Thrombolytic therapy for the treatment of prosthetic heart valve thrombosis in pregnancy with low-dose, slow infusion of tissue-type plasminogen activator.

BACKGROUND: Prosthetic valve thrombosis during pregnancy is life-threatening for mother and fetus, and the treatment of this complication is unclear. Cardiac surgery in pregnancy is associated with very high maternal and fetal mortality and morbidity. Thrombolytic therapy has rarely been used in these patients. The aim of this study is to evaluate the safety and efficacy of low-dose (25 mg), slow infusion (6 hours) of tissue-type plasminogen activator for the treatment of prosthetic valve thrombosis in pregnant women. METHODS AND RESULTS: Between 2004 and 2012, tissue-type plasminogen activator was administered to 24 consecutive women in 25 pregnancies with 28 prosthetic valve thrombosis episodes (obstructive, n=15; nonobstructive, n=13). Mean age of the patients was 29±6 years. Thrombolytic therapy sessions were performed under transesophageal echocardiography guidance. The mean dose of tissue-type plasminogen activator used was 48.7±29.5 mg (range, 25-100 mg). All episodes resulted in complete thrombus lysis after thrombolytic therapy. One patient had placental hemorrhage with preterm live birth at the 30th week, and 1 patient had minor bleeding. CONCLUSIONS: Low-dose, slow infusion of tissue-type plasminogen activator with repeated doses as needed is an effective therapy with an excellent thrombolytic success rate for the treatment of prosthetic valve thrombosis in pregnant women. This protocol also seems to be safer than cardiac surgery or any alternative medical strategies published to date. Thrombolytic therapy should be considered first-line therapy in pregnant patients with prosthetic valve thrombosis.

Utility of the NavX® Electroanatomic Mapping System for Permanent Pacemaker Implantation in a Pregnant Patient with Chagas Disease.

Chagas disease is a highly prevalent zoonosis in Mexico, Central, and South America. Early cardiac involvement is one of the most serious complications of this disease, and conduction disturbances may occur at an early age. We describe a young pregnant woman with Chagas disease and a high degree atrioventricular block, who required implantation of a permanent dual chamber pacemaker. Using an electroanatomic navigation EnSite NavX® system the pacemaker was successfully implanted with minimal fluoroscopic exposure. This case demonstrates the safety and feasibility of using an electroanatomic navigation system to guide permanent pacemaker implantation minimizing x-ray exposure in pregnant patients.

Transthoracic echocardiography of the HeartWare left ventricular assist device.

BACKGROUND: The unique findings on transthoracic echocardiography of the HeartWare left ventricular assist device (LVAD) have not been previously described. METHODS AND RESULTS: HeartWare LVADs were implanted in 19 patients from May 2009 through December 2010; 152 comprehensive transthoracic echocardiograms (TTEs) performed postoperatively on these patients were retrospectively analyzed for device component visualization, inlet cannula/outflow conduit flow velocities, and imaging artifacts. The inlet cannula was adequately visualized in 66% of studies, incompletely visualized in 14%, and not visualized in 20%. Spectral Doppler interrogation of inlet cannula flow velocity was always uninterpretable due to artifact. Standard parasternal long-axis and apical views always included the inlet cannula in the imaging sector, resulting in a prominent "waterfall" color Doppler artifact obscuring the mitral valve. Inclusion of the inlet cannula in the imaging sector also precluded spectral Doppler interrogation of the mitral valve owing to artifact. The outflow conduit was partially visualized and interrogated by spectral Doppler in 68% of studies, and the average measured peak flow velocity was 1.4 m/s (range 1.0-1.9 m/s). CONCLUSIONS: The HeartWare LVAD inlet cannula and outflow conduit are both readily visualized by TTE in a majority of patients. However, significant color and spectral Doppler artifacts occur when the inlet cannula is visualized in the imaging sector, necessitating routine off-axis Doppler interrogation of the mitral valve.

No harmful effect of dialysis-induced hypotension on the myocardium in patients who have normal ejection fraction and a negative exercise test.

