Individual reference values for 2D echocardiographic measurements. The Stockholm - Umeå Study.

OBJECTIVES: Improved reference values for 2D echocardiographic measurements are required, even when more recent echocardiographic technology is employed. In addition, it may be preferable to individualize reference values from age, gender and body characteristics of any subject. DESIGN: A material of 180 healthy subjects was collected and investigated, aiming for an even distribution of sex and age (from 20 to 80 years of age; the Stockholm material). For atrial areas, material from another 216 healthy subjects with similar sex and age distribution was added (the Umeå material). The 2D measures determined were the left and right ventricular diameters in diastole, the left ventricular diameter in systole, the thickness of septum and posterior wall, the diameters of the aortic root (sinotubular junction) and the left atrium (all in parasternal view), together with the left and right ventricular diameters in diastole and left and right atrial areas in end-systole (apical four-chamber view). The width of the inferior vena cava (from subcostal view) was also determined. RESULTS: Confidence intervals for females and males are presented for each of these measures. Multiple linear regression analyses with age, sex and measures of body characteristics as predictors were also performed, and for eight of the 12 measurements, such equations are presented. CONCLUSIONS: It is possible to obtain more highly individualized reference values for these cardiac dimensions, which may clinically be a better way of distinguishing pathological states from normal states.

No additive effect of passive containment surgery in patients with aortic regurgitation and left ventricular dilation.

BACKGROUND: After valve replacement in patients with aortic regurgitation short-term and long-term improvement of left ventricular function are related to early reduction of left ventricular dilatation. This case-control study was conducted to investigate the potential beneficial effects by concomitant application of the Acorn Cor Cap Cardiac Support Device (Acorn Cardiovascular Inc, St. Paul, MN) on reduction of ventricular dilatation in patients with aortic regurgitation and advanced ventricular dilatation undergoing aortic valve replacement. METHODS: Of ten patients with longstanding aortic regurgitation and ventricular dilatation subjected to aortic valve replacement using mechanical valve prostheses, five were in addition subjected to application of the Cardiac Support Device (Acorn). Cardiac function and dimensions were measured by echocardiography preoperatively and 3 and 12 months postoperatively. RESULTS: After aortic valve replacement, there was a rapid and sustained decrease in end-diastolic and end-systolic diameters (before operation 72 +/- 4 and 54 +/- 8 mm, to 54 +/- 10 and 40 + 11 mm at 3 months; and 53 +/- 9 and 35 +/- 6 mm, 12 months after operation). This did not differ after Cardiac Support Device (Acorn) application (before operation 74 +/- 1 and 56 +/- 5 mm; 52 +/- 8 and 39 +/- 9 mm, 3 months after operation; and 54 +/- 6 and 39 +/- 8 mm, at 12 months). The left ventricular ejection fraction remained unchanged in both groups. CONCLUSIONS: Application of the Acorn Cor Cap Cardiac Support Device in patients with aortic regurgitation and severe ventricular dilatation does not influence reverse remodeling or cardiac function compared with aortic valve replacement alone.

Electromechanical effects of cardiac resynchronization therapy during rest and stress in patients with heart failure.

BACKGROUND: Haemodynamic and functional effects of cardiac resynchronization therapy (CRT) have been studied mostly at rest. CRT effects on left ventricular (LV) dyssynchrony and function during stress have not been evaluated in detail. AIMS: We studied the electromechanical effects of CRT at rest and during Dobutamine stress echocardiography (DSE), during active and withheld CRT. METHODS: Twenty-one responders to CRT (62+/-12 yr) were assessed by walking test, quality of life, and BNP with active CRT ("on") and 2 weeks after pacing withdrawal ("off"). DSE (10 microg/kg/min) was performed both at "on" and "off" to evaluate dyssynchrony parameters, systolic and diastolic function. RESULTS: At rest, CRT withdrawal was associated with an increased interventricular mechanical delay (IVMD, from 21+/-18 ms to 49+/-24 ms, p<0.001) and impaired intraventricular synchrony. There was a significant decrease in LV systolic function and LV filling time. Dobutamine infusion had no impact on inter- and intraventricular synchrony. During stress, there was an improvement in LV performance both at "on" and "off". However, LV dp/dt, aortic VTI, cardiac output, mean systolic peak velocities and LV filling time during dobutamine stress were significantly greater with CRT "on". CONCLUSION: In long-term responders, CRT improves LV performance both at rest and during dobutamine stress. This is attributable to an improvement in LV synchrony, which is maintained during stress.

Follow-up of patients operated on with arterial patch angioplasty of the left main coronary artery.

BACKGROUND: Surgical angioplasty of the left main coronary artery (LMCA) can be performed with good results in selected patients. It restores the native antegrade blood flow in the LMCA and does not leave the patient with a graft-dependent retrograde perfusion. By using a proximal segment of the right internal mammary artery as patch material, we assumed that this would minimize the risk of restenosis of the LMCA. We here review our experience and results. METHODS: Forty-three patients were operated on with LMCA angioplasty from 1997 to 2003. Follow-up at a mean of 45 months (range, 7 to 79) included a stress test, echocardiography, and angiography with intravascular ultrasound (IVUS) of the LMCA. RESULTS: There were three late deaths, none related to failure of the angioplasty. All patients included in the follow-up had preserved preoperative left ventricular function, and there was no aortic incompetence. The angioplasties investigated were patent, and no signs of restenosis or dilatation could be observed. The dimensions of the LMCA after angioplasty was in diameter 4.8 mm (3.35 to 6.75 mm) and 5.6 mm (4 to 7.6 mm), and in area 18.9 mm2 (12.3 to 31.9 mm2) and 24.8 mm2 (14.5 to 37 mm2) in the distal and proximal parts, respectively. CONCLUSIONS: Surgical angioplasty of the left main coronary artery using a proximal segment of the right internal mammary artery as an onlay patch is safe, with good long-term results.

