The Effect of Varying Occlusal Loading Conditions on Stress Distribution in Roots of Sound and Instrumented Molar Teeth: A Finite Element Analysis.

INTRODUCTION: This study aimed to investigate whether the direction of force applied to the occlusal surface influenced the pattern of tensile stresses in roots of sound and root canal-prepared mandibular molar teeth. The effect of obturation forces on the development of apical stress was also investigated. To this end, models were constructed using micro-computed tomographic imaging and investigated using finite element analysis. METHODS: Micro-computed tomographic data established boundaries of internal and external model surfaces to allow finite element analysis. Individually segmented components were modeled based on mechanical properties in precedent literature. The following conditions were considered: axial force directed over the mesial marginal ridge, a mesial or a distal tipping force, a combination of both a torquing force and axial loading, and hydrostatic pressure. The maximum principal stresses were determined. RESULTS: The highest root stress occurred in the cervical third of root surfaces (ie, not apically) under all loading conditions. Importantly, mesial tipping forces resulted in tension on distal roots, whereas distal tipping resulted in tension in the mesial roots. Intracanal pressures produced tensile stress on the internal root canal walls in the cervical third of the root. Stresses were calculated to be less than the fatigue tensile strength of dentin. CONCLUSIONS: Static loading, under the conditions modeled, does not result in stress concentration at the root apices that would cause root fracture under normal masticatory loads. Stress patterns developing from mesial and distal tipping forces help to explain the appearance of vertical root fractures reported in sound nonrestored molar teeth.

Inflammatory Proteins in the Amniotic Fluid, Plasma, and Cervicovaginal Fluid for the Prediction of Intra-Amniotic Infection/Inflammation and Imminent Preterm Birth in Preterm Labor.

OBJECTIVE: This study was aimed to develop models using multiple cytokine/chemokine levels in cervicovaginal fluid (CVF) and plasma and widely used noninvasive parameters that have better accuracy for predicting intra-amniotic infection and/or inflammation (IAI) and imminent spontaneous preterm delivery (SPTD, ≤48 hours) in women with preterm labor (PTL). STUDY DESIGN: This was a retrospective cohort study of 95 singleton pregnant women with PTL (23-34 weeks) who underwent amniocentesis. Both CVF and plasma samples were obtained at the time of amniocentesis, and serum C-reactive protein (CRP) levels were measured. The amniotic fluid (AF), CVF, and plasma samples were assayed for interleukin (IL)-6, IL-8, IL-10, monocyte chemotactic protein-1 (MCP-1), and macrophage inflammatory protein-1ß (MIP-1ß) levels using a multiplex immunoassay kit. RESULTS: The levels of most cytokines/chemokines measured in the AF and CVF were significantly higher in the women with than in those without IAI and imminent SPTD, whereas only high-plasma IL-10 level showed a significant association with imminent SPTD. In predicting IAI, proteins in AF had significantly higher areas under the curves (AUCs) than those in CVF and plasma. However, for predicting imminent SPTD, no significant differences in the AUCs of the outcome-associated proteins were observed among the measurements in AF, CVF, and maternal plasma. By using stepwise regression analyses, noninvasive models (using protein levels in CVF and baseline clinical parameters) were developed for the prediction of IAI and imminent SPTD. The AUC of these noninvasive models were similar to those of the invasive models (using AF protein levels and baseline clinical parameters). CONCLUSION: Noninvasive models based on CVF cytokine/chemokine levels and widely used noninvasive parameters (especially CRP) act as good indicators for predicting the risk of IAI and imminent SPTD in women with PTL. Evaluation of cytokine/chemokine levels in plasma samples did not add valuable information regarding the two outcome measures in the PTL setting. KEY POINTS: · Markers in either CVF or plasma alone did not have sufficient accuracy for predicting IAI and SPTD.. · Noninvasive models using CVF cytokine and CRP act as effective tools for predicting two outcomes.. · Evaluation of cytokine level in plasma did not add valuable information regarding two outcomes..

