Evaluation of cardiac electromechanics in patients with newly diagnosed hypertension.

OBJECTIVES: This study aimed to investigate the relationship between subclinical left ventricular (LV) systolic dysfunction and ECG parameters in newly diagnosed hypertension patients. METHODS: In this cross-sectional study, adults diagnosed with hypertension based on 24-h ambulatory blood pressure monitor recordings were included. The patients were classified into two groups based on the presence of subclinical LV systolic dysfunction according to LV global longitudinal strain (LVGLS). Findings were compared between the two groups. RESULTS: A total of 244 patients (female, 55.7%) were included. Based on LVGLS, 82 (33.6%) patients had subclinical LV systolic dysfunction. The proportion of early repolarization pattern (ERP) on ECG was significantly higher in patients with subclinical LV systolic dysfunction than in patients with normal LV systolic function [24 (28.6%) vs. 8 (5%), P < 0.001]. PR and corrected QT intervals were also significantly longer in patients with subclinical LV systolic dysfunction than in patients with normal LV systolic function [median (interquartile range), 148 (132-158) vs. 141 (127-152), P = 0.036 and 443 (427-459) vs. 431 (411-455), P = 0.007, respectively]. According to multivariate regression analysis ERP, early (E) wave velocity/late (A) wave velocity (E/A), and LV mass index were independently associated with subclinical LV systolic dysfunction. CONCLUSION: In newly diagnosed hypertension patients, the ERP on admission ECG could be a sign of subclinical systolic dysfunction.

Predictive role of left atrial and ventricular mechanical function in postoperative atrial fibrillation: a two-dimensional speckle-tracking echocardiography study.

OBJECTIVE: The aim of this study was to determine the role of left-sided mechanical parameters in postoperative atrial fibrillation (POAF) in patients undergoing coronary artery bypass grafting (CABG). METHODS: Ninety patients with coronary artery disease and normal left ventricular (LV) function in sinus rhythm were enrolled in the study. Preoperative LV and left atrial (LA) mechanics were evaluated by two-dimensional (2D) speckle-tracking echocardiography (STE), including strain and rotation parameters, and volume indices. Patients were monitored in order to detect POAF during the postoperative period. RESULTS: Twenty-three of 90 patients (25.6%) developed POAF. Age (p<0.001) and preoperative beta blocker usage (p=0.001) were the clinical parameters associated with POAF. Left atrial maximum volume index (LAV[max]i) increased, and peak left atrial longitudinal strain (PALS) was impaired in POAF patients (p=0.001, p<0.001, respectively). Left ventricular twist (LVtw) and left ventricular peak untwisting velocity (UntwV) were augmented in POAF patients (p=0.013, p=0.009, respectively). Receiver operating characteristic analysis showed N-terminal pro-brain natriuretic peptide (NT-proBNP) levels above 70 pg/ml and predicted POAF with a sensitivity of 74% and specificity of 78% (area under curve: 0.758, 95% confidence interval [CI] 0.631-0.894, p<0.001). Logistic regression analysis demonstrated that age (odds ratio [OR] 1.1, CI 1.01-1.20, p=0.034), preoperative beta blocker usage (OR 8.84, CI 1.36-57.28, p=0.022), NT-proBNP (values >70 pg/ml, OR 22.377, CI 3.286-152.381, p<0.001), PALS (OR 0.86, CI 0.75-0.98, p=0.023), and UntwV (OR 1.02, CI 1.00-1.04, p=0.029) were the independent predictors of POAF. CONCLUSION: The combination of 2D STE, clinical, and biochemical parameters may help predict POAF.

Postoperative atrial fibrillation in patients with left atrial myxoma.

