New Doppler echocardiographic applications for the evaluation of early alterations in left ventricular diastolic function after coronary angioplasty.

AIMS: The early effect of percutaneous transluminal coronary angioplasty on left ventricular diastolic dysfunction was investigated with the aid of new Doppler echocardiographic applications. METHODS: Thirty patients with isolated severe left anterior descending coronary artery stenosis were included. All patients exhibited abnormal diastolic function demonstrated by prolonged isovolumic relaxation and deceleration time and decreased E/A ratio. New Doppler indexes included the flow propagation velocity of E wave, E and A waves' transit time to the left ventricular outflow tract, the ratio of these transit times in addition to the traditional isovolumic relaxation time, mitral deceleration time, and early and late transmitral peak flow velocities. All measurements were performed within 4 h before angioplasty and repeated within 24 h after the procedure. RESULTS: After angioplasty none of these parameters, except the A-wave transit time, were changed significantly. The A-wave transit time increased significantly from 57 +/- 5 ms to 78 +/- 7 ms within 24 h after successful angioplasty. The ratio of E- and A-wave transit time decreased significantly due to this significant increase in A-wave transit time. CONCLUSION: In this study, early improvement of Doppler index of left ventricular diastolic compliance is demonstrated after successful angioplasty.

Cardioversion with sotalol in selected patients with vagally and adrenergically mediated paroxysmal atrial fibrillation.

This study was designed to evaluate and compare the effects of oral sotalol for the treatment of vagal and adrenergic paroxysmal atrial fibrillation (PAF). Thirty-five eligible patients with atrial fibrillation of > 12 hours and < 7 days were enrolled in the study. Patients were classified as vagally mediated (group I, n: 14) and adrenergically mediated (group II, n: 21) PAF groups. All patients were given racemic sotalol at a dose up to 120 mg bid for 2 days. At the end of the observation period of 48 hours, 36% of patients (n: five) in group I returned to sinus rhythm. Conversion rate in group II was 71% (n: 15), and this figure was significantly higher than the success rate in group I. Mean times to cardioversion were 22 +/- 15 hours in group I and 16 +/- 14 hours in group II (p < 0.05). The result of this study suggests that oral sotalol is more effective for adrenergic PAF. This beneficial effect of sotalol is not apparent in vagal PAF patients.

Rare association of hypertrophic cardiomyopathy and complete atrioventricular block with prompt disappearance of outflow gradient after DDD pacing.

Although arrhythmias are common in hypertrophic cardiomyopathy (HCM), complete atrioventricular (AV) block is very unusual. A 27-year-old female presented with a recent history of syncope and exercise intolerance. ECG demonstrated complete AV block. Two-dimensional Doppler echocardiography revealed HCM with a 60 mmHg left ventricular outflow tract (LVOT) gradient. A temporary transvenous ventricular pacemaker was inserted urgently, and subsequently replaced by a permanent DDD pacemaker. All symptoms were eliminated. This symptomatic improvement was associated with complete disappearance of LVOT gradient at the time of implantation. No gradient was observed during early follow-up and at 6 months after DDD pacemaker implantation.

Acute electrophysiological effects of dipyridamole on sinus node function in patients with sick sinus syndrome.

One of the most widely used tests for evaluation of sinus node function is sinus node recovery time (SNRT), which requires right heart catheterization. On the other hand SNRT has high specificity but only moderate sensitivity in the diagnosis of sick sinus syndrome (SSS). The authors studied acute electrophysiologic effects of dipyridamole (0.40 mg/kg IV) in 16 patients with clinical SSS. All of them had normal SNRT and had undergone permanent DDD pacemaker implantation. By the aid of temporary pacing inhibition, the authors noninvasively measured the corrected sinus node recovery time (SNRTc) and sinus cycle length (SCL) before and after dipyridamole administration. SCL was slightly decreased from a mean basal value of 1025 +/-323 to 913+/-213 msec after dipyridamole administration (mean -10%), but this was not statistically significant. SNRTc was increased from a mean basal value of 344+/-91 to 606+/-156 msec after dipyridamole administration (+76% P< or =0.004). These results suggest that dipyridamole must be used cautiously in patients with SSS. Intravenous dipyridamole may be a useful test to assess sinus node function. SNRT measurement after intravenous dipyridamole may increase sensitivity of this test in patients with suspected SSS and normal SNRT.

Psychiatric morbidity and depressive symptomatology in patients with permanent pacemakers.

Implantation of a permanent pacemaker requires a psychological effort on the patient's part for adaptation in the acute term, and chronically, it restricts activities of the patient and may cause some psychiatric disturbances. To investigate psychiatric morbidity and depressive symptomatology of the patients with permanent pacemakers, 84 pacemaker patients were diagnosed using the DSM-III-R criteria and depressive symptoms were determined by modified Hamilton Depression Rating Scale (mHDRS). Sixteen (19.1%) patients had been given a psychiatric diagnosis. The most frequent diagnoses were adjustment disorder (5.9%) and major depressive episode (4.7%). Nine patients (10.7%) were diagnosed as having clinical depression (mHDRS > or = 17). The mean score of mHDRS was 7.57 +/- 7.46, and the severity of depression was significantly higher in females. The most frequent symptoms are difficulties in work and activities (53.6%), psychic anxiety (48.8%), loss of energy (42.9%), and hypochondriasis and insomnia (39.3%). Depressed mood, psychic anxiety, loss of energy, loss of interest, insomnia, and hypochondriasis were significantly more frequent in females. Uneducated patients had a more significant loss of energy than educated patients. Depressed mood, psychic anxiety, and somatic concerns and symptoms were more frequent in patients with permanent pacemakers than in the general population. These symptoms, resembling mixed anxiety-depression disorder, were related to fears of having a permanent pacemaker, since our series were composed of uneducated patients who did not have enough knowledge about the device.

