was found to be close to the line of identity in the range of measurements. The regression equation for SV was: SVA = 0.784.SVE + 15 (r = 0.69, p < 0.001, SEE = 10.7 ml). We conclude that automatic determination of SV and ET from ICG signals provides results comparable in absolute values with those obtained by the pulsed wave Doppler ultrasonocardiography using the apex approach for subjects remaining in the supine position.

[Primary arterial hypertension. Treatment with captopril and function of the left heart ventricle, concentration of catecholamine in blood and activity of renin]. / Pierwotne nadcsnienie tetnicze. leczenie kaptoprylem a czynnosc lewej komory serca, stezenie katecholamin we krwi i aktywnosc reniny.

We evaluated the effect of captopril treatment on left ventricular mass (LVM) and function in sustained mild-to-moderate primary hypertension. In 16 men aged 34.5 +/- 6.4 yrs. M-mode echo and pulsed wave Doppler recordings were obtained prior to and after 2 months captopril treatment (50-150 mg daily). No significant changes in heart rate, systolic blood pressure, ejection fraction, fractional shortening, cardiac output, LVM and Doppler-derived indices of mitral inflow were observed. Diastolic blood pressure measured during examination fell from 102.2 +/- 13.3 to 90.3 +/- 9 mmHg (p less than 0.026). No consistent correlations between catecholamines and indexes of left ventricular function were found. Two-month captopril therapy in mild-to-moderate hypertension results in diastolic blood pressure lowering with no effect on LVM or left ventricular function.

Factors influencing transmitral flow velocity in normal and hypertensive subjects.

Transmitral flow velocity and its determinants were examined with Doppler echocardiography in 53 hypertensive and 32 age-matched healthy normotensive men. Early and late maximal transmitral velocity, and early and late flow velocity integral were evaluated. In comparison with normal subjects, hypertensive patients were characterized by decreased maximal early velocity (66.3 +/- 12.3 versus 72.3 +/- 11.5 cm/sec, p less than 0.05), normalized early flow integral (67 +/- 7% versus 73 +/- 5%, p less than 0.001), increased maximal late flow velocity (45 +/- 10 cm/sec, p less than 0.001), and normalized late flow integral (29 +/- 7% versus 21 +/- 5%, p less than 0.001). Abnormally high late transmitral flow was found in 47% of the hypertensive group. Multiple regression analysis revealed that in normal subjects transmitral flow indexes were determined by age, relative wall thickness, and systolic blood pressure, but not by heart rate. A strong relationship of Doppler transmitral flow indexes with age was confirmed in hypertensive patients; however, relative wall thickness influenced transmitral flow velocity only weakly and systolic blood pressure did not affect transmitral flow. Left ventricular mass and diastolic blood pressure did not influence mitral filling velocity in either group. The altered pattern of mitral inflow found in a large number of hypertensive subjects is not related to elevated arterial blood pressure or to altered left ventricular geometry.

[Left ventricular systolic function in young women with hyperkinetic syndrome--echocardiographic evaluation]. / Czynnosc skurczowa lewej komory serca u mlodych kobiet z zespolem samoistnego krazenia hiperkinetycznego--ocena echokardiograficzna.

In twenty two young (mean age 31.6 years) normotensive women with hyperkinetic heart syndrome (HHS) we assessed echocardiographically left ventricular (LV) function indexes before and after 40 mg of oral propranolol. At baseline the HHS group differed from controls with respect to higher heart rate heart and diastolic blood pressure (BPs), lower systolic and systolic LV volumes, greater corrected mean circumferential fiber shortening, ejection fraction, cardiac index and contractility index (systolic blood pressure x body surface area/LV end-systolic volume ratio). Propranolol normalized nearly all analyzed indexes except for BPs which remained increased compared to controls. In young women with HHS enhanced cardiac performance is expressed by higher cardiac index and speed of blood ejection from the left ventricle, is related to tachycardia and higher contractility but not to increased preload. Results post propranolol administration speak in favour of significant role of increased beta-adrenoceptor stimulation in HHS.

