Natriuretic peptide B plasma concentration increases in the first 12 h of pulmonary edema recovery.

BACKGROUND: According to guidelines, single determination of B-type Natriuretic peptide (BNP) should be used for distinguishing between cardiac and non-cardiac acute dyspnea at the emergency room. BNP measurement is also recommended before hospital discharge in patients hospitalized for heart failure to assess prognosis and to evaluate treatment efficacy. In acute cardiogenic pulmonary edema, BNP is measured using a single BNP determination, but the temporal behavior of BNP during pulmonary edema recovery is unknown. METHODS: Fifty chronic low ejection fraction (<40%) heart failure patients (age 77 ±â€¯9 years, 17 M-33F) admitted for acute pulmonary edema were studied. Patients were grouped according to 50% dyspnea recovery time into 3 groups: ≤30 min (n = 14), 30 to 60 min (n = 19), and > 60 min (n = 17). BNP was measured at arrival and 4, 8, 12 and 24 h afterwards. RESULTS: At arrival, BNP was elevated in all patients without significant difference among groups. In the entire population, BNP median and interquartile range value were 791 (528-1327) pg/ml, 785(559-1299) pg/ml, 1014(761-1573) pg/ml, 1049(784-1412) pg/ml, 805(497-1271) pg/ml at arrival and 4, 8, 12 and 24 h afterwards, respectively, showing higher values at 8 and 12 h. This peculiar temporal behavior of BNP was shared by all study groups. Patients with the longest edema resolution showed the highest BNP level 8 and 12 h after admission. CONCLUSIONS: In acute pulmonary edema, BNP increased up to 12 h after emergency admission regardless of dyspnea recovery time, making BNP quantitative meaning in the acute phase of pulmonary edema uncertain.

Kinetics of plasma SPB and RAGE during mechanical ventilation in patients undergoing major vascular surgery.

Receptor-of-Advanced-Glycation-End-products (RAGE) and Surfactant-Protein-type-B (SPB) are reported as lung injury markers. Unlike SPB, RAGE is secreted by several tissues, so that RAGE specificity as lung injury marker is questionable. We measured SPB and RAGE in 19 patients undergoing major vascular abdominal surgery. SPB and RAGE were measured before mechanical ventilation (T0), at 1st (T1), 2nd (T2) and, when present, 3rd (T3) hour of mechanical ventilation, and 1h after extubation (T(POST)). Last data during mechanical ventilation, either T2 or T3, are reported as T(END). SPB and RAGE values were normalized for total protein (SPB(N) and RAGE(N)). SPB(N) and RAGE(N) increments from T0 to T(END) were 56.2 [39.1] ng/mg (mean [75-25 percentile]) and 10.6[7.1] pg/mg, respectively. SPB values increased progressively during mechanical ventilation, whereas RAGE values increased at T(1) but not thereafter. SPB(N) increase (T(END)-T0), but not RAGE(N), was related to ΔPaO(2)/FiO2 changes during mechanical ventilation (r=0.575, p=0.01). Plasma RAGE(N) and SPB(N) kinetics in patients undergoing major vascular surgery are different.

Erectile dysfunction in heart failure: correlation with severity, exercise performance, comorbidities, and heart failure treatment.

INTRODUCTION: Erectile dysfunction (ED) is frequent in males with chronic heart failure (HF) with a severe impact on quality of life for many individuals. The correlation of ED with age and HF severity, comorbidity, and treatment is unclear. AIM: We evaluated the correlation between ED and HF severity, treatment, and comorbidity. METHODS: One hundred one HF patients aged < or =70 years, with left ventricular ejection fraction < or =40%, and stable clinical condition took part in the study. We measured: (i) hemoglobin, glycemia, glicated hemoglobin, creatinine, cholesterol, thyroid-stimulating-hormone, C-reactive-protein, total/free testosterone; (ii) ED, depression, urological symptoms, and signs of low testosterone by means of questionnaires; and (iii) HF severity by means of echo, brain natriuretic peptide, and cardiopulmonary exercise test. MAIN OUTCOME MEASURES: ED was measured by means of International Index of Erectile Function-5 questionnaire and its score was correlated with exercise cardiopulmonary test parameters, HF severity, treatment and HF comorbidities. RESULTS: ED prevalence was 69.3%, 81.1%, and 56% in total population and in patients with and without coronary artery lesions, respectively. ED was absent in 31 while it scored mild, mild to moderate, moderate and severe in 15, 18, 12, 25 individuals, respectively. Sexual activity requires, in the orgasmic phase, an oxygen consumption (VO(2)) between 10 and 14 mL/min/kg. In none of the individuals with peak VO(2) < 10 mL/min/kg was sexual function normal or slightly impaired, while in 10/29 of patients with peak VO(2) between 10 and 14 mL/min/kg there was a normal or slightly reduced sexual performance. On monovariable analysis, several parameters were correlated with ED, but at multivariable analysis only age (P = 0.002), hemoglobin (P = 0.042), diabetes (P = 0.040), and use of diuretics (P = 0.052) remained so. CONCLUSIONS: ED is frequent in HF. A normal or only slightly impaired sexual activity is possible with peak VO(2) > 10 mL/min/kg. On multivariable analysis, only age, diabetes, use of diuretics, and hemoglobin are related to ED.

Feasibility and diagnostic accuracy of quantitative assessment of mechanical prostheses leaflet motion by transthoracic and transesophageal echocardiography in suspected prosthetic valve dysfunction.

