Expert proposal to characterize cardiac diseases with normal or preserved left ventricular ejection fraction and symptoms of heart failure by comprehensive echocardiography.

Currently, the term "heart failure with preserved left ventricular ejection fraction (HFpEF)" is based on echocardiographic parameters and clinical symptoms combined with elevated or normal levels of natriuretic peptides. Thus, "HFpEF" as a diagnosis subsumes multiple pathophysiological entities making a uniform management plan for "HFpEF" impossible. Therefore, a more specific characterization of the underlying cardiac pathologies in patients with preserved ejection fraction and symptoms of heart failure is mandatory. The present proposal seeks to offer practical support by a standardized echocardiographic workflow to characterize specific diagnostic entities associated with "HFpEF". It focuses on morphological and functional cardiac phenotypes characterized by echocardiography in patients with normal or preserved left ventricular ejection fraction (LVEF). The proposal discusses methodological issues to clarify why and when echocardiography is helpful to improve the diagnosis. Thus, the proposal addresses a systematic echocardiographic approach using a feasible algorithm with weighting criteria for interpretation of echocardiographic parameters related to patients with preserved ejection fraction and symptoms of heart failure. The authors consciously do not use the diagnosis "HFpEF" to avoid misunderstandings. Central illustration: Scheme illustrating the characteristic echocardiographic phenotypes and their combinations in patients with "HFpEF" symptoms with respect to the respective cardiac pathology and pathophysiology as well as the underlying typical disease.

[Are neurohumoral parameters predictive for the efficacy of cardiac resynchronization therapy? The role of natriuretic peptides]. / Sind neurohumorale Blutparameter wegweisend für die Effizienz der kardialen Resynchronisationstherapie? Die Rolle der natriuretischen Peptide.

During recent years, heart failure has been recognized as a complex disease involving both hemodynamic abnormalities caused by reduced contractile forces and neurohormonal changes characterized by an increase in sympathetic tone and an activation of the renin-angiotensin-aldosterone system as well as the endothelial pathways. Neurohumoral factors represent the natural response of the individual to heart failure. Among them natriuretic peptides, i. e., brain natriuretic peptide (BNP) and amino-terminal pro BNP (Nt-proBNP) release have recently been shown to be a reliable and rapid marker for diagnosis, optimization of pharmacological treatment and risk stratification in heart failure patients. This article summarizes important aspects of the release of natriuretic peptides as a guide for diagnosis, therapy and prognosis of patients with heart failure and cardiac resynchronization therapy.

Impact of cardiac resynchronization therapy using hemodynamically optimized pacing on left ventricular remodeling in patients with congestive heart failure and ventricular conduction disturbances.

OBJECTIVES: We sought to investigate the impact of six months of cardiac resynchronization therapy (CRT) on echocardiographic variables of left ventricular (LV) function. BACKGROUND: Cardiac resynchronization therapy has recently been introduced as a new therapeutic modality in patients with advanced heart failure (HF) and conduction abnormalities. However, most studies have only investigated the early hemodynamic effects of CRT. METHODS: Twenty-five patients (12 women and 13 men; 59.8 +/- 5.1 years old) with advanced HF caused by ischemic (n = 7) or idiopathic dilated cardiomyopathy (n = 18) and a prolonged QRS complex were analyzed. All patients underwent early hemodynamic testing with a randomized testing protocol; echocardiographic measurements were compared before implantation and after six months of CRT. RESULTS: Left ventricular end-diastolic and end-systolic diameters (LVEDD and LVESD, respectively) were significantly reduced after six months (LVEDD from 71 +/- 10 to 68 +/- 11 mm, p = 0.027; LVESD from 63 +/- 11 to 58 +/- 11 mm, p = 0.007), as were LV end-diastolic and end-systolic volumes (LVEDV from 253 +/- 83 to 227 +/- 112 ml, p = 0.017; LVESV from 202 +/- 79 to 174 +/- 101 ml, p = 0.009). Ejection fraction was significantly increased (from 22 +/- 7% to 26 +/- 9%, p = 0.03). "Nonresponders," with regard to LV volume reduction, had significantly higher baseline LVEDV, compared with "responders" (351 +/- 52 vs. 234 +/- 74 ml, p = 0.018). Overall, there was only mild mitral regurgitation at baseline, with a minor reduction by semiquantitative analysis. The results of early hemodynamic testing did not predict the volume response. CONCLUSIONS: Cardiac resynchronization therapy may lead to a reduction in LV volumes in patients with advanced HF and conduction disturbances. Volume nonresponders have significantly higher baseline LVEDV.