BACKGROUND: We investigated the effects of dialysis-induced hypotension (DIH) on the myocardium of patients who have a normal ejection fraction and normal treadmill stress tests. METHODS: This study included 26 end-stage renal disease (ESRD) patients with DIH, 30 ESRD patients without DIH (non-DIH), and 30 control subjects. Mitral-myocardial systolic velocity (MSV), the mitral E'/A' ratio, the left ventricle filling pressure index (E/E' ratio), tricuspid-MSV, and the tricuspid E'/A' ratio were calculated. RESULTS: Biventricular systolic and diastolic functions were impaired in dialysis patients. The mitral and tricuspid MSV were similar between DIH and non-DIH patients (8.03 ± 0.90 cm/s vs. 8.31 ± 1.68 cm/s, p = 0.896, and 13.27 ± 2.97 cm/s vs. 13.15 ± 2.37 cm/s, p = 0.980). Mitral and tricuspid E'/A' were similar between DIH and non-DIH patients. (1.30 ± 0.53 vs. 1.16 ± 0.56, p = 0.695, and 0.70 ± 0.24 vs. 0.68 ± 0.33, p = 0.976). Likewise, the E/E' ratio was similar between DIH and non-DIH patients (8.20 ± 2.83 vs. 8.28 ± 2.53, p = 0.990). CONCLUSION: Although biventricular systolic and diastolic function is impaired in dialysis patients compared to controls, DIH episodes did not have an adverse effect on the myocardial functions.

Epicardial fat thickness is associated with non-dipper blood pressure pattern in patients with essential hypertension.

OBJECTIVE: Epicardial fat tissue reflects visceral adiposity and is a suggested cardiometabolic risk factor. Patients with abdominal obesity have an increased prevalence of the non-dipper blood pressure (BP) pattern, but it is unclear whether the same is true of patients with increased epicardial fat thickness (EFT). The association between EFT and circadian BP changes in patients with recently diagnosed essential hypertension was examined. METHODS: Sixty hypertensive patients underwent echocardiography, treadmill stress testing, and 24 hours of ambulatory BP monitoring. Epicardial fat thickness and left ventricular mass (LVM) index were measured by using transthoracic echocardiography. The patients were categorized into two groups according to their BP pattern (group 1, non-dippers; group 2, dippers). RESULTS: The mean EFT and LVM of patients in group 1 (n = 24) (EFT, 7.6 ± 2.1 mm; LVM, 130 ± 31.2 g/m(2)) were significantly greater than those of group 2 (n = 36) (EFT, 5.5 ± 1.2 mm, P = .0001; LVM, 107 ± 23.7 g/m(2), P = .002). The average systolic BP over 24 hours (BP(s) 24) and average diastolic BP over 24 hours (BP(d) 24) of group 1 (BP(s) 24, 151.1 ± 17.6 mm Hg; BP(d) 24, 94.1 ± 16.5 mm Hg) were significantly higher than those of group 2 (BP(s) 24, 136.7 ± 11.9 mm Hg, P = .0001; BP(d) 24, 84.6 ± 10.6 mm Hg; P = .008). Multivariate backward logistic regression analysis demonstrated that the non-dipper BP pattern was associated with EFT (standardized ß coefficient = 0.87, P = .005) and LVM (standardized ß coefficient = 0.43, P = .016). An EFT ≥ 7 mm was associated with the non-dipper BP pattern with 44% sensitivity and 94% specificity (receiver operating characteristic area under curve of 0.72, 95% CI [0.59-0.83], P = .0007). CONCLUSIONS: Epicardial fat thickness was above average in newly diagnosed, untreated hypertensive patients with non-dipper BP pattern. The echocardiographic measurement of EFT may be used to indicate increased risk of hypertension-related adverse cardiovascular events.

Telmisartan decreases atrial electromechanical delay in patients with newly diagnosed essential hypertension.

BACKGROUND: Atrial electromechanical delay (EMD) parameters predict the development of atrial fibrillation. We investigated the effect of telmisartan treatment on atrial EMD parameters in patients with newly diagnosed essential hypertension. METHODS: Thirty-six patients with essential hypertension were treated with telmisartan (80 mg/day) for 6 months. Baseline electrocardiographic P-wave measurements and echocardiographic atrial EMD parameters were compared with the 6-month follow-up. RESULTS: Pmax and Pd were significantly decreased (108.4 ± 6.1 vs 93.9 ± 6.2 milliseconds, 33.4 ± 8.6 vs 19.5 ± 7.0 milliseconds, respectively, P = .0001 for each) after 6-month telmisartan therapy. The atrial EMD parameters were decreased from baseline (mitral EMD, 68.9 ± 4.9 vs 53.8 ± 4.9 milliseconds; septum EMD, 51.6 ± 7.1 vs 42.6 ± 7. milliseconds1; tricuspid EMD, 48 ± 6.9 vs 39 ± 6.9 milliseconds; interatrial EMD, 20.9 ± 5.5 vs 14.8 ± 5.7 milliseconds; P = .0001 for each parameter). The reduction of interatrial EMD was correlated with the reduction in systolic BP nighttime and the increase in mitral E wave velocity/mitral A wave velocity ratio. CONCLUSION: Telmisartan decreased the atrial EMD parameters in patients with newly diagnosed essential hypertension.