Urinary Concentration Defect and Renal Glycosuria in Cyclosporine-treated Rats.

BACKGROUND: Urinary concentration impairment is a major feature of cyclosporine nephrotoxicity. METHODS: We explored two possible mechanisms that may underlie cyclosporine-induced polyuria; water, and/or osmotic diuresis. Cyclosporine was subcutaneously injected to normal salt-fed Sprague-Dawley rats at a daily dose of 25mg/kg for 2 weeks (Experiment I) and 7.5mg/kg for 6 weeks (Experiment II). RESULTS: In Experiment I, cyclosporine treatment caused an increase in urine volume (2.7±0.5 vs. 10.3±1.13mL/d/100 g BW, p<0.001) and a decrease in urine osmolality (2,831±554 vs. 1,379±478mOsm/kg H2O, p<0.05). Aquaporin-2 (AQP2) protein expression decreased in cyclosporine-treated rat kidneys (cortex, 78±8%, p<0.05; medulla, 80±1%, p<0.05). Experiment II also showed that urine volume was increased by cyclosporine treatment (4.97±0.66 vs. 9.65±1.76mL/d/100 g BW, p<0.05). Whereas urine osmolality was not affected, urinary excretion of osmoles was increased (7.5±0.4 vs. 14.9±1.4mosmoles/d/100 g BW, p<0.005). Notably, urinary excretion of glucose increased in cyclosporine-treated rats (7±1 vs. 10,932±2,462 mg/d/100 g BW, p<0.005) without a significant elevation in plasma glucose. In both Experiment I and II, GLUT2 protein expression in the renal cortex was decreased by cyclosporine treatment (Experiment I, 55±6%, p<0.005; Experiment II, 88±3%, p<0.05). CONCLUSION: Both water diuresis and osmotic diuresis are induced by cyclosporine nephrotoxicity. AQP2 and GLUT2 downregulation may underlie water and osmotic diuresis, respectively.

Differences in visit-to-visit blood pressure variability between normotensive and hypertensive pregnant women.

We evaluated the relationship between blood pressure variability (BPV) and the development of hypertension during pregnancy. A total of 4163 pregnant women with normal blood pressure (BP) before 20 weeks of gestation were included in this study. The visit-to-visit blood pressure variability (VVV) was evaluated using the standard deviation (SD) of the systolic BP taken three times during pregnancy at approximately 10, 20, and 30 weeks of gestation. The VVV gradually decreased during pregnancy in normotensive subjects (SD: 7.2 ± 4.2 mmHg, 6.8 ± 3.9 mmHg, and 6.3 ± 3.6 mmHg at 10, 20, and 30 weeks, respectively). However, the VVV of hypertensive subjects did not decrease (SD: 8.2 ± 5.7 mmHg, 7.6 ± 5.0 mmHg, and 8.3 ± 5.3 mmHg at 10, 20, and 30 weeks, respectively) and was significantly greater than the VVV of normotensive subjects (p < 0.001). The VVV was significantly higher in patients who developed hypertension, and there was no decrease in VVV during pregnancy. Pregnancy complications were significantly increased in women with higher VVV at 10 and 30 weeks. Therefore, increased VVV during pregnancy may be a predictor of poor pregnancy outcomes.

Gender-specific differences in the incidence of microalbuminuria in metabolic syndrome patients after treatment with fimasartan: The K-MetS study.

