Value of latent outflow obstruction to predict clinical course of patients with hypertrophic cardiomyopathy.

Objective The frequency, significance and prognostic value of left ventricle obstruction (LVO) induced with provocation (latent LVO) is controversial for hypertrophic cardiomyopathy (HC) patients. This study was designed to assess the value of latent LVO in predicting the clinical course in 101 patients with HC. Methods and results Patients were followed for a mean of 82 ± 48 months (range 2 to 148 months) for clinical end points defined as a composite of cardiovascular death resuscitated cardiac arrest, appropriate defibrillator shock or hospitalization due to worsening of heart failure symptoms. Presence of LVO (hazard ratio 3.63; 95% confidence interval, 1.85 to 7.12; P = 0.0001) and log NT-proBNP levels (hazard ratio, 1.40; 95% confidence interval, 1.14 to 1.72; P = 0.001) were the independent variables associated with an increased risk of experiencing clinical end points. HC patients with latent LVO have a trend toward decreased survival when compared with HC patients without LVO (log rank P = 0.027), but better survival than patients with resting LVO (log rank P = 0.007). HC patients with NT-proBNP levels <1,000 pg/ml had also better survival. LVO and NT-proBNP levels are the major determinants of clinical end points in patients with HC. Conclusions Evaluation of patients without resting LVO to demonstrate latent obstruction is of critical importance in respect of outcome and selection of patients for septal reduction therapies, so routine provocative testing with physiological exercise and measurement of NT-proBNP is recommended in this patient population for risk stratification.

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.

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.

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.

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.

Incidence and predictors of radial artery spasm at the beginning of a transradial coronary procedure.

OBJECTIVES: Our aim was to establish the frequency of radial artery spasm (RAS) and its predictors at the beginning of a transradial approach (TRA). METHODS: This was a single-center prospective study. A total of 1,722 consecutive patients undergoing their first transradial coronary procedure were recruited. After radial artery puncture, a hydrophilic sheath was used to complete arterial puncture, then 500 µg glycerol trinitrate and 2.5 mg verapamil were injected into radial artery along the sheath. After retrograde radial arteriography spasm was defined angiographically as a stenosis greater than 25%. Patient demographics, procedural data such as total procedural duration, the number of catheters and guidewires used, the amount of contrast media usage, dose area product (DAP) and fluoroscopy time, and vascular complications were recorded. RESULTS: The overall spasm incidence was 10.3%. The procedural success rate was lower in patients with spasm than in patients without spasm (80% vs. 95.7%, P < 0.001). The patients with spasm were older (mean age 63.9 ± 9.4 years vs. 60.0 ± 11.2 years, P < 0.001) and more commonly female (51.3% vs. 34.4%, P < 0.001). Spasm was more common in hypertensive patients (66% vs. 56%, P < 0.009). Surprisingly, smoking was less common in patients with spasm (17% vs. 29%, P < 0.001). Multiple logistic regression analysis showed that female gender (OR = 1,524, 95% CI: 1.033-2.248, P = 0.034) was the only independent predictor of RAS at the beginning of the procedure. CONCLUSIONS: The incidence of RAS was 10,3%, and female gender was the sole independent predictor of RAS at the very beginning of the procedure in patients undergoing a TRA.

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.

Role of left ventricular dyssynchrony in predicting remodeling after ST elevation myocardial infarction.