INTRODUCTION: The aim of this study was to determine the factors associated with postoperative atrial fibrillation (AF) in patients with left atrial (LA) myxoma. METHODS: Thirty-six consecutive patients with LA myxoma (10 men, mean age: 49.3 ± 15.7 years), who were operated on between March 2010 and July 2012, were included in this retrospective study. Pre-operative electrocardiograms and echocardiographic examinations of each patient were reviewed. RESULTS: Postoperative AF developed in 10 patients, whereas there was no evidence of paroxysmal AF after resection of the LA myxoma in the remaining 26 patients. The patients who developed AF postoperatively were significantly older than those who did not develop AF (median: 61.5 vs 46 years; p = 0.009). Among the electrocardiographic parameters, only P-wave dispersion differed significantly between postoperative AF and non-AF patients (median: 57.6 vs 39.8 ms, p = 0.004). Logistic regression analysis revealed P- wave dispersion (OR: 1.11, 95% CI: 1.003-1.224, p = 0.043) and age (OR: 1.13, 95% CI: 1.001-1.278, p = 0.048) as independent predictors of postoperative AF in our cohort of patients. CONCLUSIONS: P-wave dispersion is a simple and useful parameter for the prediction of postoperative AF in patients with LA myxoma.

Right ventricular and atrial functions in patients with nonischemic dilated cardiomyopathy.

OBJECTIVE: The aim of this study was to assess the right ventricular and right atrial functions in patients with nonischemic dilated cardiomyopathy by novel echocardiographic measures. METHODS: In all, 40 patients with nonischemic dilated cardiomyopathy and 26 healthy subjects were consecutively included. Left ventricular, right ventricular, and right atrial functions were assessed by tissue Doppler imaging and two-dimensional speckle tracking echocardiography. Right ventricular systolic dysfunction was accepted moderated to severe when tissue Doppler peak systolic velocity of tricuspid lateral annulus was < 9 cm/s. RESULTS: In all, 18 of the 40 nonischemic dilated cardiomyopathy patients had peak systolic velocity of tricuspid lateral annulus < 9 cm/s and had significantly lower right ventricular free wall basal segment longitudinal strain, displacement, and right atrial functions assessed by speckle tracking echocardiography. Left ventricular tissue Doppler systolic velocity, global longitudinal and circumferential strain values were also lower in patients with moderated to severe right ventricular systolic dysfunction. Receiver operating characteristic analysis was preformed to assess the utility of right ventricular free wall basal segment longitudinal strain to predict right ventricular systolic dysfunction (peak systolic velocity < 9 cm/s). The cut off value for predicting right ventricular systolic dysfunction was - 20% with a sensitivity of 72% and specificity of 73% (AUC: 0.793; p = 0.002; 95% confidence interval: 0.645-0.941). CONCLUSIONS: Right ventricular systolic function is impaired in nonischemic dilated cardiomyopathy patients. Two-dimensional speckle tracking echocardiography represents a promising noninvasive method to evaluate right ventricular and atrial function in this patient group.

Early Detection of Bi-ventricular and Atrial Mechanical Dysfunction Using Two-Dimensional Speckle Tracking Echocardiography in Patients with Sarcoidosis.

PURPOSE: Sarcoidosis is a systemic inflammatory disease with unknown etiology involving several organs. Myocardial involvement, pericarditis, severe rhythm abnormalities, and heart valve disease due to papillary muscle dysfunction are some of the cardiac manifestations. Conventional echocardiographic methods remain insufficient for the determination of subclinical myocardial dysfunction in patients with sarcoidosis. In our study, we investigated the impact of sarcoidosis on bi-ventricular and atrial functions using two-dimensional (2D) speckle tracking echocardiography (STE). METHODS: Forty patients with sarcoidosis and 20 age and sex-matched controls were recruited into study. All subjects underwent a transthoracic echocardiography for the evaluation of ventricular and atrial functions with 2D STE. RESULTS: Left ventricular (LV) dimensions, LV ejection fraction, and right ventricular (RV) systolic velocity were similar between the two groups. Left atrial (LA) diameter was significantly higher in sarcoidosis patients than controls. Eighteen (45%) patients in the sarcoidosis group and 1 (5%) patient in the control group had LV diastolic dysfunction. LV global longitudinal, radial, circumferential strain, twist, untwists, and RV global longitudinal strain values were significantly lower in sarcoidosis patients compared to controls. LA and RA reservoir functions were also significantly lower in sarcoidosis patients than controls. CONCLUSION: Although impaired LV diastolic function was detected using conventional parameters, only novel advanced echocardiographic modalities demonstrated impaired bi-ventricular and atrial mechanical functions in patients with sarcoidosis.