BACKGROUND: The effect of resolving metabolic syndrome on target organ damage in hypertensive patients is not well described. We evaluated whether treating metabolic syndrome (MetS) with an angiotensin receptor blocker subsequently reduced microalbuminuria in the K-MetS cohort. METHODS: Among 10,601 total metabolic syndrome patients, 3,250 (52.2% male, 56.2±10.0 years) with sufficient data on five specific metabolic components were included in this study. Patients were divided into four groups based on MetS status at baseline and 3 months. All patients received an angiotensin receptor blocker, fimasartan, for these 3 months; thereafter, treatment was modified at the discretion of each patient's physician. Microalbuminuria and the albumin/creatine ratio were evaluated as a proxy of organ damage. RESULTS: Blood pressure and waist circumference decreased from baseline to 3 months and 1 year. The average albumin/creatinine ratio significantly improved during the first three months of the study from 36.0±147.4 to 21.0±74.9 mg/g (p<0.05) and was persistently high in patients with MetS at baseline and 3 months versus other groups. Women in comparison with men showed significantly lower ACR among patients with newly developed MetS at 3-month. CONCLUSIONS: Treatment of hypertensive patients for one year with the angiotensin receptor blocker fimasartan significantly reduced the albumin/creatine ratio, irrespective of whether the patient had MetS; however, the albumin/creatinine ratio was significantly higher in patents with persistent or newly developed MetS compared to patients without MetS. Additionally, these findings were more prominent in women than in men.

Epicardial adipose tissue is related to cardiac function in elderly women, but not in men.

BACKGROUND AND AIM: Epicardial adipose tissue (EAT) is easily quantifiable visceral adipose tissue that is closely associated with cardiometabolic disease including heart failure with preserved left ventricular (LV) ejection fraction. As body fat distribution and metabolism are different between men and women, we evaluated the sex difference in EAT thickness and its relationship to cardiac function. METHODS AND RESULTS: A total of 152 consecutive patients (76 men) with mean age of 62 ± 9 years were enrolled. Conventional echocardiography was performed and EAT thickness was measured perpendicularly on the right ventricular free wall at end systole. Mean EAT thickness in all patients was 6.5 ± 2.0 mm. EAT thickness was associated with patient age, body mass index, and the presence of hypertension. EAT thickness was not different by sex in patients younger than 60 years (men, 6.4 ± 2.0 mm; women, 6.2 ± 1.8 mm, p = 0.716); however, among patients aged 60 years or older, EAT thickness was significantly greater in women than men (men, 6.0 ± 1.7 mm; women 7.7 ± 2.1 mm, p < 0.001). LV function represented by E/e' and s' was significantly related to EAT thickness only in women (E/e', ß = 0.330, p = 0.002; lateral s', ß = -0.225, p = 0.042). CONCLUSION: EAT thickness was greater in women than men after 60 years old and its relationship with LV function was significant only in women. Greater increase in EAT thickness in elderly women after menopause might partially account for this difference.

Head to Head Comparison of Stress Echocardiography with Exercise Electrocardiography for the Detection of Coronary Artery Stenosis in Women.

BACKGROUND: Exercise-stress electrocardiography (ECG) is initially recommended for the diagnosis of coronary artery disease. But its value has been questioned in women because of suboptimal diagnostic accuracy. Stress echocardiography had been reported to have comparable test accuracy in women. But the data comparing the diagnostic accuracy of exercise-stress ECG and stress echocardiography directly are few. The aim of the study was to compare the diagnostic accuracy of exercise-stress ECG and dobutamine stress echocardiography (DSE) in Korean women. METHODS: 202 consecutive female patients who presented with chest pain in outpatient clinic, and who underwent treadmill exercise test (TET), DSE and coronary angiography were included for the study. The diagnostic accuracy TET and DSE were calculated by the definition of > 50% or > 75% coronary artery stenosis (CAS). RESULTS: The sensitivity and specificity were higher with DSE (70.4, 94.6%) than TET (53.7, 73.6%) for detection of > 50% CAS. The higher accuracy of DSE was maintained after exclusion of the patients who could not achieve over 85% age predicted heart rate before ischemia induction. DSE also showed greater diagnostic accuracy than TET by > 75% CAS criteria, and in subsets of patient with intermediate pretest probability. CONCLUSION: In the diagnosis of CAS, DSE showed higher accuracy than TET in female patients who presented with chest pain. As well as the test accuracy, adequate stress was more feasible with DSE than TET. These finding suggests DSE may be used as the first-line diagnostic tool in the detection of CAS in women with chest pain.