BACKGROUND: Intraventricular dyssynchrony is associated with worsening systolic function, adverse remodeling, and clinical events. The aim of this study is to investigate whether intraventricular dyssynchrony assessed by tissue Doppler imaging (TDI) can predict left ventricular (LV) remodeling after first ST segment elevation myocardial infarction (STEMI) treated successfully with primary percutaneous coronary intervention (pPCI). METHODS: Fifty-two consecutive patients who presented with first acute STEMI were included in the study. All patients underwent successful pPCI. Standard echocardiography was performed within 48 hours of admission. LV dyssynchrony was assessed by color-coded TDI. Dyssynchrony (Ts-diff) was calculated by maximal temporal difference between time to peak systolic velocities (Ts) of six basal segments. Echocardiographic examination was repeated after 6 months to reassess LV volumes. LV remodeling was defined as >15% increase in LV end-systolic volume index (LVESVI) after 6 months. RESULTS: Eleven patients (23%) developed LV remodeling. Baseline dyssynchrony was found to be correlated with percent change in LVESVI and LV end-diastolic volume index (LVEDVI) after 6 months. Ts-diff, creatine kinase-MB and mitral inflow E-wave deceleration time (DT) were the independent predictors of remodeling after STEMI in multivariate logistic regression analysis. Receiver operating characteristic curve analysis showed that Ts-diff >56 msec had 72.7% sensitivity and 83.8% specificity for predicting remodeling. CONCLUSIONS: LV dyssynchrony is a strong predictor of LV remodeling after acute myocardial infarction (AMI). It could be useful in risk stratification of patients after AMI.

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.

The predictive value of flow-mediated dilation and carotid artery intima-media thickness for occult coronary artery disease.

BACKGROUND: Multidetector row computed tomography (MDCT) is an attractive noninvasive alternative to assess overall coronary artery disease (CAD) burden and may reveal coronary plaques, which may be underestimated by conventional coronary angiography. The aim of this study was to determine whether brachial artery flow-mediated dilation (FMD) and carotid artery intima-media thickness (CIMT) might accurately predict patients with occult coronary plaques whose conventional coronary angiographies revealed normal coronary arteries (NCA). METHODS: Thirty-five patients with angiographically NCA were consecutively recruited into the study. They underwent MDCT and were divided into NCA group (18 patients; 8 male; 47 ± 9 years) and occult CAD group (17 patients; 11 male; 50 ± 10 years) according to presence of coronary plaque. Nineteen consecutive patients with evident CAD (16 male; 54 ± 7 years) and 19 healthy subjects (10 male; 50 ± 6 years) were included as control groups. FMD and CIMT were measured by brachial and carotid artery ultrasonography. RESULTS: Occult CAD group had significantly lower FMD and insignificantly higher CIMT than NCA group whereas they had significantly higher FMD and insignificantly lower CIMT than evident CAD group. NCA group had significantly lower CIMT than evident CAD group. Receiver operating characteristic curve analysis demonstrated FMD < 8% (sensitivity: 94.4%; specificity: 73.0%; PPV: 77.3%; NPV: 93.1%) and CIMT ≥ 0.65 cm (sensitivity: 72.2%; specificity: 62.2%; PPV: 65.0%; NPV: 69.7%) could predict patients with CAD. FMD and CIMT were independent predictors of CAD (P < 0.001; OR: 45.630; 95%CI: 5.38-386.983 and P = 0.015; OR: 14.226; 95%CI: 1.666-121.467, respectively). CONCLUSION: FMD and CIMT might predict patients with occult CAD and be helpful in selecting patients for MDCT.

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.

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.

Impact of systemic sclerosis on electromechanical characteristics of the heart.

Primary myocardial involvement is common in systemic sclerosis (SSc). We evaluated the atrial and ventricular electromechanical characteristics by using tissue Doppler echocardiography in SSc patients with subclinical cardiac involvement. Twenty-seven consecutive patients (24 women; mean age +/- SD 49.9 +/- 11.3 years) presenting with SSc without pulmonary arterial hypertension or symptomatic heart failure were prospectively studied. Electrocardiographic P-wave dispersion (Pd), corrected QT dispersion (QTcd), interatrial, intra-atrial, interventricular, and intraventricular electromechanical delays were analyzed by tissue Doppler echocardiography, and brain natriuretic peptide levels were measured. Results were compared with 17 healthy controls. There was no difference in conventional and tissue Doppler parameters between the two groups. However, patients with SSc had higher mean Pd (mean [+/-SD] 46.8 +/- 15 and 36 +/- 8 ms, respectively, P = 0.004) and mean interatrial electromechanical delay time (DT) (mean [+/-SD] 32.2 +/- 9.2 and 24.7 +/- 9.7 ms, respectively, P = 0.01), mean electromechanical delay time for all segments (Mean Ts) (mean [+/-SD] 148.8 +/- 18.8 and 129.3 +/- 13.4 ms, respectively, P < 0.001), and intraventricular DT (mean [+/-SD] 27.6 +/- 12.5 and 16.2 +/- 7.2 ms, respectively, P < 0.001). Intraventricular DT was the only parameter that correlated significantly with the Mean Ts. Brain natriuretic peptide levels were within normal limits in both groups; however, they were higher in patients with SSc than in controls (mean [+/-SD] 37.5 +/- 28.5 and 23.1 +/- 16.0 pg/ml, respectively, P = 0.03). The evaluation of atrial and ventricular electromechanical parameters by using tissue Doppler echocardiography seems to be useful for detection of subclinical cardiac involvement in SSc patients with normal conventional echocardiographic findings.