Apical transverse motion is associated with speckle-tracking radial dyssynchrony in patients with non-ischemic dilated cardiomyopathy.

OBJECTIVE: Apical transverse motion (ATM) is a new parameter for assessing left ventricular (LV) dyssynchrony. Speckle-tracking radial strain analysis seems to be the best method to identify potential responders to cardiac resynchronization therapy. The aim of our study was to investigate the association between ATM and radial dyssynchrony assessed by speckle-tracking echocardiography in patients with non-ischemic dilated cardiomyopathy (NDC). METHODS: We examined 35 NDC patients (mean age 49.2 ± 28.1 years; 21 males). Cardiac dimension and ejection fraction (EF) were measured. Speckle-tracking analysis was performed on two-dimensional greyscale images in the mid-LV short axis view and apical views to calculate global radial, circumferential, and longitudinal strain (GRS, GCS, GLS), as well as rotational indexes (LV twist and torsion). Radial dyssynchrony was defined as a difference in time to peak systolic radial strain between the anteroseptal and posterior segments with a cut-off value of 130 ms. ATM was estimated using motion traces of 2 opposite apical segments. RESULTS: Radial dyssynchrony was significantly correlated with ATMloop (r = 0.78, p < 0.001), ATM4CV (r = 0.71, p = 0.001), ATM3CV (r = 0.67, p = 0.003), GRS (r = -0.51, p = 0.04), GCS (r = -0.55, p = 0.03), LV twist (r = -0.58, p = 0.02), and LV torsion (r = -0.56, p = 0.03). The receiver operating characteristics analysis for ATMloop to distinguish between patients with and without radial dyssynchrony revealed an area under the curve value of 0.88 (CI: 0.73-1.04, p = 0.005). The best cut-off value was 2.5 mm for ATMloop (85% sensitivity and 86% specificity). CONCLUSION: Apical transverse motion is closely associated with radial dyssynchrony assessed by speckle-tracking echocardiography. Quantitative measure of apical rocking has the potential for clinical applications.

Two-dimensional strain and strain rate imaging of the left atrium and left ventricle in adult patients with atrial septal defects before and after the later stage of percutaneous device closure.

AIM: Atrial septal defect (ASD) causes chronic volume overload of the right heart. The potential adverse effects of this long-standing volume overload to left atrium (LA) and left ventricle (LV) and their response to ASD closure has been poorly studied. METHODS: We studied 20 ASD patients before the procedure, at the 24-hour and 1 month following the percutaneous closure. Twenty age-matched controls served as the control group. The analysis for atrial deformation was performed on the lateral wall, mid segment of the LA from apical four-chamber view. Peak longitudinal strain (S) and strain rate (SR) during LA reservoir, passive emptying, atrial contraction phases and LV global longitudinal systolic S and SR were measured. RESULTS: Peak S and SR at LA reservoir, conduit and late contraction phases in ASD patients were similar to controls. All of these parameters increased immediately after the closure of the defect. Similarly, SLV and SRLV in ASD patients were not significantly different from the controls and significantly increased after the closure. But LA S, SR and LV S, SR results decreased in 1 month after the closure. SLV in ASD patients was significantly correlated with echocardiographic findings and the invasively measured defect size. CONCLUSION: LA and LV S and SR are not significantly affected in ASD patients. However, correction of the long-standing volume overload by percutaneous closure causes an early increase in LA and LV longitudinal deformation that correlates with the magnitude of the atrial septal defect. But this increase decreased in 1 month after closure.

Right ventricular function in hypertrophic cardiomyopathy: A speckle tracking echocardiography study.