Significant interarm blood pressure difference predicts cardiovascular risk in hypertensive patients: CoCoNet study.

There has been a rising interest in interarm blood pressure difference (IAD), due to its relationship with peripheral arterial disease and its possible relationship with cardiovascular disease. This study aimed to characterize hypertensive patients with a significant IAD in relation to cardiovascular risk. A total of 3699 patients (mean age, 61 ±â€Š11 years) were prospectively enrolled in the study. Blood pressure (BP) was measured simultaneously in both arms 3 times using an automated cuff-oscillometric device. IAD was defined as the absolute difference in averaged BPs between the left and right arm, and an IAD ≥ 10 mm Hg was considered to be significant. The Framingham risk score was used to calculate the 10-year cardiovascular risk. The mean systolic IAD (sIAD) was 4.3 ±â€Š4.1 mm Hg, and 285 (7.7%) patients showed significant sIAD. Patients with significant sIAD showed larger body mass index (P < 0.001), greater systolic BP (P = 0.050), more coronary artery disease (relative risk = 1.356, P = 0.034), and more cerebrovascular disease (relative risk = 1.521, P = 0.072). The mean 10-year cardiovascular risk was 9.3 ±â€Š7.7%. By multiple regression, sIAD was significantly but weakly correlated with the 10-year cardiovascular risk (ß = 0.135, P = 0.008). Patients with significant sIAD showed a higher prevalence of coronary artery disease, as well as an increase in 10-year cardiovascular risk. Therefore, accurate measurements of sIAD may serve as a simple and cost-effective tool for predicting cardiovascular risk in clinical settings.

Assessment of Left Ventricular Function by Layer-Specific Strain and Its Relationship to Structural Remodelling in Patients With Hypertension.

BACKGROUND: Systemic arterial hypertension causes functional and structural remodelling of the left ventricle, which is related to subclinical left ventricular (LV) dysfunction and heart failure. This study assessed LV functional change using layer-specific strain and its relationship to structural remodelling in patients with hypertension. METHODS: A total of 145 patients (61 ± 12 years) with primary hypertension and preserved LV ejection fraction and 31 normotensive controls (63 ± 9 years) were prospectively included. Longitudinal strains of the endocardium, myocardium, and epicardium (LSendo, LSmyo, and LSepi) were obtained by averaging peak systolic strain of the left ventricle, with 18 segments in each layer. RESULTS: Layer-specific strains showed a decreasing gradient from the endocardium to the epicardium in both controls and patients with hypertension (P < 0.001 in both) and were significantly different between controls and patients with hypertension in all 3 layers (LSendo, -20.4% ± 2.4% vs -19.2% ± 2.2%; P = 0.007; LSmyo, -15.8% ± 2.0% vs -14.8% ± 1.9%; P = 0.005; LSepi, -11.8% ± 2.0% vs -11.0% ± 1.8%,; P = 0.04). Both LSendo and LSmyo were lower even in patients with hypertension and no LV hypertrophy than in controls (both P < 0.05), although global LS was not different. New patients with hypertension showed more decreased LSendo and LSmyo than controls even with their younger age. LSs of all 3 layers were related to LV mass index and mitral annular velocity parameters. CONCLUSIONS: Layer-specific evaluation of the left ventricle provides an understanding of the layer-specific properties of the LV wall and the process of LV impairment, and it may be helpful in managing patients with hypertension, thus preventing further damage.

Fulminant lymphocytic myocarditis associated with orbital myositis and diaphragmatic paralysis.

Although the clinical presentation of myocarditis is very diverse, ranging from mild dyspnea to hemodynamic collapse, myocarditis accompanied with extracardiac myositis is extremely rare. We report a single case of fulminant myocarditis associated with orbital myositis and diaphragmatic paralysis in a 40-year-old man, which was successfully managed by immunosuppressive therapy with steroid.