[Improved identification of suitable patients for cardiac resynchronization therapy by transthoracic echocardiography]. / Verbesserte Identifizierung geeigneter Kandidaten für die kardiale Resynchronisationstherapie mittels transthorakaler Echokardiographie.

Transthoracic echocardiography provides numerous options for the evaluation and quantification of contractile cardiac asynchrony in patients with advanced heart failure. Important information on the presence of asynchrony can be obtained already during a standard routine examination with conventional techniques (2D, M-mode and Doppler). Newer techniques such as tissue Doppler imaging and real-time 3D-echocardiography enable us to better quantify the degree of asynchrony. The following article describes the echocardiographic features of asynchrony and algorithms for the improved identification of suitable patients for cardiac resynchronization therapy.

Echocardiographic evidence of hemodynamic and clinical improvement in patients paced for heart failure.

Dilated cardiomyopathy is frequently associated with electrical conduction disturbances. Development of left bundle-branch block with discoordinated ventricular contraction pattern further contributes to impaired hemodynamic performance. Biventricular pacing has evolved as a new treatment option for patients with dilated cardiomyopathy and conduction disturbances. The "electrical" approach aims to normalize the disturbed contraction pattern, thereby improving hemodynamic function by simultaneous stimulation at different ventricular sites. Acute hemodynamic improvement with biventricular pacing has been demonstrated in patients with depressed left ventricular function and delayed intraventricular conduction. Due to the variations in optimal pacing site and atrioventricular delay, individual optimization to achieve optimal hemodynamic benefit is necessary. Echocardiography has the potential to provide hemodynamic data by Doppler techniques and combine these with geometric information about ventricular volumes, ejection fraction, and contraction patterns. This article focuses on the use of echocardiographic techniques for noninvasive optimization in cardiac pacing and presents preliminary experience from the initial trials on multisite pacing in heart failure.

Potential benefit of biventricular pacing in patients with congestive heart failure and ventricular tachyarrhythmia.

Treatment of congestive heart failure (CHF) aims for symptomatic relief and reduction of mortality both from sudden death and pump failure. The implantable cardioverter defibrillator (ICD) is highly effective in the prevention of sudden death, but no mortality benefit in advanced CHF has yet been shown. Biventricular pacing may lead to functional improvement in selected patients with CHF. Thus, a biventricular pacemaker with defibrillation capabilities may be ideal for patients with advanced CHF. We retrospectively analyzed the data from 384 patients (age 59 +/- 12 years, 322 male and 62 female) with regard to New York Heart Association (NYHA) CHF class, mean QRS duration, mean PR interval, presence of a QRS > 120 msec and incidence of atrial fibrillation at the time of ICD implantation. Based on eligibility criteria from studies in biventricular pacing, we analyzed how many patients may benefit from biventricular pacing. Patients with CHF were older (NYHA class III: 60.9 +/- 9.7, class II: 61.3 +/- 10 versus class I: 50.8 +/- 13.6 years, p < 0.001 each) and mean QRS duration was longer with advanced CHF (NYHA class III 127.8 +/- 30 msec; class II 119.4 +/- 27.7 msec; class 0-1: 103.9 +/- 17.7 msec, p < 0.001, analysis of variance) as was the mean PR interval (NYHA class III 189.9 +/- 33.5 msec; class II 176.1 +/- 29.3 msec; class 0-1 162.7 +/- 45.9 msec, p < 0.001, analysis of variance). The incidence of atrial fibrillation was higher in class III (25.5%) compared with class 0-1 (16.9%) and class II patients (14.1%, p = 0.043, chi-square test). A total of 28 patients (7.3%) fulfilled eligibility criteria for biventricular pacing if NYHA class III patients were considered candidates and 48 (12.5%) if patients with NYHA II CHF and ejection fraction < or = 30% were included. Thus, biventricular pacing may offer a promising therapeutic approach for a significant proportion of patients with CHF at risk for ventricular tachyarrhythmia.

