Early left ventricular longitudinal systolic dysfunction and cardiovascular risk factors in 1,371 asymptomatic subjects with normal ejection fraction: a tissue Doppler study.

BACKGROUND: Nowadays early diagnosis of left ventricular (LV) dysfunction represents a major challenge in asymptomatic subjects with cardiovascular (CV) risk factors. Tissue Doppler imaging (TDI) recently emerged as an important tool with clinical relevance in several cardiac diseases. AIM: To evaluate the ability of TDI in detecting early longitudinal ventricular dysfunction in asymptomatic subjects, with LV ejection fraction >55%, normal diastolic function, and its relationship with CV risk factors. METHODS: A total of 1,371 subjects (median age 60 years, 595 males) formed our study population: Controls, 265 healthy subjects; Group I, 434 subjects with one CV risk factor; Group II, 401 subjects with two CV risk factors; Group III, 271 subjects with ≥ 3 CV risk factors. All subjects underwent a comprehensive standard echo Doppler evaluation, including PW-TDI study. RESULTS: Diastolic parameters such as (E\A, A-wave, Em\Am; E\Em) were able to discriminate the number of CV risk factors. The only systolic parameter that progressively reduced by increasing the number of CV risk factors was LV global longitudinal systolic function (Sm), (P < 0.0001). At multivariate analysis, the only functional parameter able to predict the increasing number of CV risk factors was Sm (P < 0.001). CONCLUSIONS: TDI is able to identify early longitudinal LV systolic abnormalities in presence of apparently normal systolic and diastolic function and progressively impairs with increasing CV risk factors. These findings could be clinically relevant in identifying asymptomatic subjects who need a early tailored preventive treatment.

Transcranial Doppler and transesophageal echocardiography: comparison of both techniques and prospective clinical relevance of transcranial Doppler in patent foramen ovale detection.

BACKGROUND: Patent foramen ovale (PFO) has been investigated in several conditions apart from cryptogenic ischemic stroke. Contrast transesophageal echocardiography (cTEE) is the gold standard for the diagnosis, although it has some known limitations. Contrast transcranial Doppler (cTCD) allows a semiquantitative estimation of right-to-left shunt (RLS) volume. The aims of our study were to confirm the diagnostic accuracy of cTCD in PFO diagnosis and to compare the abilities of cTCD and cTEE to detect a RLS and PFO, respectively, under normal breathing. The latter could represent an important feature for its clinical significance. METHODS: A total of 100 consecutive patients (59 women and 41 men, age 46 +/- 12 years) were evaluated after stabilized ischemic stroke/transient ischemic attack, migraine, and lacunae, and before neurosurgery in sitting position. All patients undertook cTEE and cTCD, at rest and under Valsalva maneuver (VM). cTEE under VM was the reference standard. A categorization of patients and a semiquantitative cTCD classification were proposed. RESULTS: In all, 63 of 100 patients had PFO diagnosed by cTEE. A general concordance of up to 90% between both techniques was found. cTCD sensitivity and specificity were 96.8% and 78.4%, respectively. In 17 of 100 patients with cTEE-proven PFO under VM, cTCD and cTEE detected RLS at rest in 75% (95% confidence interval [CI] 62%-85%) and 48% (95% CI 35%-61%) of cases, respectively (P < .001). cTEE disclosed RLS at rest in about 71% (95% CI 9%-42%) of cTCDs showing a "shower-curtain" pattern and only in about 22% (95% CI 52%-85%) of those cTCDs without that pattern. CONCLUSIONS: In diagnosing PFO, cTCD has a good accuracy compared with cTEE. To detect a RLS at rest, cTCD appears to be more sensitive than cTEE. The latter resulted positive under normal breathing, mostly in cases of significant RLS at cTCD. Our results point out the impact of cTCD in the evaluation of RLS volume, thus aiding, in association with the anatomic details by cTEE, in the prevention of the occurrence or recurrence of paradoxical embolism in individuals with and without cerebrovascular diseases. The combination of cTEE and cTCD could be considered the real gold standard for PFO in the near future.