Medical literature searches: a comparison of PubMed and Google Scholar.

BACKGROUND: Medical literature searches provide critical information for clinicians. However, the best strategy for identifying relevant high-quality literature is unknown. OBJECTIVES: We compared search results using PubMed and Google Scholar on four clinical questions and analysed these results with respect to article relevance and quality. METHODS: Abstracts from the first 20 citations for each search were classified into three relevance categories. We used the weighted kappa statistic to analyse reviewer agreement and nonparametric rank tests to compare the number of citations for each article and the corresponding journals' impact factors. RESULTS: Reviewers ranked 67.6% of PubMed articles and 80% of Google Scholar articles as at least possibly relevant (P = 0.116) with high agreement (all kappa P-values < 0.01). Google Scholar articles had a higher median number of citations (34 vs. 1.5, P < 0.0001) and came from higher impact factor journals (5.17 vs. 3.55, P = 0.036). CONCLUSIONS: PubMed searches and Google Scholar searches often identify different articles. In this study, Google Scholar articles were more likely to be classified as relevant, had higher numbers of citations and were published in higher impact factor journals. The identification of frequently cited articles using Google Scholar for searches probably has value for initial literature searches.

Attenuated cardiovascular response to sympathetic system activation during exercise in patients with dialysis-induced hypotension.

BACKGROUND: We wished to investigate potential causes of dialysis-induced hypotension (DIH), including the attenuated cardiovascular response to sympathetic system activation during exercise and myocardial dysfunction. METHODS: This study included 26 end-stage renal disease (ESRD) patients with DIH, 30 ESRD patients without DIH (Non-DIH), and 30 control subjects. Each patient was evaluated with echocardiography and a symptom-limited treadmill stress test. The chronotropic index (CRI), heart rate recovery (HRR), systolic blood pressure response to exercise (SBP response), and tissue Doppler systolic myocardial velocities were calculated. RESULTS: The HRR and velocities were reduced in dialysis patients compared to controls; however, they were similar in patients with and without DIH. Patients with DIH had the lowest CRI compared to the Non-DIH group (0.62 ± 0.15 vs. 0.73 ± 0.17, p = 0.020) and controls (0.62 ± 0.15 vs. 0.86 ± 0.11, p < 0.001). Similarly, patients with DIH had the lowest SBP response values compared to the Non-DIH (34.88 ± 15.01 vs. 55.67 ± 25.42, p = 0.002) and controls (34.88 ± 15.01 vs. 59.70 ± 23.04, p < 0.001). CONCLUSION: Patients with DIH have inadequate sympathetic activity of the cardiovascular system during exercise and impaired left ventricular systolic function. Both factors could contribute to the development of hypotension during hemodialysis.

Assessment of atrial conduction time in patients with coronary artery ectasia.