New onset complete heart block and corrected transposition of great arteries in the seventh decade.

A 65-year-old female was hospitalized for syncope due to new onset complete heart block. An apical holosystolic murmur was detected on physical examination. Echocardiography revealed corrected transposition of great arteries, and Ebstein-like anomaly with regurgitation at the left-sided tricuspid valve. A single chamber (VVI) pacemaker was implanted and patient has been asymptomatic thereafter.

The influence of different AV delays on left ventricular diastolic functions and on incidence of diastolic mitral regurgitation.

In patients with a DDD pacemaker (PM), programming of atrioventricular (AV) delay can influence ventricular filling and function. In this study the authors used color Doppler echocardiography to evaluate the effect of different AV delays on left ventricular diastolic function (LVDF) and on the incidence of diastolic mitral regurgitation. In 26 patients with DDD PM, the following parameters were evaluated during five different AV delays by echocardiography: (1) mitral E wave amplitude (by pulsed Doppler), (2) mitral A wave amplitude (by pulsed Doppler), (3) isovolumetric relaxation time (IVRT), (4) deceleration time (DT), (5) LV diastolic dimension (LVDd), (6) LV systolic dimension (LVDs), (7) ejection fraction (EF), and (8) diastolic mitral regurgitation (DMR). Patients had been paced for symptomatic AV block (n: 16, 62%) and sick sinus syndrome (n: 10, 38%). Mean age of patients was fifty-two (nineteen to sixty-three) and 13 (50%) of them were women.

Pacemaker inhibition and asystole in a pacemaker dependent patient.

A 17-year-old female with Kearns Sayre syndrome, complete heart block, and an implanted single chamber (VVIR) pacemaker, underwent testing with a GSM cellular phone that was placed directly over the pacemaker site. The pacemaker was immediately inhibited when the phone began to operate. A 6.5-second period of complete heart block with asystole occurred until the phone was switched off.

Effect of the number of ventricular leads on right ventricular hemodynamics in patients with permanent pacemaker.

During pacemaker replacement most of the old leads are not suitable for recent needs or may show signs of dysfunction. These leads are difficult to extract and are therefore left-in situ. In this study 32 patients with one ventricular lead (Group I) were compared echocardiographically with 18 patients with two ventricular leads (Group II) in regard to their right ventricular (RV) hemodynamics. Mean age of the patients in each group was sixty-one years. Patients were evaluated echocardiographically after two years of lead implantation. Two groups were compared for right atrial (RA) area, RA and RV diameters, tricuspid insufficiency (TI), and intravascular and intracardiac thrombosis. There were no significant differences between the two groups in terms of RA and RV diameters, RA area, and venous and intracardiac thrombosis. In group I, 15 patients with (46.9%) grade I, 14 (43.7%) with grade II, and 3 (9.4%) with grade III TI were detected. In group II 2 patients (11.1%) with grade I, 6 (33.3%) with grade II, and 10 (55.6%) with grade III TI were detected. In conclusion, the incidence of TI was more frequent and of higher degree in group II than in group I, but this finding was hemodynamically insignificant.

ACE inhibitors and cough.

Probably the most common and irritating side effect of angiotensin-converting enzyme (ACE) inhibitors is cough. In this retrospective study the incidence of cough was investigated in 1113 patients with arterial hypertension who were receiving ACE inhibitors alone or in combination with other antihypertensive agents. Patients were treated with one of the following ACE inhibitors: enalapril 10-20 mg/day (n:668), captopril 25-75 mg/day (n:234), perindopril 2-8 mg/day (n:90), or lisinopril 5-20 mg/day (n:121). Mean follow-up periods were twenty-six months with enalapril, twenty-nine months with captopril, eleven months with perindopril, and thirteen months with lisinopril. Spontaneously declared cough incidence in enalapril, captopril, perindopril, and lisinopril groups were 7%, 5.1%, 2.2%, and 1.6%, respectively. Cough was not dose related. Treatment was stopped in all patients with cough. In 59% of patients the onset of cough occurred after the first month of treatment (thirty to one hundred eighty days). Cough decreased by 50% within three days of drug cessation and disappeared in ten days. Mean age of patients with cough was 58.7 years and 79% of them were women. In patients without cough, mean age was 57.8 years and 56% of them were women. There was no significant difference between the two groups regarding mean age, but the sex difference between groups was statistically significant (P < 0.05). In conclusion, although cough may occur with all four types of ACE inhibitors, the incidence of this side effect was higher during enalapril and captopril treatment than during lisinopril and perindopril treatment. The incidence was also greater in women than in men.