The effect of cardiac fibrosis on left ventricular remodeling, diastolic function, and N-terminal pro-B-type natriuretic peptide levels in patients with nonischemic dilated cardiomyopathy.

BACKGROUND: Cardiac fibrosis is common and associated with poor prognosis in patients with heart failure. We investigated the effect of cardiac fibrosis on the left ventricular (LV) diastolic function, functional capacity, LV remodeling, and biochemical parameters in patients with nonischemic dilated cardiomyopathy (NIDC). In addition, we investigated the biochemical and echocardiographic predictors of cardiac fibrosis in this group. METHODS AND RESULTS: Forty patients with NIDC were enrolled. Cardiac fibrosis was evaluated according to the presence of late gadolinium enhancement (LGE) on cardiac magnetic resonance (CMR) imaging. Nineteen patients had cardiac fibrosis (Group I) and 21 patients did not have cardiac fibrosis (Group II). LV systolic and diastolic parameters were assessed with conventional and tissue Doppler echocardiography. N-terminal pro-B-type natriuretic peptide (NT-pro BNP) levels of each patient were recorded. Patients with cardiac fibrosis had impaired diastolic function, higher functional class and NT-pro BNP levels, and significant LV remodeling than the patients without cardiac fibrosis. A correlation analysis revealed that the cardiac fibrosis severity was associated with functional class, cardiac chamber sizes, NT-pro BNP levels, diastolic parameters such as E/Se. A linear regression analysis demonstrated that NT-pro BNP and E/Se were the independent predictors of cardiac fibrosis. CONCLUSION: Cardiac fibrosis correlates with impaired LV diastolic function and functional capacity, elevated NT-proBNP levels, and adverse cardiac remodeling in patients with NIDC. Therefore, the assessment of cardiac fibrosis can be useful in the management of these patients.

Grading functional mitral regurgitation by tissue Doppler-derived isovolumic acceleration parameters in patients with nonischemic dilated cardiomyopathy.

Functional mitral regurgitation (FMR) is relatively common in heart failure and it is associated with adverse prognosis. The severity of FMR is usually assessed by echocardiography. Tissue Doppler echocardiography is used to acquire signals to determine the myocardial systolic functional parameters, including systolic ejection velocity and the systolic isovolumic acceleration (IVAs) rate. We investigated the utility of isovolumic acceleration parameters to grade the severity of FMR in nonischemic dilated cardiomyopathy (DC) patients. We analyzed the left ventricular systolic IVA rate, systolic isovolumic contraction (IVCs) velocity, and IVA duration (IVAd) values in 73 patients with DC. Patients were subgrouped according to FMR grade (Group I = mitral regurgitation mild and moderate; Group II = mitral regurgitation severe). IVAs was similar between two groups; however IVCs and IVAd were significantly higher in Group II than Group I. The IVCs cutoff value to predict severe FMR was 1.2 cm/sec (sensitivity 75% and specificity 70%). The IVAd cutoff value to predict severe FMR was 33 ms (sensitivity 77% and specificity 77%). Patients with IVCs ≥ 1.2 cm/sec and IVAd ≥ 33 ms had significantly higher FMR volume than the other subgroups. IVCs and IVAd values are useful to determine FMR severity in patients with DC.

