Influence of load changes on tricuspid inflow.

In healthy subjects, the right ventricular filling pattern estimated from tricuspid valve inflow is highly load-dependent. This can be clearly demonstrated by changes of Doppler inflow tracings recorded during tidal breathing at rest. The aim of our study was to test the magnitude of tricuspid inflow changes during more pronounced load changes induced by specific maneuvers. In 31 apparently healthy subjects (16 men and 15 women, mean age 36+/-16 years) we recorded pulsed Doppler tracings of tricuspid inflow during forced inspiration, elevation of lower extremities (increased preload) and handgrip exercise (increased afterload). The obtained values were compared with end-expiratory phase of tidal breathing at rest. We found a significantly larger increase in the early and late filling velocities (for E and A p<0.001) under the conditions of increasing preload (elevation of legs) and less pronounced, but still significant changes with isometric exercise (for E p<0.001 and for A p<0.01). We conclude that the right ventricular filling pattern in healthy humans is highly load-sensitive and for this reason the effect of any intervention (e.g. pharmacological) must be studied under strict and well-defined resting conditions.

[Infectious endocarditis as a complication of cardiac pacemakers requiring emergency removal of the stimulating electrode]. / Infekcní endokarditida jako komplikace trvalé kardiostimulace s nutností chirurgické extrakce stimulacní elektrody.

Case report describes a patient with permanent pacemaker (implanted in childhood) who has developed infectious endocarditis with bacterial vegetation on the stimulation electrode while no febrile condition occurred and laboratory tests showed no inflammation. The course of the disease was affected by the previous inappropriate outpatient treatment of an infection in the suture after the pacemaker exchange. It should be noted that echocardiographic examination was essential for both the diagnostics and the choice of strategy. The therapeutic approach consisted of the combination of long-term antibiotic therapy and the explantation of the infected stimulation system. As it was not possible to accomplish by endovasal methods only, cardiosurgery for extraction of the lead was chosen.

[Cardiac bradyarrhythmia ]. / Srdecní bradyarytmie.

Permanent cardiac pacing was introduced in 1958 and till the end of 70s this method saved lives in particular of the patients with advanced atrioventricular block. The implantation technique has changed from complicated thoracotomy to endovasal approaches. The introduction of physiological AV sequenced atrioventricular pacing marked a significant progress in this field. Acute haemodynamic studies documented positive effect of the atrial contribution. Numerous studies subsequently analyzed the influence of different pacing regimes on total and specific cardiovascular mortality and morbidity. It can be concluded that on the basis of present evidence-based medicine the use of physiological pacing is clearly indicated in the patients with expressed sinus bradycardia and AV block of a higher degree. Atrial pacing remains an ideal solution for the patients with isolated sinus node dysfunction and sufficient atrioventricular conduction capacity. Research is continued in order to clarify how to influence the occurrence of ventricular fibrillation by permanent cardiac pacing including the use of preventive algorithms. This topic has not yet been reliably and unambiguously concluded. Biventricular pacing is currently established and recognized not only for typical indications in cases of bradyarrhythmias but also to solve primary haemodynamic problems in the patients with advanced heart failure and evidence of ventricular dyssynchrony.

[Hyperhomocysteinemia. A risk factor for the development of vascular diseases not associated with lipid levels]. / Hyperhomocysteinémie. Rizikový faktor pro vznik cévních onemocnení nezávislý na hladinách lipidu.

BACKGROUND: Elevated total homocysteine plasma levels are considered a significant factor of vascular damage. As they are encountered in more than half the patients with atherosclerotic vascular damage the importance as a lipid-dependent or lipid-independent risk factor in the promotion of pathophysiological processes is discussed. METHODS AND RESULTS: In a group of 100 healthy subjects and 529 patients with indication for an aortocoronary or peripheral arterial bypass and in patients from the lipid clinic the mutual relation between total plasma homocysteine levels and selected indicators of the lipid metabolism was investigated. The following results more obtained: for total cholesterol a correlation coefficient of r = 0.26, for HDL-cholesterol r = 0.20, for LDL-cholesterol r = 0.21, for triacylglycerols r = 0.29, apolipoprotein A-I r = 0.06, apolipoprotein B r = -0.12 and for Lp(a) r = -0.03. To ensure correct evaluation of the homocysteine levels simultaneously also folate levels were examined (correlation coefficient r = 0.28), vitamin B12 r = (0.03) and fibrinogen r = (0.09). CONCLUSIONS: The authors did not detect an unequovical relationship between the total homocysteine level and selected lipid indicators in any of the patient groups (p < 0.05).