Layer-specific dyssynchrony and its relationship to the change of left ventricular function in hypertensive patients.

Left ventricular (LV) remodeling in systemic arterial hypertension causes electrical conduction delay and impairs synchronous contraction, which may contribute to the development of heart failure. This study aimed to assess the change of LV mechanics in hypertension by layer-specific dyssynchrony. One hundred and twenty-one patients with primary hypertension and LV ejection fraction >50 % (mean age, 62 ± 10 years) and 31 normotensive controls (mean age, 63 ± 9 years) were prospectively included. Layer-specific dyssynchrony index (DI) was defined as standard deviation of time interval (TI) from the onset of Q wave to peak longitudinal strain obtained from 18 segments in each endocardial, myocardial, and epicardial layer. The global TI between the onset of Q wave to peak global longitudinal strain in each layer was obtained and the time difference (TD) of global TI between layers was calculated. DIs were significantly different in three layers (P < 0.001 in both groups), and were significantly greater in hypertensive patients than in controls except epicardial DI. End diastolic filling pressure and LV global longitudinal strain were related with endocardial DI. TD between endocardium and myocardium was greater in hypertensive patients than in controls (P = 0.001). Layer-specific DI revealed delayed contraction in each layer and between layers in hypertensive patients, which were apparent in endocardium and between endocardium and myocardium. Increased layer-specific DIs were associated with subclinical LV dysfunction, although LV ejection fraction was preserved. These may be helpful to understand layer-specific mechanical property of LV myocardium and for early detection of subclinical impairment of myocardial function.

Vasculopathy of Aging and the Revised Cardiovascular Continuum.

There have been attempts to explain the process of developments in overt cardiovascular disease, resulting in the presentation of the classic cardiovascular disease continuum and the aging cardiovascular continuum. Although the starting points of these two continua are different, they meet in the midstream of the cycle and reach a consensus at the end of the process. The announcement of the aging cardiovascular continuum made both continua complete, explaining the cardiovascular events in patients without atherosclerotic cardiovascular disease with aging. Impairment of the vascular structure by pulse wave and reflected wave is considered the cause of aortic damage, which influences the development of ischemic heart disease and the development of overt renal disease or cerebrovascular disease. The pathophysiology of vascular aging through pulse wave and its effect on other organs was discussed with Prof. Michael F. O'Rourke who devised the aging cardiovascular continuum.

Clinical Significance of Dynamic Left Ventricular Outflow Tract Obstruction During Dobutamine Stress Echocardiography in Women With Suspected Coronary Artery Disease.

BACKGROUND: Although dobutamine stress echocardiography (DSE) is frequently associated with dynamic left ventricular outflow tract obstruction (DLVOTO), little is known about its clinical significance in women with suspected coronary artery disease (CAD). METHODS AND RESULTS: One hundred and two female patients (57±10 years) who underwent DSE as part of the Korean women's chest pain registry study were included. Doppler echocardiography was performed during DSE to assess the presence of DLVOTO. Patients with DLVOTO (n=52) were older than those without DLVOTO (n=50; P=0.001). Hypertension was more prevalent in patients with DLVOTO (P=0.02). Patients with DLVOTO had smaller LV diameter, but higher LV mass index and relative wall thickness (P<0.05 for all). LV diastolic function (as reflected by late diastolic velocity, deceleration time of early diastolic velocity [E], and ratio of E velocity to early diastolic mitral annular velocity), was worse in patients with DLVOTO (P<0.05 for all). Patients with DLVOTO had shorter exercise time (P=0.02) and lower amount of work (P=0.04) than patients without DLVOTO. DSE-provoked DLVOTO was not related to the presence of CAD in these patients. CONCLUSIONS: In Korean women with suspected CAD, DSE-provoked DLVOTO is correlated with LV concentric remodeling and LV diastolic dysfunction, and may be associated with limited exercise tolerance and symptoms of chest pain.