OBJECTIVE: The aim of this study was to explore right ventricular (RV) mechanical function in patients with hypertrophic cardiomyopathy (HCM) by 2-D speckle tracking echocardiography (2-D-STE). METHODS: Forty-three patients with HCM (mean age 48, 17 females) and 40 healthy subjects were consecutively included in this cross-sectional study. The diagnosis of HCM was based on the presence of typical clinical, electrocardiographic (ECG), and echocardiographic features. Patients with LV systolic impairment, significant valvular disease, history of coronary artery disease, hypertension, malignancy, and chronic obstructive pulmonary disease were excluded. Right and left ventricular (LV) function was assessed by tissue Doppler imaging (TDI) and 2-D-STE. Hypertrophic cardiomyopathy patients were divided into two groups according to ACC/ESC guidelines (LVOT gradient below and above 30 mm Hg). Student t-test was used to compare differences between groups. Non-parametric tests (Mann-Whitney U) were used in cases of abnormal distribution. RESULTS: Hypertrophic cardiomyopathy patients had a significantly larger right atrium and RV diameters compared to controls. Mean pulmonary artery pressures (mPAB) were significantly higher in HCM patients (19.01±13.09 mm Hg vs. 8.40±4.50 mm Hg; p<0.001). Although RV Sm measurements were similar, RV strain measurements (-28.51±5.36% vs. -32.06±7.65%; p=0.016) were significantly lower in HCM patients. Left ventricular global longitudinal, radial, and circumferential strain values were also significantly different between the two groups (-20.50±3.58% vs. -24.12±3.40%; p<0.001, 38.18±12.67% vs. 44.80±10.15%; p=0.012, -21.94±4.28% vs. -23.91±3.95%; p=0.036 consecutively). Rotational movement of LV in each apical, mid-, and basal left ventricular segment was determined, and only mid-ventricular rotation of the HCM patients was more clockwise (-1.71±2.16 ° vs. 0.04±1.72 °; p<0.001). Although mPAP measurements were higher in HCM patients with significant LVOT obstruction (21.52±13.26 mm Hg vs. 12.31±10.53 mm Hg; p=0.049), none of the other TDI or 2-D-STE parameters was significantly different between groups. CONCLUSION: Speckle tracking echocardiography-derived right ventricular systolic function is impaired in HCM patients when compared with healthy subjects. However, RV systolic function is not affected form LVOT obstruction and left ventricular rotation dynamics in HCM patients.

Effect of increased severity of mitral regurgitation and preprocedural right ventricular systolic dysfunction on biventricular and left atrial mechanical functions following percutaneous mitral balloon valvuloplasty.

BACKGROUND: Severe mitral stenosis (MS) may impair left atrial (LA) pump function, and increase LA and pulmonary venous pressure resulting in right ventricular (RV) systolic dysfunction. The aim of this study was to evaluate biventricular and LA function after percutaneous mitral balloon valvuloplasty (PMBV) by tissue Doppler (TDI) and speckle tracking echocardiography (STE). METHODS: Twenty-eight consecutive patients with severe symptomatic rheumatic MS (11 men, mean age: 39 ± 7 years) who were referred for PMBV were included in the study. In addition to conventional echocardiography, all patients underwent TDI and two-dimensional (2D) (STE) to assess left ventricular (LV), LA, and RV function before and 3 months after PMBV. Severity of mitral regurgitation (MR) was graded by the ratio of MR jet area to LA area (JA/LAA) method and any postprocedural progression of the JA/LAA ratio was defined as worsening of MR. Peak systolic velocity of tricuspid lateral annulus (RVs) <11.5 cm/sec was accepted as RV dysfunction. RESULTS: Left atrial diameter and area were decreased, while LV dimensions were unchanged following the valvuloplasty. PMBV improved STE-based LV mechanical indices, LA reservoir and conduit function, and RV free wall basal longitudinal strain (LS) and displacement. Increased severity of MR was detected in 6 patients, and PMBV did not improve the STE-based RV or LV function in these patients, while LA reservoir and conduit function were both improved independent of MR worsening. There was significant improvement in RVs and RV basal LS in the 15 patients with preprocedural RV systolic dysfunction, while the improvement in patients with normal preprocedural RV function was not significant. CONCLUSION: Percutaneous mitral balloon valvuloplasty may improve both LA and biventricular function in patients with severe symptomatic MS. Both TDI and STE are useful to determine biventricular and LA function after PMBV. Although the number of patients was insufficient, worsening of MR after PMBV may limit the improvement in RV and LV function, while preprocedural RV dysfunction does not seem to limit the improvement in RV function and pulmonary artery systolic pressure. Large scale follow-up studies are required to see whether the changes observed in cardiac mechanics are persistent.