[Incidence and changes in mitral regurgitation in balloon valvotomy of the mitral valve. A color Doppler study]. / Výskyt a zmeny mitrální regurgitace u balónkové valvulotomie mitrální chlopne. Barevne dopplerovská studie.

The objective of the work was a detailed examination of the incidence and changes of mitral regurgitation (MR) in conjunction with percutaneous transluminal valvotomy of the mitral valve (VMCH). Using coloured Doppler mapping, the authors examined a total of 40 patients before and in the course of one week after VMCH. They assessed the number of regurgitation jets the site of their development, the timing and haemodynamic impact of MR. Knowing the site of development of MR, the authors were able to assess whether the regurgitation after VMCH persisted, developed de novo or disappeared. The total number of mitral regurgitation increased after VMCH from 38 to 51 (increase by 34%, p < 0.05) with a significant rise of the number of double regurgitation jets (4 before as compared with 12 after VMCH, p < 0.05). Before VMCH the authors recorded a holocystic MR in 53%, after VMCH in 86% of the patients (p < 0.01). While before VMCH almost half the regurgitation jets originated in the central portion of the valve, after VMCH MR originated mainly from the area of commissures (48% regurgitation jets before, 79% after VMCH, p < 0.01). Only in 33% of MR after VMCH persisting regurgitation was involved, almost half (47%) of 38 regurgitation jets present before VMCH, disappeared after valvulotomy. MR displays a considerable variability. This may be one of the reasons why prediction of the development and severity of MR after PTMV is difficult.

[The effect of isometric loading on diastolic left ventricular filling in healthy individuals studied by the Doppler technic]. / Vliv izometrické záteze na prubeh dopplerovsky hodnoceného diastolického plnení levé komory u zdravých osob.

The authors examined by Doppler echocardiography 30 subjects aged 21-30 years, exposed during examination to an isometric load by using a manual balloon dynamometer. The authors investigated different indicators of left ventricular filling during diastole and their indexes which evaluate indirectly the left ventricular diastolic function. The assessed correlations of some indicators with the quantitative expression of the isometric load (double product) were as follows: peak speed E - r = 0.3671 (p < 0.05), peak speed A - r = 0.6098 (p < 0.001), index of rations of peak speeds E/A - r = 0.6098 (p < 0.0001, sum of speed--time integrals TVIE + TVIA - r = 0.6469 (p < 0.001) and the time of retardation of the early filling phase of the left ventricle related to the heart rate DCT/TF - r = 0.7249 (p < 0.001). A statistically significant increase during the load was recorded in the peak speed A and a reduction of the E/A ratio (p < 0.01). The time speed integral TVIE increased (p < 0.01), both indexes TVI E + A and TVI E/A declined (p < 0.05). The time of retardation of the early filling stage to the early filling time DCT/DFT increased (p < 0.05) and DCT in relation to the heart rate DCT/TF declined significantly (p < 0.01). There was an insignificant decline of the peak speed of early filling E and its time-speed integral, TVI E. The sum of time-speed integrals TVIE + A did not change significantly.(ABSTRACT TRUNCATED AT 250 WORDS)

[Clinical interpretation of the character of mitral valve flow in relation to diastolic properties of the left ventricle]. / Klinická interpretace charakteru mitrálního vtoku ve vztahu k diastolickým vlastnostem levé komory srdecní.

Based on their own experience and data in the literature the authors describe the Doppler method of evaluation of properties of the left ventricle. In patients with early disorders of the diastolic function, when above all relaxation of the left ventricle is affected, a reduced rate of early diastolic filling (E) is a typical finding. There is also compensatory increase in the rate of filling during auricular contraction (A) with the appropriate increase of the A/E ratio and the ratio of rate velocity integrals (TVIA/TVIE). At the same time the maximal flow through the mitral orifice is reduced during early diastole (PFR), the deceleration time is protracted and so is the time of isovolumic relaxation. For more advanced stages of cardiac damage when impaired compliance of the left ventricle predominates, typical features are the so-called restrictive type of filling with a high rate of E, short DT and a relatively low velocity A. There exists a number of intermediary types between these extreme types of flow. The final shape of the flow curve is influenced also by the actual haemodynamic condition of the subject (heart rate, pre-load, after-load, pressure in left, ventricle, left ventricular systolic function etc.). The authors draw therefore attention to possible errors during interpretation of assessed indicators. In the conclusion they recommend methodical principles for examination of left ventricular diastolic function by Doppler echocardiography. Above all it is necessary to respect restrictions due to valvular defects, arrhythmias, the action of drugs with haemodynamic action, the presence of signs of left ventricular failure, the influence of respiration on the flow rate, etc.