[Adaptation of the left ventricle to increased load in primary arterial hypertension]. / Adaptacja lewej komory serca do zwiekszonego obciazenia w pierwotnym nadcisnieniu tetniczym.

Adaptational mechanisms of the left ventricle to increased afterload in essential hypertension were studied in a group of 53 males with essential hypertension and in 32 normotensive males of the control group. M-mode echocardiograms were performed in all patients. The degree of hypertrophy, contractility, end-systolic stress index were assessed. The group with essential hypertension had increased peripheral vascular resistance and normal LV out put. In this group there was also increase of LV contractility. Increased LV contractility and LV hypertrophy are adaptational mechanisms maintaining normal cardiac output in patients with hypertension through a decrease in end-systolic stress.

Attempts at measuring pulmonary arterial pressure by means of Doppler echocardiography in patients with chronic lung disease.

In 72 patients with severe chronic pulmonary or pulmonary vascular disease pulmonary arterial pressure was measured by means of right heart catheterization. Forty three patients had pulmonary hypertension, (32 +/- 11 mmHg) and 27 patients had normal pressure (14 +/- 3 mmHg). These patients were examined with continuous wave (CW) and pulsed wave (PW) Doppler echocardiography. The retrograde systolic tricuspid valve pressure gradient assessed with CW Doppler correlated with systolic pulmonary pressure (r = 0.92, p less than 0.001, SEE 7.7 mmHg) but was measurable in only 17 of the 70 patients. The flow velocity pattern in the right ventricular outflow tract could be recorded in 68 of the 70 patients. Acceleration time (AcT) from systolic flow onset to peak velocity correlated with mean pulmonary artery pressure (r = 0.72, p less than 0.001, SEE 8.3 mmHg). An AcT less than 90 msec had an 84% positive predictive value for pulmonary hypertension. Right ventricular isovolumic relaxation time could be measured in 59 of the 70 patients and correlated with systolic pulmonary artery pressure (r = 0.69, p less than 0.001, SEE 12.4 mmHg). No single Doppler method is at the same time easily applicable and accurate in prediction of pulmonary arterial pressure in patients with chronic lung diseases.

Effect of endurance training on cardiovascular response to static exercise performed with untrained muscles.

Eighteen male volunteers (20-23 years) were submitted to 13 weeks of training consisting of 30 min of exercise (at 50%-75% VO2max) on a bicycle ergometer, performed three times a week. Every 4 weeks the heart rate (HR), blood pressure (BP), and systolic time interval (STI) responses to the static handgrip (at 30% MVC) were examined. Before and after 13 weeks of training echocardiograms were recorded in seven subjects at rest and during the handgrip. Significant decreases in HR and BP responses to static exercise were found already after 4 weeks of training. Resting STI and left ventricular dimensions were not affected by training, but during the static exercise the pre-ejection period (PEP) and isovolumic contraction time interval (ICT) at the corresponding HR were significantly shortened after 8 weeks of training. The values of echocardiographic indices of left ventricular function obtained during exercise after training did not differ significantly from those found before training. It is concluded that endurance training of moderate intensity improves cardiac function during static exercise performed with untrained muscles.

Right atrial mobile thrombi: two-dimensional echocardiographic diagnosis and clinical outcome.

Four patients with pulmonary embolism and right atrial mobile thrombi (RAMT) are described. One patient died during intravenous heparin treatment because of a "saddle" pulmonary artery embolus, another died from surgical complications after successful embolectomy. One of the two survivors was treated with intravenous streptokinase and the other with intravenous heparin. Echocardiographically detected RAMT seems a reliable sign of impending massive pulmonary embolism. Pulmonary angiography is unnecessary and may be dangerous. Surgical removal of RAMT, fibrinolytic treatment or intravenous heparin introduced promptly may be lifesaving.