Non-contrast second harmonic imaging improves interobserver agreement and accuracy of dobutamine stress echocardiography in patients with impaired image quality.

OBJECTIVE: To examine the influence of second harmonic imaging during dobutamine echocardiography on regional endocardial visibility, interobserver agreement in the interpretation of wall motion abnormalities, and diagnostic accuracy in patients with reduced image quality. DESIGN: Blinded comparison. SETTING: Tertiary care centre. PATIENTS: 103 consecutive patients with suspected coronary artery disease and impaired transthoracic image quality (>/= 2 segments with poor endocardial delineation). METHODS: Fundamental and second harmonic imaging were performed at each stage of a dobutamine stress echocardiography. Coronary angiography was undertaken within three weeks of dobutamine echocardiography in 75 patients. MAIN OUTCOME MEASURES: Evaluation of regional endocardial visibility (scoring from 0 = poor to 2 = good) and of segmental wall motion abnormalities for both modalities separately. A second blinded examiner analysed 70 studies to determine interobserver agreement. RESULTS: Mean (SD) visibility score for all segments was 1.2 (0.4) using fundamental imaging and 1.7 (0.2) using second harmonic imaging at rest (p < 0.001), and 1.1 (0.4) v 1.6 (0.3), respectively, at peak dobutamine dose (p < 0.001). The average number of segments with poor endocardial visibility was lower for second harmonic than for fundamental imaging (0.6 (1.1) v 3.8 (2.6) at rest, p < 0.001; 0.9 (1.3) v 4.3 (2.9) at peak dose, p < 0.001). Improvement was most pronounced in all lateral and anterior segments. The kappa value for identical study interpretation increased from 0. 40 to 0.69 (p < 0.05). Sensitivity for the diagnosis of coronary artery disease was 64% using fundamental imaging versus 92% using harmonic imaging (p < 0.001), while specificity remained unchanged at 75% for both imaging modalities. CONCLUSIONS: Second harmonic imaging enhances endocardial visibility during dobutamine echocardiography. Consequently, interobserver agreement on stress echocardiography interpretation and diagnostic accuracy are significantly improved compared to fundamental imaging. Thus, in difficult to image patients, dobutamine echocardiography should be performed using second harmonic imaging.

Clinical outcome and quality of life after interventional treatment of left main disease with drug-eluting-stents in comparison to CABG in elderly and younger patients.

INTRODUCTION: The aim of this study was to prospectively assess the clinical outcome and quality of life of elderly patients who underwent either coronary artery bypass grafting (CABG) or percutaneous coronary intervention (PCI) with drug-eluting stents (DES) for treatment of significant left main disease (LMD) compared to a younger patient population. METHODS: Consecutive patients, admitted into our institution between 04/2004 and 12/2007 with LMD and a life expectancy of >1 year were prospectively included and stratified in two groups (either CABG or left main stenting [LMS] with DES) based on the patients' age at inclusion (> or ≤75 years). Rates of death, myocardial infarction (MI), stroke, and target lesion revascularization (TLR) were evaluated over a 12 month follow-up. Six months after the initial procedure, additionally, quality of life was assessed using the SF-36 questionnaire. RESULTS: A total of 300 patients was included; 56 of the 95 PCI patients (59%) were ≤75 years and 39 (44%) >75 years, whereas 155 of 205 patients in the CABG group were ≤75 years (76%), and 50 patients (24%) were >75 years. Mean follow-up was 312 ± 226 days in the PCI and 377 ± 286 in the CABG group. Rates of death and MI were not significantly different between the four groups at the end of follow-up. There was no difference in quality of life after 6 months. CONCLUSION: In this prospective trial, PCI of LM with DES in elderly patients was feasible with a short- and intermediate term outcome comparable to CABG procedure and to a younger patient cohort.