[The dipyridamole echocardiography test combined with isometric loading in the diagnosis of syndrome "X"]. / Dipyridamolový echokardiografický test kombinovaný s izometrickou zátezí v diagnostice syndromu "X".

Syndrome "X" comprises a heterogeneous group of patients with normal coronarographic findings whose repeatedly occurring chest pain is of ischaemic origin, similarly as angina pectoris in patients with CHD. One of the signs of ischaemic etiology of pain in these patients is significant depression of the ST interval on the ECG during ergometry. We were interested to know whether the depression of the ST interval and angina pectoris which develop during a load are associated also with a transient disorder of left ventricular local kinetics. We examined therefore five patients, using the dipyridamol test combined with an isometric load evaluated by two-dimensional (2D) echocardiography. All examinations revealed a normal coronarographic finding and significant electrocardiographic manifestations of ischaemia during ECG stress test. The investigation showed that none of the patients with "X" syndrome suffered from transient changes in the local kinetics of the heart muscle and we assume therefore that myocardial ischaemia in syndrome "X" does not affect a sufficiently large portion of the cardiac wall in the transmural section to be manifested by impaired kinetics detectable by 2D-echocardiography.

[2-dimensional echocardiography in the evaluation of right ventricular volume and function. Comparison with echocardiography]. / Dvourozmerná echokardiografie pri hodnocení objemu a funkce pravé komory. Srovnání s echokardiografií.

Using two-dimensional echocardiography (ECHO), the authors examined within one week preceding right-sided catheterization of the right ventricle (RV) 44 patients. Of three tested ECHO techniques for calculation of right ventricular volumes and/or function the best correlations were obtained by the method of evaluation of area-length of the right ventricle from two orthogonal projections (apical 4-cavity and subcostal with visualization of the outflow portion of the RV). The following correlations were assessed: telediastolic volume--r = 0.831, telesystolic volume--r = 0.815 stroke volume--r = 0.810 and ejection fraction (EF)--r = 0.752 (p less than 0.001 for all correlations). The tested method enables us at the same time to screen at least existing right ventricular dysfunction (sensitivity 0.68; specificity 0.82). In the presence of tricuspidal insufficiency (TI) increase in right ventricular function occurs which may mask its existing failure (dependence of EF on the mean pressure level in pulmonary artery was proved only in patients without TI--r = 0.594). We assume that information on right ventricular function is important not only in diseases affecting primarily the right heart but also in advanced stages of left-sided failure. Follow-up of the natural course of the disease and the effect of provided treatment by the non-invasive ECHO method is thus useful not only in research but also in clinical practice.

Doppler echocardiographic assessment of the diastolic properties of the cardiac ventricle in ischaemic heart disease.

The authors offer their experience with diastolic function assessment using Doppler echocardiography in ischaemic heart disease. Information on the diastolic properties of the ventricle is obtained from recordings of the blood flow velocity curve in mitral and tricuspid valve orifices. Doppler echocardiography, allowing to monitor the velocity curve of ventricular filling, represents one of the most modern techniques of examination. Diastolic function is commonly significantly affected by ischaemic heart disease, not only in terms of energy requirements; other factors such as the volume of venous return, extent of ischaemia, its time course, and so on, come into play. Changes in myocardial rigidity and filling pressures are two factors which exert a substantial effect on the character of inflow curves. The article describes typical recordings obtained from individual clinical manifestations of acute and chronic states in ischaemic heart disease, and reviews the still limited body of data regarding the effect of drug and/or surgical therapy on the diastolic properties of the affected ventricle.

Three echocardiographic methods in right ventricular function evaluation.

We employed two-dimensional echocardiography for the assessment of right ventricular (RV) volumes and/or function in a series of 44 patients. The results of three different echocardiographic approaches were compared with the data obtained from single-plane RV angiography following ultrasound within a 7-day interval. Only the echocardiographic area length method with two orthogonal imaging planes employed (apical 4-chamber and subcostal projections) yielded the beneficial results. The correlations between echocardiographic and angiographic RV volume estimates were rather high (end-diastolic volume: r = 0.83, end-systolic volume: r = 0.82, stroke volume: r = 0.81) and satisfactory in ejection fraction (r = 0.75). Using the method mentioned, the differentiation of patients with an angiographic evidence of RV failure (echocardiographic ejection fraction less than 0.55) from those without it was possible with a sensitivity of 0.68 and a specificity of 0.82. Concerning the clinical impact of the presented study, we can recommend the technique in question as a screening procedure for the detection of changes in RV function exceeding 12% (95% confidence limits).