BACKGROUND: Coronary artery ectasia (CAE) is associated with increased sympathetic activity, plasma levels of inflammatory markers, and oxidative stress. These factors can also cause arrhythmias such as atrial fibrillation. Atrial conduction abnormalities in patients with CAE have not been investigated in terms of atrial electromechanical delay obtained by tissue Doppler echocardiography. METHODS: Ninety patients with pure CAE (n = 30), nonobstructive coronary artery disease (NO-CAD) (n = 30), and angiographically normal coronary arteries "controls" (n = 30) were compared in terms of electrocardiographic P-wave measurements, echocardiographic atrial electromechanical coupling (AEC) parameters, and interatrial conduction delay. RESULTS: The mean left atrium diameter in the CAE group was similar to the NO-CAD group but significantly greater than the control group (3.62 ± 0.28 vs 3.46 ± 0.32 vs 3.41 ± 0.31 cm, P = 0.021). P maximum and P-wave dispersion were significantly increased in the CAE group compared to the NOCAD group and the control group (108.6 ± 6.6 vs 97.9 ± 6.6 vs 93.5 ± 6.2, P = 0.0001; 34.4 ± 7.6 vs 23.2 ± 7.8 vs 19.4 ± 7.7 ms, P < 0.0001). Mitral AEC, septal AEC, and tricuspid AEC were significantly higher in the CAE group than the NO-CAD group and the control group (68 ± 4.5 vs 57 ± 4.5 vs 53 ± 4.6 ms, P < 0.0001; 50.7 ± 7 vs 42.7 ± 7 vs 41.7 ± 7.2 ms, P = 0.0001; 47 ± 6.7 vs 39.1 ± 6.7 vs 38.1 ± 6.6 ms, P < 0.0001). Interatrial conduction delay was significantly increased in the CAE group compared to the NO-CAD group and the control group (21 ± 5.5 vs 17.8 ± 5.6 vs 15 ± 5.6 ms, P < 0.0001).The correlation analysis demonstrated that the interatrial conduction delay and P-wave dispersion (Pd) were positively correlated with number of ectatic segments (ESN) (r = 0.41, P = 0.024 vs r = 0.49, P = 0.006). Stepwise multiple linear regression analysis revealed that the ESN was the only independent determinants of interatrial conduction delay (P = 0.024). CONCLUSION: Pd and interatrial conduction delay are prolonged in patients with CAE compared to NO-CAD patients and the healthy controls.

Heyde's syndrome: A critical review of the literature.

Heyde's syndrome is an uncommon association between aortic stenosis and gastrointestinal bleeding. Although initially described during the late 1950s, with subsequent reports of a possible link between these disorders, controversy persists regarding the incidence, pathogenesis, and treatment of this syndrome. The main disagreements center on the actual association of aortic stenosis and angiodysplasia, though other controversies include the pathogenesis of Heyde's syndrome, ranging from von Willebrand factor deficiency and age-related degeneration to mucosal ischemia and cholesterol embolization. A variety of treatment modalities of the syndrome has been applied, including medical management, endoscopic therapy, embolization, and aortic valve replacement. Here, the controversies surrounding Heyde's syndrome, which focus on pathogenesis and treatment, are reviewed with the aim of providing a clearer understanding of the syndrome and the implications for patient care.

Intraventricular and papillary muscle dyssynchrony is related to the diastolic phase of functional mitral regurgitation in patients with non-ischemic dilated cardiomyopathy.

BACKGROUND AND AIM OF THE STUDY: Functional mitral regurgitation (FMR) is commonly encountered in patients with heart failure, and is associated with an adverse prognosis. It is hypothesized that left ventricular (LV) and papillary muscle systolic dyssynchrony causes diastolic mitral regurgitation (DMR) in non-ischemic dilated cardiomyopathy (DC) patients. METHODS: A total of 77 patients with non-ischemic DC was enrolled, of whom 25 were without DMR (group I) and 52 with DMR (group II). Mitral valve apparatus measurements were calculated using two-dimensional echocardiography, while LV/papillary muscle (Pap-index) systolic dyssynchrony parameters were calculated using tissue Doppler echocardiography. RESULTS: The FMR volumes were similar between the two groups (19.4 +/- 10.6 and 22.4 +/- 11.1 ml/beat in groups I and II, respectively). Both groups had similar mitral valves, as assessed by the geometry of the mitral valve apparatus parameters, including tent area, mitral annulus diameter, and tethering distance. However, the maximal intraventricular mechanical delay (MIMD; p < 0.001), peak (+/- SD) myocardial sustained systolic velocity (Ts-SD; p < 0.001) and Pap-index (p < 0.001) were each significantly increased in group II. Strong correlations were apparent between DMR and dyssynchrony parameters [(Ts-SD; r = 0.74, p < 0.001), MIMD (r = 0.78, p < 0.001) and Pap-index (r = 0.78, p < 0.001)]. Linear regression analysis revealed the MIMD (OR 2.94, 95% CI 2.7-6.6, p < 0.001), Ts-SD (OR 3.6, 95% CI 1.2-3.5, p < 0.001) and Pap-index (OR 2.2, 95% CI 1.27-1.35, p = 0.001) to be independent predictors of DMR. CONCLUSION: In patients with non-ischemic DC, DMR may serve as a useful indicator of mechanical LV/papillary muscle dyssynchrony, especially when used in combination with the other echocardiographic parameters.

