Usefulness of tissue Doppler imaging for assessing left ventricular filling pressure in patients with stable severe systolic heart failure.

The ratio of early transmitral blood flow velocity over tissue Doppler early diastolic mitral annulus velocity (E/e') was found unreliable for estimating pulmonary capillary wedge pressure (PCWP) in patients with decompensated systolic heart failure (HF). The objective of this study was to test its reliability in stable HF. Therefore, 130 consecutive patients with a left ventricular (LV) ejection fraction of <35% and stable HF underwent right-sided cardiac catheterization and transthoracic echocardiography with measurement of transmitral flow velocities (E, A) and mitral annulus velocities during systole (s') and diastole (e'). Mean age was 56 ± 11 years and mean LV ejection fraction was 28 ± 8%; 48% had PCWP of >15 mm Hg. E/e'septal correlated more strongly with PCWP (r = 0.53) compared with E/e'lateral (r = 0.41) and E/e'mean (r = 0.50; all p values <0.001). The area under the receiver operating characteristic curve (AUC) of E/e' ratios for PCWP estimation was 0.79 (95% confidence interval [CI] 0.70 to 0.87) for E/e'septal, 0.72 (95% CI 0.63 to 0.82) for E/elateral, and 0.79 (95% CI 0.70 to 0.87) for E/emean (all p values <0.0001). AUCs of E/eseptal and E/emean did not vary with s'septal, QRS width, or resynchronization. Using a cutoff of 8, negative predictive value of E/e'septal was 89% and negative likelihood ratio of 0.15. E/e'lateral showed good diagnostic performance only in patients with s'lateral of >4.5 cm/s (n = 77, 59%; AUC = 0.82; 95% CI 0.71 to 0.92; s'lateral of ≤4.5 cm/s: AUC = 0.54; 95% CI 0.38 to 0.70; p = 0.005). In conclusion, e' is useful for estimating LV filling pressure in stable severe systolic HF. E/e'septal showed good diagnostic performance for detecting normal filling pressures.

[Senile systemic amyloidosis: definition, diagnosis, why thinking about?]. / Amylose systémique sénile : définition, diagnostic, pourquoi y penser ?

Senile systemic amyloidosis (SSA) is characterized by infiltration of amyloid transthyretin fibrils in the myocardium. SSA occurs mainly (but not always) in elderly men. SSA leads to hypertrophic and/or restrictive cardiomyopathy complicated by conduction disturbances, atrial arrhythmia and systemic embolization (stroke…). That is why SSA needs a special care and to be diagnosed. Cardiac SSA diagnosis needs to exclude two other forms of cardiac amyloidosis: AL amyloidosis (light chain) and hereditary transthyretin amyloidosis (genetic testing). Scintigraphic 99mTc-DPD heart retention is observed in cardiac amyloidosis. DPD heart retention is more frequent in cardiac transthyretin amyloidosis than in cardiac AL amyloidosis. Specific treatments of cardiac TTR amyloidosis are in development.

Feasibility limits of transradial primary percutaneous coronary intervention in acute myocardial infarction in the real life (TRAP-AMI).

BACKGROUND: There is growing evidence that transradial (TRI) as compared to transfemoral (TFI) percutaneous coronary intervention (PCI) is associated with improved clinical outcome driven by less hemorrhagic complications, in particular in STEMI patients receiving aggressive antithrombotic treatment. Feasibility rate of TRI in STEMI patients has not yet been evaluated. METHODS/RESULTS: Four-hundred seventy-five consecutive STEMI patients (<12h) without cardiogenic shock were prospectively screened for this all-comer single-centre registry between January 2008 and August 2010. Nine patients were excluded for a priori ineligibility for TRI (forearm shunt for dialysis, prior TRI failure). In the 466 patients enrolled, the operator's opinion about ease of radial puncture was assessed in 4 categories, based on radial pulse quality. Operators were advised not to attempt TRI if ease of puncture was judged "probably difficult/impossible". In case of puncture failure the operator switched immediately to TFI. The mean age of patients was 61 ± 14 (range 27-94) years. Seventy-three percent were men, 17% had diabetes. Nine percent had previous PCI. Glycoprotein inhibitors were used in 70%, and thrombectomy was performed in 70% of patients. PCI was performed using 6F and 5F guiding catheters. Procedural success rate was 98.2% (TIMI flow ≥ 2). In 4.1% (n=19) of patients the operator judged ease of radial puncture "probably difficult/impossible" and no TRI attempt was performed (primary TFI). In the 447 patients with TRI attempt, TRI failure requiring switch to TFI (secondary TFI) was necessary in 22 patients (4.7% of total) following radial puncture failure (n=15), dissection of the radial artery (n=1), prohibitive tortuosities or stenosis of the upper limb axis (n=2), or non-selective position or lack of stability of the guiding catheter (n=2). After the start of the angioplasty procedure, switch from TR to TF was not necessary in any patient. In total, the overall feasibility rate of TRI was 91.2%. Independent predictors of final TFI were age ≥ 80 years (adjusted OR: 2.37; 95% CI:1.05-5.34, p=0.037), body weight<60 kg (adjusted OR: 2.84; 95% CI:1.22-6.59, p=0.015); and previous PCI (adjusted OR: 3.42; 95% CI:1.40-8.37, p=0.007); female gender was borderline significant (adjusted OR:2.10; 95% CI:0.97-4.54, p=0.059). CONCLUSION: In STEMI patients without cardiogenic shock and without a priori indication for TFI, PCI can be performed via the radial artery in more than 90% of cases with high procedural success rate. Operator's judgement of eligibility for TRI based on radial pulse quality is predictive of successful TRI in 95% of cases. TR failure is significantly more common in the elderly and in patients with low body weight.

Impaired left ventricular function in the presence of preserved ejection in chronic hypertensive conscious pigs.

Systolic function is often evaluated by measuring ejection fraction and its preservation is often assimilated with the lack of impairment of systolic left ventricular (LV) function. Considering the left ventricle as a muscular pump, we explored LV function during chronic hypertension independently of increased afterload conditions. Fourteen conscious and chronically instrumented pigs received continuous infusion of either angiotensin II (n = 8) or saline (n = 6) during 28 days. Hemodynamic recordings were regularly performed in the presence and 1 h after stopping angiotensin II infusion to evaluate intrinsic LV function. Throughout the protocol, the mean arterial pressure steadily increased by 55 ± 4 mmHg in angiotensin II-treated animals. There were no significant changes in stroke volume, LV fractional shortening or LV wall thickening, indicating the lack of alterations in LV ejection. In contrast, we observed maladaptive changes with (1) the lack of reduction in isovolumic contraction and relaxation durations with heart rate increases, (2) abnormally blunted isovolumic contraction and relaxation responses to dobutamine and (3) a linear correlation between isovolumic contraction and relaxation durations. None of these changes were observed in saline-infused animals. In conclusion, we provide evidence of impaired LV function with concomitant isovolumic contraction and relaxation abnormalities during chronic hypertension while ejection remains preserved and no sign of heart failure is present. The evaluation under unloaded conditions shows intrinsic LV abnormalities.