Influence of age on pain perception in acute myocardial ischemia: a possible cause for delayed treatment in elderly patients.

BACKGROUND: Elderly patients tend to seek later for medical help during myocardial infarction. This may be caused by impaired pain perception with ageing. The aim of our study was to prospectively evaluate age-dependent differences in pain perception during temporary induced coronary ischemia. METHODS: In 102 patients (68 male, age 68±11 years) undergoing percutaneous coronary intervention, ischemia was induced by balloon inflation for up to 120 s. Time to onset of perceived pain, pain characteristics and pain severity (0=no pain, 100=worst pain possible) was registered. This was repeated twice to evaluate ischemic preconditioning. A 12 lead ECG-tracing was simultaneously recorded. Patients were divided by their median age into 2 groups with comparable demographics: ≤69 years (group 1) and >69 years (group 2). RESULTS: Group 1 patients demonstrated earlier onset of pain (most apparent during the second inflation: 31±15 s vs. 46±26 s; p<0.001), and greater pain severity (inflation #1: 64±21 vs. 51±25 [p=0.017]; #2: 66±23 vs.52±27 [p=0.008]; #3: 63±23 vs. 54±24 [p=0.085]). ST-changes did not differ (0.24±0.10 vs. 0.20±0.14, [p=0.18]; 0.27±0.17 vs. 0.20±0.14, [p=0.11]; 0.19±0.13 vs. 0.16±0.09; [p=0.32]). Time from occlusion to onset of ECG changes did not differ between the groups, but increased with repetitive inflations (inflation #1: 29±11 s vs. 29±11 s; #2: 31±14 vs. 33±11; #3: 39±21 vs. 40±15 s [increase p=0.017; p<0.001]). CONCLUSION: These data suggest that the perception of pain from myocardial ischemia in the elderly is significantly less severe and delayed compared to younger patients.

[Tissue Doppler imaging of the fetal heart--a new parametric ultrasound technique in prenatal medicine]. / Tissue Doppler Imaging am fetalen Herzen--eine neue parametrische Ultraschalltechnik in der pränatalen Medizin.

Tissue Doppler imaging is a new ultrasound technique for the acquisition and analysis of myocardial velocity and deforming parameters in the human heart. In cardiology this innovative technique is used to identify ischemic regions and stunned areas after cardiac infarction and to diagnose dyssynchrony. In the last two years, our research group has been using this technique extensively on fetal hearts. It is possible to establish the fetal cardiac cycle clearly just by analyzing the typical courses of myocardial velocity curves. The quality of the curves is comparable to the results in adult cardiology. Consequently, many innovative analysis options can be acquired, e.g., the comparison of the kinetics of several myocardial regions in the cardiac cycle, the determination of pre- and post-systolic intervals (isovolumic contraction time, isovolumic relaxation time), the evaluation of diastolic function by analyzing the E(m) and A(m) waves and the detection of the atrial contraction. These parameters are currently used in cardiology for extended function analysis. Tissue Doppler imaging is the first step in parametric imaging of the fetal heart and consequently marks the beginning of a new era in fetal echocardiography.

Detection of early systolic dysfunction with strain rate imaging in a patient with light chain cardiomyopathy.

Congestive heart failure (CHF) in cardiac amyloidosis has been attributed to the development of diastolic dysfunction, because severe CHF symptoms have been observed despite a normal or only mildly reduced LV ejection fraction (EF). An early impairment of longitudinal systolic function has been described by means of tissue Doppler-derived myocardial deformation imaging ('strain rate imaging', SRI). Our patient presented with signs of CHF and significantly increased brain-natriuretic peptide (BNP) levels. Conventional measures of systolic contractile function were within the normal range and mitral inflow Doppler showed only moderate diastolic dysfunction. Histopathological examination by endomyocardial biopsy revealed interstitial deposition of amyloid fibers. Quantitative assessment of myocardial velocities (TDI) and deformation properties (Strain) from the apical view demonstrated a significant impairement of systolic longitudinal myocardial function. In patients with isolated diastolic dysfunction detected by conventional Doppler echocardiography, the quantitative assessment of myocardial strain and strain rate can be helpful in the early detection of systolic dysfunction.