Rosiglitazone, but not pioglitazone, improves myocardial systolic function in type 2 diabetic patients: a tissue Doppler study.

OBJECTIVE: Despite many potential benefits, thiazolidinedione (TZD) use has been associated with increased exacerbation rate of heart failure due to fluid retention. In our study, the effect of rosiglitazone and pioglitazone on myocardial function in patients with type 2 diabetes mellitus (DM) and normal left ventricular systolic function was evaluated by both conventional echocardiography and tissue Doppler imaging (TDI). METHODS: Forty patients who were diagnosed type 2 DM according to the American Diabetes Association criteria were included in the study. After baseline evaluation, all patients were randomly assigned to receive either rosiglitazone 4 mg twice daily or pioglitazone 30 mg daily for 4 months. Blood samples were taken and detailed pulsed-wave and tissue Doppler echocardiographic examination was performed at baseline and 4 months after TZD therapy. RESULTS: Left ventricular systolic velocity (Sm) values were found to be significantly increased in the rosiglitazone group (+2.6 + or - 0.7 cm/sec, P < 0.0001), while they remained unchanged in the pioglitazone group. Left ventricular early diastolic velocity (Em) increased at the same extent in both groups after treatment (rosioglitazone: +0.7 + or - 0.7 cm/sec; pioglitazone: +0.5 + or - 0.4 cm/sec, P < 0.05). CONCLUSION: In conclusion, while rosiglitazone and pioglitazone therapy improved metabolic parameters, blood pressure values and diastolic function similarly, in type 2 diabetic patients, only rosiglitazone improved systolic myocardial function significantly. (Echocardiography 2010;27:512-518).

Assessment of atrial electromechanical delay by tissue Doppler echocardiography in patients with nonischemic dilated cardiomyopathy.

BACKGROUND: Atrial electromechanical delay (AEMD) calculated from tissue Doppler imaging (TDI) echocardiography can be an alternative to invasive electrophysiologic studies. We investigated whether the AEMD obtained from TDI is prolonged in patients with nonischemic dilated cardiomyopathy (DCM). METHODS: Fifty-five patients with nonischemic DCM (23 men/32 women; age, 43.9 +/- 14.8 years) and 55 controls (20 men/35 women; age, 41.3 +/- 13.4 years) were included in this study. Atrial electromechanical delay (the time interval from the onset of P wave on electrocardiogram to the beginning of late diastolic wave [Am wave] on TDI) was calculated from the lateral and septal mitral annulus, and lateral tricuspid annulus (PA lateral, PA septum, and PA tricuspid, respectively). P-wave dispersion was calculated from the 12-lead electrocardiogram. RESULTS: PA lateral and PA septum duration were significantly longer in patients with nonischemic DCM than the controls (78.4 +/- 19.7 versus 53.8 +/- 6.6 and 55.2 +/- 16.3 versus 40.5 +/- 6.2, P < .0001 for both; respectively). However, PA tricuspid duration was statistically similar between the 2 groups (36.4 +/- 10.9 versus 37.2 +/- 5.7, P > or = .05). P-wave dispersion was significantly higher in nonischemic DCM patients than the controls (53.0 +/- 14.4 versus 37.5 +/- 5.5, P < .0001). PA lateral was correlated with the left atrial maximal volume (r = 0.64, P < .0001), P-wave dispersion (r = 0.65, P < .0001), and log B-type natriuretic peptide (NT proBNP) (r = 0.63, P < .0001). There was a statistically significant and negative correlation between the PA lateral and left ventricular ejection fraction (r = -0.63, P < .0001) and E-wave deceleration time (r = -0.34, P < .0001). Multivariate analysis revealed that left atrial maximal volume and log NT proBNP were the independent predictors of PA lateral (P < .0001 and P = .003, respectively). CONCLUSION: The AEMD was significantly prolonged in patients with nonischemic DCM. Left atrial enlargement and log NT proBNP were the independent predictors of this prolongation.