The value of plasma D-dimer level on admission in predicting no-reflow after primary percutaneous coronary intervention and long-term prognosis in patients with acute ST segment elevation myocardial infarction.

D-dimer is a final product of fibrin degradation and gives an indirect estimation of the thrombotic burden. We aimed to investigate the value of plasma D-dimer levels on admission in predicting no-reflow after primary percutaneous coronary intervention (p-PCI) and long-term prognosis in patients with ST segment elevation myocardial infarction (STEMI). We retrospectively involved 569 patients treated with p-PCI for acute STEMIs. We prospectively followed up the patients for a median duration of 38 months. Angiographic no-reflow was defined as postprocedural thrombolysis in myocardial infarction (TIMI) flow grade <3 or TIMI 3 with a myocardial blush grade <2. Electrocardiographic no-reflow was defined as ST-segment resolution <70%. The primary clinical end points were mortality and major adverse cardiovascular events (MACE). The incidences of angiographic and electrocardiographic no-reflow were 31 and 39% respectively. At multivariable analysis, D-dimer was found to be an independent predictor of both angiographic (p < 0.001), and electrocardiographic (p < 0.001) no-reflow. Both mortality (from Q1 to Q4, 5.7, 6.4, 11.3 and 34.1%, respectively, p < 0.001) and MACE (from Q1 to Q4, 17.9, 29.3, 36.9 and 52.2%, respectively, p < 0.001) rates at long-term follow-up were highest in patients with admission D-dimer levels in the highest quartile (Q4), compared to the rates in other quartiles. However, Cox proportional hazard model revealed that high D-dimer on admission (Q4) was not an independent predictor of mortality or MACE. In contrast, electrocardiographic no-reflow was independently predictive of both mortality [Hazard ratio (HR) 2.88, 95% confidence interval (CI) 1.04-8.58, p = 0.041] and MACE [HR 1.90, 95% CI 1.32-4.71, p = 0.042]. In conclusion, plasma D-dimer level on admission independently predicts no-reflow after p-PCI. However, D-dimer has no independent prognostic value in patients with STEMI.

Left ventricular and atrial functions in hypertrophic cardiomyopathy patients with very high LVOT gradient: a speckle tracking echocardiographic study.

BACKGROUND: Determination of myocardial deformation (strain) by two-dimensional (2D) speckle tracking echocardiography (STE) is a new method for evaluating left ventricular (LV) regional function in patients with hypertrophic cardiomyopathy (HCM). The aim of this study was to assess LV and left atrial (LA) functions with 2DSTE in HCM patients and to investigate relation between strain analysis and LV outflow tract (LVOT) gradient. METHODS: Forty consecutive HCM patients (26 male, mean age: 47.7 ± 15.2 years), and 40 healthy volunteers (22 male, mean age: 46.6 ± 11.2 years) were included in the study. All subjects underwent a transthoracic echocardiography for evaluation of LV and LA functions with 2DSTE. The HCM patients were divided into 2 groups according to the presence of resting LVOT gradient >100 mmHg. RESULTS: Left ventricular global longitudinal strain (GLS), global radial strain (GRS), and global circumferential strain (GCS) were significantly lower in patients with HCM compared with controls (-20.3 ± 3.6% vs. -24.1 ± 3.4% P < 0.001, 38.1 ± 12.8% vs. 44.8 ± 10.2% P = 0.012, and -22.0 ± 4.4% vs. -23.9 ± 4.0% P = 0.045, respectively). Although basal and apical rotation were similar between the groups, mid-rotation was significantly clockwise in HCM patients (-1.53 ± 2.06° vs. 0.05 ± 1.7° P < 0.001). Both LA reservoir functions and LA conduit functions were significantly lower in HCM patients (21.6 ± 9.1% vs. 39.4 ± 10.6% P < 0.001, and 10.5 ± 4.3% vs. 15.7 ± 5.3%, P < 0.001). Fifteen patients had a resting LVOT gradient of >100 mmHg and they had significantly decreased GLS, twist and untwist compared to the HCM patients with lower resting LVOT gradient (-18.7 ± 2.3% vs. -21.2 ± 3.9% P = 0.016, 19.4 ± 4.3° vs. 23.5 ± 7.4° P = 0.038 and -94.0 ± 29.1°/sec vs. -134.9 ± 55.8°/sec, 0.005, respectively). Although basal and apical rotation were similar between the 2 groups, mid-rotation was significantly clockwise in HCM patients with higher LVOT gradient (-2.52 ± 1.76° vs. -0.96 ± 2.03°, P = 0.018). Correlation analysis revealed that LVOT peak velocity was associated with GLS (r = -0.358, P = 0.023), LV mid-rotation (r = -0.366, P = 0.024), and LV untwist (r = -0.401, P = 0.013). CONCLUSIONS: Left ventricular and LA functions are impaired in patients with HCM. 2DSTE is useful in determining patients with impaired myocardial mechanics. High LVOT gradient may be one of the responsible factors that trigger deterioration of LV longitudinal strain and twist mechanics in patients with HCM. Further studies are required to clarify the preliminary results of this study.