Improvement of Predictive Value for Thromboembolic Risk by Incorporating Left Atrial Functional Parameters in the CHADS2 and CHA2DS2-VASc Scores.

The discriminative ability of the widely used CHADS2 and CHA2DS2-VASc scores for risk stratification of thromboembolism in atrial fibrillation (AF) is known as modest. Some echocardiographic parameters are known risk factors for thromboembolism. This study aimed to evaluate whether combining echocardiographic parameters with CHADS2 and CHA2DS2-VASc scores can improve the predictive power for embolic risk in AF.A total of 526 (F/M = 83/433, mean age = 57.6 ± 10.7 years) patients with non-valvular AF were enrolled. The predictability for left atrial (LA) thrombus or dense spontaneous echo contrast (SEC) using clinical scores or echocardiographic parameters or combining clinical scores and echocardiographic parameters was calculated and compared.Dense SEC or thrombus was present in 51 patients. The predicting powers of the CHADS2 and CHADS2-VASc scores for the presence of dense SEC or thrombus were modest (c-statistics 0.65 and 0.68, respectively, 95% confidence interval [CI] 0.61-0.69 and 0.64-0.74, respectively, both P < 0.001). Impaired LA function was the most descriptive predictor for the presence of thrombus or dense SEC among echocardiographic parameters. Combining impaired LA function (LA emptying fraction < 30%) with the CHADS2 and CHA2DS2-VASc scores showed the improvement of predictive power in detecting dense SEC or thrombus (c-statistics 0.78 and 95% CI 0.74-0.81 and c-statistics 0.77 and 95% CI 0.73-0.81, respectively, both P < 0.001).Adding LA functional markers to the CHADS2 or CHA2DS2-VASc score improved the predictive value of the presence of thrombus or dense SEC. In clinical situations, anticoagulation should be considered to prevent embolism in patients with low-risk scores when they have LA dysfunction.

Unexpected Pathologic Diagnosis of the Mitral Valvular Mass.

A 59-year-old man with multifocal cerebral infarction was found to have the large obstructive mitral valvular mass. Although benign tumor was under suspicion before surgery, he was finally diagnosed as chronic infective endocarditis by microscopic evaluation. The precise diagnosis and the proper management of a cardiac mass are very important since even the benign tumor may cause fatal complications. However, primary cardiac mass has the broad spectrum from pseudo-tumor to malignancy and the differential diagnosis using non-invasive methods is not easy even with the currently available imaging techniques.

The difference of predictors for recurrence after catheter ablation of non-paroxysmal atrial fibrillation according to follow-up period.

The aim of this study was to assess the clinical and echocardiographic predictors for the recurrence of persistent atrial fibrillation (AF) after ablation during a long-term period.A total of 130 patients with persistent AF who had undergone radiofrequency catheter ablation (RFCA) were enrolled. We analyzed the relation between clinical parameters, echocardiographic parameters, and AF recurrences at 6 months, 1 year, and 2 years after ablation.During the 2-year follow-up, AF recurred in 61 patients (46.6%). In the 6 month follow-up, AF recurrence was associated only with total ablation time only. However, during the 1-year and 2-year follow-up periods, the presence of hypertension, impaired left atrial (LA) emptying fraction (eF) (≤ 20%), decreased LA appendage (LAA) emptying velocity (≤ 20 cm/sec), and LAAeF (≤ 20%) were correlated with AF recurrence (odds ratio [OR] = 1.87, 2.45, 1.93, and 2.15 respectively, P = 0.016, 0.004, 0.029, and 0.004 respectively). Among these factors, impaired LAeF was the only independent predictor of AF recurrence in multivariate analysis (OR = 2.81, P = 0.012).In patients with persistent AF who had undergone RFCA, the best predictor of AF recurrence after ablation varied according to the follow-up period. Diminished LA function was the only predictor of recurrence in the 2-year follow-up. Pre-procedural assessment of LA function might be helpful in selecting those patients who would benefit from RFCA.