Prognostic utility of anemia and pro-B-type natriuretic peptide in patients with nonischemic dilated cardiomyopathy and normal renal function.

BACKGROUND: Idiopathic dilated cardiomyopathy frequently coexists with anemia and high plasma NT proBNP levels. However, the prognostic impact of these features on the disease course is uncertain, especially in patients with normal renal function. METHODS: Forty-seven patients with idiopathic dilated cardiomyopathy with sinus rhythm and normal renal function were prospectively followed for a mean 25+/-18 months period. Clinical end points were death (sudden cardiac death and deaths because of worsening heart failure) and cardiac transplantation. Prognostic impact of NT proBNP levels, anemia, echocardiographic and clinical parameters on the clinical end points was evaluated with Kaplan-Meier survival analysis. Cut-off values of hemoglobin and plasma NT proBNP levels for predicting end points were determined by receiver operating curve analysis. RESULTS: Twenty-eight patients (59.6%) suffered clinical end points. The patients who suffered clinical end points were anemic (P=0.002), had lower systolic (P<0.003) and diastolic (P<0.0001) blood pressures, and higher NYHA functional classes (P=0.005), lower left ventricle ejection fractions (P=0.003), higher E/A ratios (P=0.001), shorter E-wave deceleration times (P=0.001), isovolumetric relaxation times (P=0.05) and pulmonary acceleration times (P=0.004), and higher plasma NT proBNP levels (P<0.0001). Anemic patients had more clinical end points (P=0.002). In univariate analysis the prognostic predictors of life expectancy were log NT proBNP, anemia, NYHA functional class, systolic blood pressure, left ventricle ejection fraction, and E-wave deceleration time. However, multivariate analysis revealed only plasma NT proBNP as independent predictor of clinical end points. CONCLUSION: Tracking plasma NT proBNP levels is a useful strategy during routine follow-ups of patients with nonischemic dilated cardiomyopathy. Its predictive value for prognosis needs more evaluation in larger controlled studies. In addition, the importance of anemia in those patients needs more study.

The influence of dipper and nondipper blood pressure patterns on left ventricular functions in hypertensive patients: a tissue Doppler study.

OBJECTIVES: We investigated the effect of dipper and non-dipper blood pressure patterns on left ventricular diastolic filling parameters in hypertensive patients. STUDY DESIGN: Fifty-five hypertensive patients (37 women, 18 men; mean age 55+/-10 years) were evaluated with echocardiography and ambulatory 24-hour blood pressure monitoring. All the patients received antihypertensive drug therapy for at least three months prior to the evaluations. Tissue Doppler-derived systolic and diastolic parameters were compared. RESULTS: Dipper and nondipper blood pressure patterns were found in 22 patients (40%) and 33 patients (60%), respectively. Both groups had similar left ventricular systolic and diastolic diameters. Dipper patients had significantly lower values for left atrial diameter (p<0.0001), interventricular septum (p=0.001) and posterior wall (p=0.012) thickness, left ventricular mass (p=0.017) and mass index (p=0.021). Both groups had similar mitral E and A waves, E/A ratio, E-wave deceleration time, isovolumetric relaxation time, and tissue Doppler-derived A' wave. Dipper patients had a significantly lower E/E' ratio (10.8+/-3.4 vs. 14.1+/-3.6; p=0.002) and significantly higher systolic (S') (p=0.05) and early diastolic (E') (p=0.027) tissue velocities. Based on the E/E' ratios being <15 or = or >15, the frequency of dipper hypertension was significantly higher in patients with E/E' <15 (48.8% vs. 9.1%; p=0.019). The frequency of dippers was also higher among patients having an E/E' ratio of <8, compared to those having an E/E' ratio of = or >8 to <15 (90% vs. 35.3%; p=0.019). CONCLUSION: Nondipper blood pressure pattern may be associated with increased left ventricular mass, impaired left ventricular systolic and diastolic dysfunction, and higher left ventricular filling pressures.