Soluble CD40 ligand release in patients with stable coronary artery disease during elective stent implantation: effect of drug-eluting stent over bare metal stent.

OBJECTIVES: We aimed to determine the effect of drug-eluting stent (DES) implantation on soluble CD40 ligand (sCD40L) levels in patients with stable coronary artery disease undergoing stent replacement. STUDY DESIGN: Eighty-nine consecutive patients (33 women, 56 men; mean age 61±10 years) with stable coronary artery disease undergoing stent replacement were recruited. Pre- and post-procedural blood samples were collected for sCD40L analysis, and differences in plasma levels were calculated and expressed as delta sCD40L. Total size and length of implanted stents and pre- and post-dilatation procedures were recorded for each patient, for possible impact on sCD40L release. Patients were followed for one year following procedures for possible adverse cardiac events such as death, myocardial infarction and revascularization. RESULTS: Forty-nine patients received bare metal stent (BMS) and 40 patients received DES. There were no differences between BMS- and DES-implanted patients in terms of age, stent size and length, and delta sCD40L plasma levels. Delta sCD40L was correlated only with total implanted stent length (r=0.374, p<0.001). Delta sCD40L levels were divided into quartiles for better determination of the procedural parameters that are effective on biomarker release. Total stent length (p=0.008), stent size (p=0.038) and pre-dilatation procedure (p=0.034) were the statistically differing parameters between delta sCD40L quartiles. Although statistically non-significant, all three adverse events were observed in patients with the highest quartile (p=0.179). CONCLUSION: Procedural sCD40L release did not differ between DES- and BMS-implanted stable coronary artery disease patients. Total implanted stent length, stent size and pre-dilatation procedure were the influential parameters on procedural sCD40L release.

The effect of myocardial fibrosis on left ventricular torsion and twist in patients with non-ischemic dilated cardiomyopathy.

BACKGROUND: Left ventricular (LV) rotation, twist, and torsion are important aspects of the cardiac performance. Myocardial fibrosis can be identified as the late gadolinium enhancement (LGE) in cardiac magnetic resonance (CMR). In this study, we investigated the association between myocardial fibrosis and LV rotational parameters in patients with nonischemic dilated cardiomyopathy (NDC). METHODS: Twenty-two NDC patients were enrolled. LV dimensions, volumes and ejection fraction (EF) were measured, conventional tissue Doppler imaging data was acquired. Speckle tracking imaging was performed to measure LV deformation, LV rotational parameters. Blood samples were obtained for NT-proBNP. Late gadolinium enhanced cardiac magnetic resonance (LGE-CMR) was used to assess cardiac fibrosis index. RESULTS: Myocardial deformation was similar between LGE+ and LGE- groups. LGE+patients have significantly higher basal and lower apical systolic rotation, lower twist and torsion when compared to LGE- patients. However, untwisting rate was similar between the groups. Torsion was significantly correlated with LVEF and MR-index. Patients with reversed apical systolic rotation had significantly greater NT-proBNP values, basal systolic rotation and significantly lower apical systolic rotation, torsion, and MR-index. CONCLUSIONS: Cardiac fibrosis index is closely related with myocardial torsion and LV systolic function and may be used for the evaluation of cardiac condition. Reversed apical systolicrotation indicated more extensive cardiac fibrosis as it may reflect severe LV dyssynchrony andpoor LV performance.