Echocardiographic epicardial fat thickness is associated with carotid intima-media thickness in patients with metabolic syndrome.

BACKGROUND: Carotid intima-media thickness (CIMT) is a potential indicator of subclinical atherosclerosis in patients with metabolic syndrome (MetS). Epicardial fat thickness (EFT) is suggested as a new cardiometabolic risk factor. We investigated the association between EFT and CIMT in patients with MetS. METHODS: Forty patients with MetS were compared with 40 age- and sex-matched subjects without MetS in terms of echocardiographic EFT, CIMT, anthropometric measurements, and metabolic profile in this cross-sectional study. RESULTS: The waist circumference, total and LDL-cholesterol, fasting glucose, triglycerides, systolics and diastolic blood pressure levels, hs-CRP, and homeostasis model assessment index for insulin resistance (HOMA-IR) were significantly increased in patients with MetS. The EFT and CIMT were also increased significantly in patients with MetS compared to controls (7.2 ± 2 mm vs. 5.7 ± 1.9 mm; P = 0.001, 0.74 ± 0.1 mm vs. 0.59 ± 0.1 mm; P < 0.01, respectively). Echocardiographic EFT was the only independent predictor of CIMT in the multivariate analysis (standardized ß coefficient = 0.74, P < 0.001). CONCLUSION: EFT is associated with increased CIMT in patients with MetS.

Fragmented QRS complexes are associated with cardiac fibrosis and significant intraventricular systolic dyssynchrony in nonischemic dilated cardiomyopathy patients with a narrow QRS interval.

BACKGROUND: Myocardial scar causes heterogeneous ventricular activation, which results in fragmentation of QRS complexes on ECG. Myocardial fibrosis in patients with nonischemic cardiomyopathy (NDCM) can be identified as late gadolinium enhancement (LGE) areas on cardiac magnetic resonance (CMR) studies. We investigated the association of fragmented QRS (fQRS) complexes with systolic dyssynchrony and myocardial fibrosis in patients with NDCM. METHODS: Twenty patients with NDCM and sinus rhythm who had fQRS complexes were evaluated with CMR. The association of fQRS complexes with LGE and systolic dyssynchrony was investigated. RESULTS: Nineteen patients had significant systolic dyssynchrony with echocardiography. Among 19 patients with significant dyssynchrony, 14 (74%) patients had fQRS complexes in the most delayed contracting segment or one of the dyssynchronous segments, whereas five patients (26%) had fQRS complexes in a lead which is discordant with the dyssynchronous segment on echocardiography. Seventeen patients had LGE in their CMR. Among the 17 patients with LGE; 13 patients (76%) had fQRS complexes concordant with LGE present segments. CONCLUSION: Fragmentation of QRS complexes on ECG is associated with intraventricular systolic dyssynchrony and subendocardial fibrosis in NDCM patients with a narrow QRS interval and sinus rhythm.

The role of isovolumic acceleration in predicting subclinical right and left ventricular systolic dysfunction in hypertensive obese patients.

OBJECTIVES: Isovolumic acceleration assessed by tissue Doppler imaging has been proposed as a preload-independent indicator of left ventricular contractility. We investigated the utility of isovolumic acceleration in the prediction of preclinical right and left ventricular systolic dysfunction in hypertensive and obese subjects. STUDY DESIGN: Seventy-eight obese subjects (BMI >30 kg/m2; 57 women, 21 men; mean age 51±8 years) were prospectively enrolled. Fifty patients (64.1%) had hypertension and 33 patients (42.3%) had diabetes mellitus. All the subjects were assessed by conventional and tissue Doppler echocardiography. Myocardial velocities of the left ventricular septal and lateral mitral annulus and lateral tricuspid annulus were determined. Isovolumic contraction wave was defined as the preceding wave of the systolic wave that began before the peak of the R wave on the electrocardiogram. Myocardial isovolumic acceleration was measured by dividing the peak velocity by the time passed from the onset of the wave (zero-crossing) during isovolumic contraction to the peak velocity of the wave. RESULTS: Waist circumference was in positive correlation with left ventricular end-systolic (r=0.22, p=0.047) and end-diastolic (r=0.384, p=0.001) diameters, and in negative correlation with the peak systolic velocity of the tricuspid annulus (r=-0.311, p=0.006). Although hypertensive and normotensive (n=28) obese subjects had similar myocardial velocities, lateral tricuspid annular isovolumic acceleration (p=0.027), septal isovolumic acceleration (p=0.026), and septal isovolumic contraction myocardial velocity (p=0.018) were significantly lower in hypertensive patients. CONCLUSION: Isovolumic acceleration and isovolumic contraction myocardial velocity analysis may be useful in the diagnosis of subclinical left and right ventricular dysfunction in hypertensive obese patients.