Transthoracic (TTE) and transesophageal echocardiography (TEE) are the standard techniques for the evaluation of prosthetic valve function. However, quantitative evaluation of leaflet(s) motion is not routinally carried out, although leaflet(s) opening and closing angle measurements are important information to recognize prosthetic dysfunction. For this purpose, cinefluoroscopy is considered the "gold standard" technique. The aim of this study was the evaluate the diagnostic accuracy of TTE and TEE in the quantitative assessment of leaflet motion in patients with mechanical protheses. One hundred-eleven patients with mitral (single disk 18; bileaflet 48) and aortic (single disk 22; bileaflet 23) prostheses, were referred to TTE, TEE, and cinefluoroscopy for electrical cardioversion of atrial fibrillation (n = 40) or suspected prosthesis dysfunction (n = 71). Echocardiographic evaluation included leaflet(s) opening and closing angle measurements; results were compared with cinefluoroscopy. For mitral prostheses, opening and closing angles were correctly identified by TTE in 85% and by TEE in 100% of patients, regardless of prosthetic valve type, with a good concordance with cinefluoroscopy. For aortic prostheses, opening angles were correctly identified by TTE and TEE, respectively, in 40% and 77% of patients with single-disk and in 13% and 35% of patients with bileaflet prostheses. Both TTE and TEE were rarely able to identify closing angles. In conclusion, quantitative evaluation of mitral leaflet(s) motion may be accurately achieved with TTE and TEE, leading to increased diagnostic efficacy of prosthetic valve dysfunction. In the aortic position, TTE and TEE allow a quantitative evaluation of leaflet(s) dynamics only in a minority of patients and cinefluoroscopy still remains the first-choice technique.

Usefulness of multiplane transesophageal echocardiography in the recognition of artifacts and normal anatomical variants that may mimic left atrial thrombi in patients with atrial fibrillation.

BACKGROUND: Transesophageal echocardiography (TEE) is the method of choice for the evaluation of the left atrium and of left atrial appendage (LAA) thrombosis. However, the anatomy of the left appendage is complex and reverberations from anatomical structures may create images and ghosting which mimic left atrial thrombosis. The purpose of this study was to investigate whether a systematic approach through TEE may facilitate the recognition of LAA anatomical variants and artifacts. METHODS: One hundred and sixty-four consecutive patients scheduled for cardioversion of atrial fibrillation (study population) and 30 patients (control group) undergoing mitral valve surgery were submitted to TEE using a multiplane probe in order to obtain a systematic evaluation of the LAA. The number of LAA lobes and the presence of thrombi and artifacts were evaluated. RESULTS: The majority of the study patients had a bilobed (53.1%) or single-lobed (34.1%) LAA. Thrombi were identified in 6%. Artifacts were found in 38 cases (23.2%) and their position was localized precisely at a distance from the transducer which was twice that from the partition-bend between the left upper pulmonary vein and left appendage, suggesting a reverberation. No differences in echocardiographic parameters were found in patients with (group 1) or without (group 2) artifacts. Cardioversion was successful in a similar percentage of cases in the two groups (group 1 68%, group 2 76%) without complications. In controls, the percentages of a single-(33%) and bilobed (40%) left appendage were similar to those found in the study population. Artifacts were identified in 11 controls (37%); no thrombi were detected during surgical left appendage inspection in these cases. CONCLUSIONS: A systematic approach with multiplane TEE facilitates the evaluation of the LAA anatomy and the recognition of artifacts, thus reducing the likelihood of false positive or negative diagnoses of left appendage thrombi.

Pulmonary hemodynamic and tidal volume changes during exercise in heart failure.

BACKGROUND: Impairment of lung mechanics, increase of pulmonary artery pressure and limitation of exercise capacity are common findings in chronic heart failure. The objective of the present study was to evaluate whether pulmonary mechanics are correlated with pulmonary hemodynamics, whether both are correlated with the functional capacity and whether the time course of their changes during exercise correlates with the exercise capacity. METHODS: We performed a cardiopulmonary exercise test (breath by breath analysis of ventilation and gas exchange, cycloergometer, 25 W increments every 3 min) with pulmonary hemodynamic monitoring in 38 heart failure patients. The parameters were analyzed at rest, 1 min after the work rate increase and at peak exercise. RESULTS: A significant linear correlation with peak oxygen consumption was found at rest for: mean pulmonary artery pressure (mPAP, r = -0.56), right atrial pressure (RAP, r = -0.42), pulmonary wedge pressure (PWP, r = -0.53), and total pulmonary (TPR, r = -0.53) and pulmonary vascular resistances (PVR, r = -0.45); after 1 min of exercise for: cardiac index (CI, r = 0.49), mPAP (r = -0.57), RAP (r = -0.60), PWP (r = -0.45), and TPR (r = -0.67) and PVR (r = -0.38); at peak exercise for: tidal volume (r = 0.63), CI (r = 0.63), RAP (r = -0.43), TPR (r = -0.65) and PVR (r = -0.43). A significant linear correlation with peak oxygen consumption was found, for the increment between rest and 1 min of exercise, for RAP (r = -0.58) and CI (r = 0.42) and, for the increments between rest and peak exercise, for tidal volume (r = 0.79) and CI (r = 0.61) and, for the ratio between the increment between rest and 1 min of exercise/increment between rest and peak exercise, for mPAP (r = -0.42), RAP (r = 0.51) and CI (r = -0.54). The same ratio of increment of mPAP (r = 0.39) and CI (r = 0.36) correlated with that of tidal volume. CONCLUSIONS: This study provides evidence of a strong correlation between the respiratory function and pulmonary vascular pressure changes during exercise in heart failure.