The effect of acute and chronic nitrate administration in precapillary and postcapillary pulmonary hypertension.

The effect of nitrates was monitored in 16 patients with precapillary, and in 12 patients with postcapillary pulmonary hypertension (PH). The patients had haemodynamic examination on acute administration of 10 mg of isosorbide nitrate (ID) in infusion and after 2-month therapy with 120 mg of isosorbide dinitrate retard daily. Acute ID administration decreased filling pressure of both ventricles, pulmonary and aortic pressure, pulmonary and systemic resistance and increased blood flow. No significant difference was found between the two types of PH. Long-term administration resulted in a statistically significant decrease in filling pressure (in both ventricles) and pulmonary pressure, even though the decrease was less pronounced than those seen following acute administration. Again, no statistical differences were noted between the two types of PH. While acute administration of nitrates decreases both preload and afterload, chronic administration decreases only preload. The implications of this finding for therapeutic practice are discussed.

[Estimation of systolic pressure in the right ventricle (pulmonary artery) using Doppler and its importance in the detection of pulmonary hypertension]. / Dopplerovský odhad systolického tlaku v pravé komore (plicnici) a jeho význam pro odhalování plicní hypertenze.

Using the pulsed Doppler system with a high reparative frequency (HPRF), the authors made within 1 hour and 3 days after diagnostic right-sided catheterization 38 measurements of the trans-tricuspid pressure gradient in 31 consecutive patients. To the gradient calculated from the absolute velocity of flow through the jet of tricuspid regurgitation the authors added two different arbitrarily determined pressure values in the right atrium to obtain the systolic pressure in the right ventricle--RVSP (which assuming the absence of an obstruction between the right ventricle and pulmonary artery equals the systolic pressure in this artery). The calculated RVSP from the Doppler assessment correlated highly significantly with the directly manometrically obtained values of the same indicator (r = 0.973; p less than 0.001). An even closer correlation was obtained when using a differentiated estimate of the pressure in the right atrium/according to the filling of the jugular veins) (r = 0.977; p less than 0.001). From the RVSP values the authors tried to predict the presence of pulmonary hypertension (PH) diagnosed from the median pressure in the pulmonary artery (PAP greater than or equal to 20 mm Hg which was considered conclusive). Using the arbitrarily assessed range of systolic PH greater than 35 mm Hg, the sensitivity of the ultrasonographic estimate was 79% with a 60% specificity, while when the criterium of greater than 40 mm Hg was used, the corresponding values were 64% and 90%.(ABSTRACT TRUNCATED AT 250 WORDS)

Long-term effect of isosorbide dinitrate and nifedipine, singly and in association, in patients with chronic heart failure.

The effect of 2-month treatment with isosorbide dinitrate (120 mg day-1), nifedipine (2 x 20 mg day-1) and their combination has been assessed in 16 patients with mild to moderate chronic cardiac failure. Isosorbide dinitrate decreased right atrial (-23%), pulmonary wedge (-20%) and pulmonary arterial (-17%) pressures but did not significantly change either cardiac output or systemic and pulmonary vascular resistance. Nifedipine increased cardiac output (+13%) and decreased systemic and pulmonary vascular resistance (both -17%) with no change of pressures. Combined therapy with both drugs decreased ventricular filling pressures (-8% and -15%), systemic (-20%) and pulmonary (-13%) arterial pressures, increased cardiac output (+26%) and decreased both systemic (-29%) and pulmonary (-29%) vascular resistances. Changes during exercise were almost the same as at rest. The effect of both drugs was more pronounced in patients with more severely pathological haemodynamic measurements before treatment. We conclude that combined treatment with both preload- and afterload-reducing agents can preserve or even potentiate a favourable haemodynamic effect of individual drugs.

[Noninvasive quantification of the severity of aortic defects using the Doppler method]. / Neinvazívní kvantifikace závaznosti aortálních vad Dopplerovou metodou.