Soluble endothelial protein C receptor levels and protein C activity in patients with acute ST-segment elevation myocardial infarction.

OBJECTIVES: In contrast to its membrane-bound form, soluble endothelial protein C receptor (sEPCR) expresses procoagulant activity through binding to protein C. We aimed to investigate the relationship between sEPCR levels and protein C activity in patients with ST-segment elevation myocardial infarction (STEMI). METHODS: The study population included 60 STEMI patients who had undergone a primary percutaneous coronary intervention and 29 patients with stable angina pectoris (SAP) with significant coronary stenosis on angiography. Preprocedural sEPCR levels and protein C activity were determined in all study patients. RESULTS: In the STEMI group, the baseline sEPCR level was significantly higher (172.0±89.3 vs. 107.1±39.2 ng/ml, P<0.001) and protein C activity was significantly lower (91.9±26.4 vs. 124.5±16.2%, P<0.001) compared with patients with SAP. There was a significant negative correlation between protein C activity and sEPCR in the STEMI group (r=-0.38, P=0.002); however, no significant correlation was observed in the SAP group (r=0.02, P=0.91). Angiographic thrombus load and the incidence of no-reflow phenomenon were significantly higher in STEMI patients with protein C activity under the median level. CONCLUSION: The ratio of sEPCR levels to protein C activity is high, with a significant negative correlation in patients with STEMI. Lower protein C activity is associated with the development of no-reflow in STEMI patients. However, the sEPCR level has no relation to the development of no-reflow. The clinical significance of elevated sEPCR level in STEMI should be evaluated in larger studies.

Time course of right ventricular remodeling after percutaneous atrial septal defect closure: assessment of regional deformation properties with two-dimensional strain and strain rate imaging.

BACKGROUND: Quantitative assessment of the right ventricular (RV) function in atrial septal defect (ASD) patients before and after closure remains difficult. The aim of this study was to assess the regional RV function in ASD patients, to evaluate the extent and time course of RV remodeling following ASD closure, and to investigate whether any regional difference exists in RV remodeling. METHODS: Twenty patients with ASD and 20 age-matched controls were included. All underwent standard echocardiography and two-dimensional strain (S) and strain rate (SR) imaging by speckle tracking before, and 24 hours and 1 month after the defect closure. RESULTS: Right ventricular S was higher in ASD patients except apical lateral segment S, which was lower when compared with controls. There was no difference in RV SR between ASD patients and controls. RV septal S and SR, and lateral SR decreased in 24 hours after the procedure and remained the same at 1 month. RV lateral basal and mid S decreased and apical S increased in 24 hours after the closure. All 3 segments showed some more increase at 1 month. RV apical S showed strong correlations with systolic pulmonary artery pressure and global RV systolic function indices. CONCLUSIONS: Chronic volume overload in ASD patients causes alterations in RV deformation. Percutaneous closure results in rapid remodeling and normalization of RV deformation. The major geometrical and deformational changes are completed in 24 hours. Lateral wall S seems to reflect the RV deformational changes due to volume loading and unloading better than SR in ASD patients.

Anemia in heart failure.