Brain natriuretic peptide release in cardiac surgery patients.

Brain natriuretic peptide (BNP) release is a marker of increased myocardial wall tension, which is elevated in patients with disturbed left ventricular function. As it is increasingly being used as a reliable marker for diagnosis, optimization of pharmacological treatment, and risk stratification, BNP measurement might be also relevant for patients undergoing cardiac surgery. Measured BNP levels can be used to predict postoperative complications and the risk of further cardiac events. Preoperative BNP levels support the decision for the timing of aortic valve replacement in asymptomatic severe aortic stenosis. An increase in BNP levels early predicts allograft rejection after cardiac transplantation or ineffective cardiac resynchronization therapy. Moreover, BNP levels can be used to differentiate between cardiac and non-cardiac reasons for acute dyspnea in the management of surgical patients. Finally, the application of recombinant human BNP seems to improve recovery after cardiac surgical procedures. Thus, BNP can be a helpful tool for monitoring and treating patients before, during, and after cardiac surgery to predict and improve the effectiveness of therapy and reduce hospitalization and costs.

Established and evolving indications for cardiac resynchronisation.

Randomised trials involving large number of patients have demonstrated the benefits of cardiac resynchronisation therapy (CRT) in patients with heart failure who have failed optimal medical treatment. Echocardiography plays an important role in defining dyssynchrony which is key to optimal patient selection. The electrocardiographic criteria for patient selection is supplemented by the finding of dyssynchrony on Doppler myocardial imaging, and echocardiography with Doppler myocardial imaging may eventually replace the electrocardiographic criteria for selection of patients who derive benefit from CRT.

[Life threatening acute complications of dobutamine-atropine stress echocardiography--a case report]. / Lebensbedrohliche Akut-Komplikationen der Dobutamin-Atropin-Stressechokardiographie--ein kasuistischer Beitrag.

The presented case report describes lifethreatening complications of pharmacological stress echocardiography with dobutamine. A 66-year old male suffered an acute anterior wall myocardial infarction during dobutamine atropine stress echocardiography. Symptoms and signs of myocardial infarction developed after maximal dobutamine-dose (40 micrograms/kg/min) and the additional application of atropine. Emergency coronary angiography revealed extensive coronary artery disease with proximal occlusion of the left anterior descending artery which was successfully recanalized. In a second patient ventricular fibrillation echocardiography and electrocardiographic signs of acute myocardial ischemia developed after high-dose dobutamine stress and required prolonged resuscitation. The possible mechanisms, incidence and risk of acute myocardial ischemia during dobutamine-atropine stress are discussed and compared to bicycle ergometry. The presented life threatening complications of dobutamine-atropine stressechocardiography emphasize the important of available and adequate emergency facilities.

Successful thrombolysis of right atrial and ventricle thrombi encircling a temporary pacemaker lead in a patient with heparin-induced thrombocytopenia type II.

Only few reports exist addressing the problem of temporary pacemaker leads associated with thromboembolic disease. We report the case of a 67-year-old patient who required a temporary transfemoral pacemaker due to AV block grade III. The patient developed extensive right atrial and ventricle thrombus formation attached to the pacing wire, as well as venous thrombosis at the insertion site due to heparin-induced thrombocytopenia type II (HIT type II). After short-term thrombolysis with 1 mg rt-PA/kg b.w. complete resolution of all clots could be shown by B-mode sonography and transthoracic, as well as transesophageal echocardiography.

Mid-systolic septal deceleration. A new sign of left ventricular outflow tract obstruction obtained by color-coded tissue Doppler echocardiography.

Hypertrophic obstructive cardiomyopathy (HOCM) is characterized by the presence of a dynamic left ventricular outflow tract gradient. We studied septal longitudinal motion by color coded tissue Doppler echocardiography in a 69-year old HOCM patient during and after catheter based treatment by trans coronary alcohol ablation of septal hypertrophy. The presence of dynamic left ventricular outflow tract obstruction was associated with a characteristic abrupt mid-systolic septal deceleration pattern in the tissue Doppler velocity trace. Five weeks after treatment, this pattern was no longer visible at rest.