Synthesis and reactivity of laquinimod, a quinoline-3-carboxamide: intramolecular transfer of the enol proton to a nitrogen atom as a plausible mechanism for ketene formation.

5-Chloro-N-ethyl-1,2-dihydro-4-hydroxy-1-methyl-2-oxo-N-phenyl-3-quinolinecarboxamide (laquinimod, 2) is an oral drug in clinical trials for the treatment of multiple sclerosis. The final step in the synthesis of 2 is a high-yielding aminolysis reaction of ester 1 with N-ethylaniline. An equilibrium exists between 1 and 2, and removal of formed methanol during the reaction is a prerequisite for obtaining high yields of 2 from 1. The reactivity of 1 and 2 is explained by a mechanistic model that involves a transfer of the enol proton to the exocyclic carbonyl substituent with concomitant formation of ketene 3. This proton transfer is especially facilitated for 2 because the intramolecular hydrogen bond to the carbonyl oxygen is weakened due to steric interactions. Both 1 and 2 undergo solvolosis reactions that obey first-order reaction kinetics, further supporting the theory that these two molecules are able to decompose unimolecularly into ketene 3. The solvent-dependent spectroscopic features of 2 indicate that the molecule mainly resides in two conformations. One conformation is favored in nonpolar solvents and is likely the result of intramolecular hydrogen bonding. The other conformation is favored in polar solvents and probably exhibits less intramolecular hydrogen bonding.

Echocardiographic findings using tissue velocity imaging following passive containment surgery with the Acorn CorCap cardiac support device.

OBJECTIVE: To echocardiographically evaluate the effects of passive containment surgery using the CorCap Cardiac Support Device in heart failure patients with dilated cardiomyopathy. METHODS: Twelve patients with dilated cardiomyopathy subjected to cardiac surgery received the Cardiac Support Device. Patients with ischemic cardiomyopathy (n=5) underwent coronary artery bypass surgery receiving 1-3 bypass grafts. In the idiopathic cardiomyopathy group (n=7), mitral valve annuloplasty was performed in five patients while two patients received the Cardiac Support Device only. RESULTS: Following surgery there was a gradual, sustained improvement in cardiac dimensions (decreased left ventricular end-diastolic diameter and left ventricular end-systolic diameter) combined with an increase in functional status (6-min walk and NYHA class). Concomitantly there was a marked decrease in right ventricular function (decrease in tricuspid annular systolic and diastolic velocities) while the left ventricular function (mitral annular systolic and diastolic velocities) and output (ejection fraction, stroke volume) remained unchanged. CONCLUSIONS: Addition of the Cardiac Support Device to conventional cardiac surgery improves patient status and decreases left ventricular size in heart failure patients with dilated cardiomyopathy. The positive effect on left ventricular dimensions is not accompanied by any improvement in cardiac output but rather right ventricular dysfunction, although the functional significance of this is unclear.

Reversal of ventricular dilatation in aortic regurgitation after valve replacement and cardiac support implant surgery using the CorCap cardiac support device.

The effects of combined aortic valve replacement, coronary bypass surgery, and passive containment surgery in a patient with long-standing aortic regurgitation and marked ventricular dilatation are described. After surgery there was a rapid decrease in left ventricular size and maintained ventricular function.

Early results with cardiac support device implant in patients with ischemic and non-ischemic cardiomyopathy.

OBJECTIVE: To evaluate the possible beneficial echocardiographic, functional and quality of life improving effects of passive containment surgery using the CorCap Cardiac Support Device in heart failure patients with dilated cardiomyopathy. DESIGN: Eight patients with dilated cardiomyopathy subjected to cardiac surgery received the Cardiac Support Device. Patients with ischemic cardiomyopathy (n = 4) underwent coronary artery bypass surgery receiving one to three bypass grafts. In the idiopathic cardiomyopathy group (n = 4) mitral valve plasty was performed in two patients while two patients received the Cardiac Support Device only. RESULTS: All patients survived the surgery and were discharged to home. There was a gradual, sustained improvement in cardiac dimensions (left ventricular end-diastolic diameter, left ventricular end-systolic diameter) and functional improvement (ejection fraction, 6-min walk, NYHA functional class) as well as quality of life. These beneficial effects developed more rapidly and more extensively in the idiopathic cardiomyopathy group. CONCLUSION: Addition of the Cardiac Support Device to conventional cardiac surgery, or applied alone, is safe and simple. The device seems to reverse ventricular dilatation and improve functional capacity and well-being of heart failure patients with dilated cardiomyopathy. Further studies will delineate what patient population will best benefit from passive containment surgery using the CorCap Cardiac Support Device.

Initial experience with GLP-1 treatment on metabolic control and myocardial function in patients with type 2 diabetes mellitus and heart failure.

Congestive heart failure (CHF) is a serious disease with a poor prognosis. Diabetes is an independent risk factor for CHF, probably in part due to disturbances in myocardial metabolism. Glucagon-like peptide-1 (GLP-1) causes glucose-dependent secretion of insulin, improving glycaemic control. In turn, this may improve myocardial metabolism and myocardial function. The aim of the present study was to assess the feasibility and safety of three days' infusion of recombinant GLP-1 in an open observational study in six patients with type 2 diabetes and CHF. The study included assessment of myocardial function. There were no major complications of the infusion, and all patients completed the study protocol. Some improvement was observed in glycaemic state, and there was an insignificant trend towards improved myocardial function. It is concluded that GLP-1 deserves further evaluation in such patients.