Chronic heart failure is a common problem and a major cause of death, hospital admission, poor physical function and impaired quality of life. In addition to the direct effect of heart failure on prognosis, several modifiable and non-modifiable factors contribute to the worse prognosis in heart failure. Anemia, which is common in patients with heart failure, may represent a modifiable risk factor for adverse outcome. It is also a marker for co-morbidity burden and greater disease severity. If anemia is a marker, treatment may not obviate the increased risk associated with anemia, but if it is a mediator, treatment may be helpful to reduce morbidity and mortality in heart failure. As anemia has been identified as an independent prognostic factor of both morbidity and mortality for patients with congestive heart failure, there is an increased interest in the hypothesis that the correction of anemia with erythropoietin or iron supplementation might lead to an improvement on patients' symptoms and functional status. Large randomized trials are necessary to show the effect of anemia and the specific treatments on the outcome in these patients. This article reviews the mechanisms, impact on outcomes and therapy of anemia in patients with heart failure.

In-hospital prognostic value of hemoglobin levels on admission in patients with acute ST segment elevation myocardial infarction undergoing primary angioplasty.

PURPOSE: Anemia is a common comorbidity in patients presenting with ST-elevation myocardial infarction (STEMI). The aim of this study was to investigate the in-hospital prognostic value of admission hemoglobin (Hb) levels in patients with acute STEMI undergoing primary percutaneous coronary intervention (p-PCI). METHODS: This is a retrospective study of 1,625 patients with STEMI stratified by quartiles of admission Hb concentration (Q1 ≤12.5 g/dl, Q2 12.6-13.8 g/dl, Q3 13.9-15.0 g/dl, Q4 ≥15.1 g/dl). Main outcome measures were in-hospital rates of all cause mortality, re-infarction, target vessel revascularization, stroke, heart failure (HF) and bleeding complications. RESULTS: The incidences of in-hospital mortality according to quartiles from Q1 to Q4 were 8.6, 3.9, 2.4 and 2.6%, respectively (p < 0.001). The incidences of major hemorrhage and HF were significantly higher in Q1, compared to the other quartiles (7.4, 1.9, 3.1, 2.8%, p < 0.001; 16.3, 8.5, 7.7, 9.8%, p < 0.001, respectively). Multiple logistic-regression analysis showed that low admission Hb level (Q1) is an independent and a potent predictor for in-hospital mortality [unadjusted odds ratio (OR): 3.84, 95% confidence interval (CI): 1.78-7.82; p < 0.001]. CONCLUSION: Lower concentrations of Hb on admission are associated with higher rates of in-hospital mortality, heart failure and major bleeding after p-PCI.

Intracoronary bolus-only compared with intravenous bolus plus infusion of tirofiban application in patients with ST-elevation myocardial infarction undergoing primary percutaneous coronary intervention.

OBJECTIVES: The aim of this pilot study was to compare intracoronary bolus-only with standard intravenous bolus plus maintenance infusion of tirofiban with respect to improvement in myocardial reperfusion after primary percutaneous coronary intervention (p-PCI). BACKGROUND: Changes in clinical practice may obviate the need for a maintenance infusion of small molecule glycoprotein IIb/IIIa inhibitors in current practice. METHODS: Forty-nine patients undergoing p-PCI were randomized to either intracoronary bolus-only (n = 25) or intravenous bolus plus infusion (n = 24) of tirofiban. The primary end point was coronary hemodynamic indices of microvascular perfusion measured 4-5 days after p-PCI. The secondary end points were ST segment resolution at 90 min, the corrected TIMI frame count and myocardial blush grade. At 6 months, echocardiography and technetium-99m single-photon-emission computed tomography were performed. RESULTS: Microvascular perfusion did not differ significantly between the two treatment groups: index of microvascular resistance (27 ± 13 vs. 35 ± 15 U, P = 0.08) and coronary flow reserve (2.2 ± 0.7 vs. 1.9 ± 0.6, P = 0.25). The corrected TIMI frame counts assessed in the first (P = 0.13) and the second (P = 0.09) catheterization or the myocardial blush grades evaluated immediately (P = 0.23) and 4-5 days after MI (P = 1.00) were not significantly different between the two groups. At 6 months, there was no difference between the two groups in infarct size, left ventricular volumes, or ejection fraction. CONCLUSIONS: The standard intravenous bolus plus maintenance infusion of tirofiban in p-PCI is not superior to intracoronary bolus-only administration with respect to microvascular perfusion. Further, adequately powered randomized trials are warranted to evaluate the clinical outcomes associated with this strategy.