[Comparison of psychosocial risk factors between patients who experience acute myocardial infarction before and after 40 years of age]. / Kirk yas altinda ve üzerinde akut miyokart enfarktüsü geçiren hastalarda psikososyal risk faktörlerinin karsilastirilmasi

OBJECTIVES: Several studies have shown that psychosocial risk factors such as stress and depression make substantial contribution to the pathogenesis of coronary artery disease. This study aimed to investigate acute stress factors prior to acute myocardial infarction (AMI), and stress, depression, and anxiety levels during the subacute period in AMI patients aged ≤ 40 years, in comparison with AMI patients aged >40 years. STUDY DESIGN: The study included 200 first-time AMI patients aged ≤ 40 years (n=100; mean age 35 ± 4 years) and >40 years (n=100; mean age 54 ± 9 years). The DASS 21 scale (Depression Anxiety Stress Scales) was administered via face-to-face interviews in the early recovery period of AMI. The patients were also questioned whether they had experienced acute stress factors such as severe emotional or physical stressful events within two hours before the onset of chest pain. In addition, coronary angiography results were assessed based on the two age groups. RESULTS: Comparison of the two age groups showed significantly higher frequencies of family history of CAD and smoking in the younger group, and significantly higher frequencies of hypertension, diabetes mellitus, and dyslipidemia in the older group (p<0.05). History of acute stress factors was significantly more common (52% vs. 20%, p<0.01) and stress, depression, and anxiety scores of the DASS 21 scale were all significantly higher in the younger group (p<0.01). On coronary angiography, younger patients predominantly had normal coronary arteries and single-vessel disease, whereas multi-vessel disease was more prevalent in the older age group (p<0.01). CONCLUSION: Triggers of acute stress and psychosocial risk factors may contribute to the occurrence of AMI in individuals younger than 40 years.

Radial artery access as an emerging factor for decreasing mortality in cardiovascular interventions.

Transradial access for coronary interventions provides increased patient comfort, fewer access site complications, and reduced hospital stay and costs. However, the potential benefits favoring transradial access may be even more than these apparent advantages. Major bleeding after coronary interventions is an important factor contributing to mortality rates and can be dramatically reduced with the selection of the radial artery as the access site. Recent evidence suggests that the decrease in bleeding complications with transradial access may translate into a short- and long-term decrease in mortality in patients undergoing elective or urgent coronary interventions. In the era of complex coronary interventions with use of multiple antiplatelet and antithrombotic treatment regimens, the simple choice of transradial access for increasing patient comfort and decreasing bleeding complications and mortality is promising.

The importance of papillary muscle dyssynchrony in predicting the severity of functional mitral regurgitation in patients with non-ischaemic dilated cardiomyopathy: a two-dimensional speckle-tracking echocardiography study.

AIMS: In our study, we investigated the impact of papillary muscle systolic dyssynchrony (DYS-PAP) and the configuration of mitral leaflets in the prediction of significant functional mitral regurgitation (MR) with two-dimensional (2D) speckle-tracking strain analysis in non-ischaemic dilated cardiomyopathy (DCM) patients with sinus rhythm. METHODS: Thirty-six non-ischaemic DCM patients (left ventricular ejection fraction <40%) with sinus rhythm were recruited. The quantification of functional MR was performed using the proximal isovelocity surface area method. The configuration of mitral leaflets [mitral annulus, coaptation height (CH), and tethering distances for papillary muscles] was evaluated in the parasternal long-axis and apical four-chamber views. The assessment of DYS-PAP was performed by applying 2D speckle-tracking imaging to the apical four-chamber view for anterolateral papillary muscle and to the apical long-axis view for posteromedial papillary muscle. RESULTS: Fifteen (41.6%) patients had mild MR and 21 (58.3%) patients had moderate or moderate-to-severe MR. Patients with higher levels of MR had larger mitral annulus size (P = 0.02), tethering-AL (P = 0.04), higher MR volume (P < 0.0001), effective regurgitant orifice area (P < 0.0001), and DYS-PAP (P < 0.0001) values, but lower CH (P = 0.001), global longitudinal (P = 0.005), radial (P = 0.03), and circumferential strain (P = 0.01) than those with mild MR. Receiver operating characteristic analysis was performed to assess the utility of DYS-PAP to predict moderate or moderate-to-severe functional MR. A DYS-PAP value >30 ms predicted moderate-to-severe MR with 85% sensitivity and 87% specificity [area under the curve: 0.897, 95% confidence interval (CI): 0.781-0.999, P < 0.0001]. Logistic regression analysis revealed that DYS-PAP (odds ratio: 3.2, 95% CI: 1.22-47.7, P = 0.037) was the only independent predictor of moderate or moderate-to-severe functional MR. CONCLUSION: DYS-PAP is correlated with functional MR in non-ischaemic DCM patients with sinus rhythm. A DYS-PAP cut-off value of 30 ms is a useful tool to identify patients with moderate-to-severe functional MR.