Resistant hypertension caused by stenosis of the aorta in elderly women: three case reports.

Arterial hypertension is the most common cardiovascular disease in older than middle-aged patients. Reported incidence of secondary hypertension in this age group is around 10%. To evaluate secondary hypertension, history taking and physical examination should be precise, which are usually not routinely performed in busy outpatient clinic. Here, we report three cases of elderly women who are taking antihypertensive and visited outpatient clinic for uncontrolled hypertension. Their diagnosis of aortic stenosis was delayed, and its presence was suggested by detection of high abdominal aortic flow velocity during transthoracic echocardiography. This case report gives us lessons that suspicion of secondary hypertension and careful physical examination are most important to make diagnosis early.

Should preoperative chest CT be recommended to all colon cancer patients?

OBJECTIVE: The aim of this study was to evaluate the efficacy of preoperative chest computed tomography (CT) and the risk factors for lung metastasis in colon cancer patients without liver metastasis who had negative findings on initial chest X-ray (CXR). BACKGROUND: Preoperative staging with chest CT is recommended in colon cancer patients. However, there have been only scant data on the clinical efficacy. METHODS: Three hundred nineteen consecutive colon cancer patients without liver metastasis were retrospectively reviewed and analyzed. The patients had negative findings on preoperative CXR, and they underwent surgery for colon cancer during the period of January 2008 to April 2010. RESULTS: Lung nodule on chest CT was found in 136 patients (42.6%). Twenty of those were definitely diagnosed with lung metastasis (6.3%) by follow-up chest CT or pathologic confirmation. There was no case of delay in surgery due to findings of lung nodule. Comparing the group with lung metastases to that without lung metastases, postoperative pathologic findings reported more advanced T and N status (P = 0.004, P < 0.001, respectively), and lymphatic invasion was more frequent (P = 0.003) in the group with lung metastasis. By multivariate analysis, CT-predicted lymph node metastases and pathologic lymph node metastases were risk factors for lung metastases. CONCLUSIONS: Preoperative staging chest CT is not beneficial to colon cancer patients without liver metastasis and lymph node metastasis suggested on abdominal and pelvic CT who had negative finding on initial CXR.

Presence of preoperative diastolic dysfunction predicts postoperative pulmonary edema and cardiovascular complications in patients undergoing noncardiac surgery.

OBJECTIVE: The aim of this study was to evaluate the impact of left ventricular diastolic dysfunction on predicting postoperative pulmonary edema and major cardiovascular events (MACE) in patients who underwent low- or intermediate-risk noncardiac surgery. METHODS: A total of 692 patients aged >60 years who underwent transthoracic echocardiography (TTE) before undergoing elective low- or intermediate-risk noncardiac surgery were prospectively enrolled. The medical history and TTE variables were assessed. Each patient was clinically evaluated for postoperative pulmonary edema and MACE. The presence of postoperative pulmonary edema and MACE were evaluated during a 30-day follow-up period after surgery. RESULTS: We identified 166 patients with pulmonary edema and 49 patients with MACE. After adjusting for clinical and TTE variables, multivariate analysis demonstrated that a ratio of early transmitral flow velocity to early diastolic velocity of the mitral annulus (E/e') >15, pulmonary artery systolic pressure (PASP) ≥35 mmHg, and left ventricular hypertrophy (LVH) were significantly associated with postoperative pulmonary edema (E/e', P < 0.001: PASP, P = 0.005; LVH, P = 0.017). The multivariate analysis for MACE after adjusting for clinical risk factors indicated that MACE were significantly associated with an E/e' > 15 (P < 0.001). CONCLUSION: E/e' > 15, PASP elevation, and LVH on preoperative TTE predicted postoperative pulmonary edema, and E/e' > 15 predicted MACE in the patients who underwent low- or intermediate-risk noncardiac surgery. Thus, we believe that clinicians need to be cautious when providing perioperative care to patients with high E/e' ratios who are indicated for TTE.