Using Doppler method (HPRF and CW regime), the authors assessed the peak velocity of flow in an aortal spurt in 41 patients with aortal stenosis. For calculation of the transaortal pressure gradient they used a modified Bernoulli equation. The values of the calculated gradients were compared with those obtained by direct manometric assessment during catheterization of the heart after an interval of several hours to five days. Combination of two Doppler techniques correlated closely with direct assessment (r = 0.811; p less than 0.001). By application of the continuity equation in the best records of spectral analysis of velocity curves the authors calculated in 8 patients the area of the reduced aortal orifice which was very close to the area calculated by means of Hakki's formula from direct haemodynamic indicators (r = 0.948; p less than 0.001). In 33 patients the authors quantified by Doppler method the severity of aortal regurgitation from the ratio of forward and backward flow in the descending portion of the aortal arch (expressed as the % regurgitation fraction--RF). The RF values correlated well with the angiographic semiquantitative scale of severity of aortal insufficiency (r = 0.805; p less than 0.001), although they enabled the authors only to make a partial differentiation of haemodynamically severe regurgitations and mild or insignificant ones. The authors conclude that the Doppler approach makes it possible to evaluate sufficiently accurately the severity of aortic valve disease (in insufficiencies the authors recommend a more comprehensive approach), which when correctly applied and interpreted, can make non-invasive clinical diagnosis more accurate and thus permits also more accurate indication of surgical treatment of these patients.

[Long-term fate of intraventricular thrombi after myocardial infarct]. / Dlouhodobý osud nitrokomorového trombu po infarktu myokardu.

Using two-dimensional echocardiography, the authors followed up 30 patients where in the course of treatment of acute myocardial infarction an intraventricular thrombus developed. A benign character (i. e. adjacent and immobile thrombus) was found in 21 patients, while a malignant (freely movable, floating, protruding) thrombus was recorded in 9 cases (70% as compared with 30%). All patients were followed up to the period of disappearance (regression) of the thrombus or within two years after infarction. The authors evaluated above all the ability of regression of thrombi and influencing their complication (above all systemic embolisms). In the whole group regression of thrombosis occurred in 25 patients (82%). In benign thrombi early regression--within three weeks after the development of infarction--occurred in 10 patients (33%) and late regression (more than three weeks) also in 10 patients. Analysis of the applied treatment revealed that all patients with early and nine patients with late regression of cardiac thrombosis had anticoagulation therapy till the thrombus disappeared. As to malignant thrombi, regression occurred only in five patients, always after at least three weeks. Systemic embolization (once into the cerebral arteries, twice into the arteries of the lower extremities) was recorded in three patients always with a malignant thrombus which was not affected by anticoagulant therapy. From the results of the investigation thus ensues that anticoagulation treatment during acute myocardial infarction and after it has in case of an intraventricular thrombus a favourable effect on the regression of the formed thrombus and it can reduce significantly the frequency of systemic embolisms which are the most serious complication.

Cardiac hypertrophy in hypertension.

The time course of regression of left ventricular hypertrophy and changes in left ventricular function were followed in 52 middle-aged hypertensive patients divided into two groups: 30 treated with betablockers and 22 with methyldopa. In case of inadequate blood pressure control, diuretics and/or vasodilators were added in both groups. Blood pressure decreased significantly over a three-year follow-up period. The decrease was most pronounced during the first three months. The biggest decrease in posterior wall and interventricular septum thickness was detected by echocardiography also within the first three months. While complete regression of posterior wall hypertrophy was noted within the next three months, interventricular septum thickness decreased steadily over a period of two years. No significant change was seen in the septum in the third year of follow-up. Complete regression of hypertrophy was found in 30 (57.7%) of probands, with no change altogether observed in as few as two patients. Regression was incomplete in 20 (38.4%) obese patients with manifest hypertrophy at the start of the study. Regression of hypertrophy was not associated with left ventricular function deterioration and was observed even after vasodilator administration. There were no differences between the two groups of patients.

The effect of thrombolytic therapy on the development of intraventricular thrombosis in acute myocardial infarction.

The authors studied the possibility to prevent the development of intraventricular thrombosis (IVT) following acute myocardial infarction (AMI) by application of early treatment of AMI, sought to identify the risk factors of IVT development, and were successful in reducing the potential of IVT to embolism by administration of appropriate therapy. A total of 200 patients with AMI were examined, with IVT diagnosed in 30 (15%). Results show that streptokinase treatment of AMI plays a role in preventing the development of IVT (1.0% incidence of IVT), with somewhat lesser protection conferred by heparin (with an incidence of 19%), and IVT present in 47% of cases when no thrombolytic or anticoagulation therapy had been administered. Of the risk factors making the patient susceptible to developing IVT, presence of an aneurysm, anteroseptal or apical AMI, decreased left ventricular ejection fraction and female sex were found to be statistically significant (p less than 0.05). Follow-up of IVT confirmed the risk of embolism in systemic arteries, especially in malignant IVT (p less than 0.01). In this case, anticoagulation therapy appears to be an effective therapeutic technique that must be initiated once the diagnosis has been established, and continued until 50% regression of the thrombus, or its complete disappearance.