Treatment of prosthetic valve thrombosis: rationale for a prospective randomized clinical trial.

BACKGROUND AND AIM OF THE STUDY: Prosthetic valve thrombosis (PVT) is a serious complication that may cause significant morbidity and mortality. Despite advances in valve technology, patient education and adequate anticoagulation, the risk of PVT persists indefinitely. Certain clinical and prothrombotic states, including atrial fibrillation, insufficient anticoagulation and pregnancy, predispose these patients to develop PVT. The optimal treatment of the condition is controversial, and to date no randomized clinical trials have been conducted to assist in decision making. Consequently, the guidelines lack definitive Class I recommendations, have significant disparities, and--in most cases--leave the decision to the clinician's experience. METHODS: A review of the studies, guidelines, and expert opinions on the treatment of PVT was conducted, and treatment recommendations made for obstructive and non-obstructive thrombotic cases, based on the results of the recent reports. RESULTS: Although surgical therapy has been the traditional therapeutic approach, studies with low-dose and slow-infusion rates of thrombolytic agents have revealed excellent results in these patients. Surgery should be considered first in patients with left atrial thrombus, active bleeding, and within the first four days after valve replacement. Patients with nonobstructive PVT can initially be managed with an intensification of anticoagulation. CONCLUSION: The management of PVT remains controversial. Clearly, a prospective randomized clinical trial is required, and this could be achieved by developing an international database for patient enrollment and randomization into available treatment strategies.

Severe tricuspid regurgitation in a patient receiving low-dose cabergoline for the treatment of acromegaly.

Cabergoline, an ergot-derived dopamine receptor agonist, is used widely in the treatment of Parkinson's disease (PD) and hyperprolactinemia, but may cause heart valve fibrosis, retraction, and clinically significant regurgitation in PD patients. While cabergoline has been used at much lower doses in patients with hyperprolactinemia, controversy persists as to whether it may cause heart valve disease in this situation. Cabergoline is also used in acromegaly at doses similar to those used in hyperprolactinemia. The case is reported of a female patient with acromegaly who had been taking low-dose (0.5 mg/day) cabergoline for one year, and presented with signs and symptoms of right-sided heart failure. Echocardiography revealed a thickened and retracted tricuspid valve associated with severe tricuspid regurgitation and enlargement of the right-heart chambers. The morphology of the tricuspid valve was typical for cabergoline-related valvulopathy. Cabergoline may not be totally safe even at lower doses, and close echocardiographic monitoring is recommended in patients receiving cabergoline treatment, regardless of the dose level employed.

Gender differences in platelet aggregation in healthy individuals.

This study evaluated gender variability in platelet aggregation in response to common agonists. Platelet aggregation was measured in 36 healthy men and women free of any antiplatelet medication, aged 22-36 years, of Caucasian (White not of Hispanic origin), Hispanic, and African-American not of Hispanic origin. In this ex-vivo study, we investigated platelet aggregation in response to adenosine-5'-diphosphate (ADP), epinephrine (EPI), arachidonic acid (AA) and collagen (COL), using a platelet ionized calcium aggregometer (Chrono-Log Co.). Platelet aggregation response to all tested agonists was higher in females than in males regardless of ethnicity. The most significant differences were observed with collagen (P < 0.01). Among the ethnic groups, Caucasian women were most prone to platelet aggregation. Gender is a determinant of agonist effects on platelet aggregability in healthy subjects.