Atrial fibrillation after non-cardiac surgery: P-wave characteristics and Holter monitoring in risk assessment.

BACKGROUND: We investigated the role of 12-lead ECG P-wave duration and dispersion and of Holter monitoring as predictors of post-thoracic surgery atrial fibrillation. METHODS: One hundred and five consecutive patients (88 males-17 females; age 60+/-9), undergoing thoracic surgery at National Cancer Institute between 2001 and 2003, were enrolled and both standard ECG and Holter monitoring were obtained from each patient. P-wave study was made on a magnified ECG paper copy. Holter monitoring was performed 1-3 days before surgery; patients were divided into three classes according to number and complexity of premature supra ventricular complexes (0: <30/h and no repetitive forms; 1: >30/h or couplets; 2: run of supraventricular tachycardia or atrial fibrillation). RESULTS: Atrial fibrillation was detected in 12 patients (11%) within 96 h from surgery. In univariable logistic model, P-wave duration was not associated with postoperative atrial fibrillation while P-wave dispersion and Holter monitoring demonstrated a statistically significant association with the occurrence of atrial fibrillation (OR of 30 vs 20 ms=2.06; CI: 1.17-3.64; p=0.012, OR of class 1-2 vs class 0=8.16; CI: 2.04-35.59; p=0.003, respectively). In the multivariable model, both P-wave dispersion and Holter were shown to be significantly associated with the end-point. Holter monitoring enhanced the predictive ability of P-wave dispersion (area under the ROC curve increased from 0.64 to 0.80). CONCLUSIONS: P-wave dispersion, but not duration, was associated with atrial fibrillation after thoracic surgery. Preoperative Holter monitoring adds further information and could be used to enhance the P-wave predictive power.

Clinical and subclinical cardiac late effects in pediatric Hodgkin's lymphoma survivors.

PURPOSE: Cardiac late effects are responsible for a significant burden of mortality and morbidity among pediatric Hodgkin's lymphoma (HL) survivors (HLS). The aim of our study was to assess clinical and subclinical cardiac sequelae in a cohort of childhood HLS treated in the 1980s with doxorubicin, bleomycin, vinblastine, and dacarbazine (the ABVD regimen) and limited-field radiotherapy (RT). METHODS: We retrospectively examined a series of HLS treated from 1979 to 1989. We searched for subtle cardiac abnormalities in a subgroup of asymptomatic individuals, who underwent rest and exercise echocardiography at least 20 years after completing their therapies. Their cardiac assessment included physical examination, electrocardiogram (ECG), and resting and postexercise echocardiograms. RESULTS: On thorough cardiac assessment a mean of 21 years after their diagnosis, none of the 53 unselected asymptomatic HLS showed physical signs or significant ECG abnormalities during or after the stress echo test. Twenty-two (41%) of the 53 patients revealed valvular abnormalities, with mitral regurgitation in 28%, aortic regurgitation in 9%, and both in 4%. No significant myocardial dysfunction as a result of previous combined doxorubicin treatment and chest RT was identified. Only 2 individuals had mild pericardial alterations. CONCLUSIONS: The present study shows that long-term cardiac effects are common in HLS treated with the ABVD regimen and RT. The most frequent complications observed in this sample were essentially coronary artery disease and valvular abnormalities. None of the survivors in this sample showed overt congestive heart failure, a finding in contrast with larger studies.

Non-invasive monitoring of cardiac hemodynamic parameters in doxorubicin-treated patients: comparison with echocardiography.

Cardiotoxicity represents the major factor that limits the use of anthracyclines in long-term cancer chemotherapy, therefore, the early detection of cardiac dysfunction is very important. Currently, the left ventricular ejection fraction is routinely used to screen cardiotoxicity. The most common methods in use are represented by 2-dimensional (2D) echocardiography and radionuclide angiography. The aim of the present investigation was to compare the findings obtained in patients subjected to doxorubicin (DXR) chemotherapy, by 2D echocardiography with hemodynamic parameters, resulting from a new non-invasive method based on an inert gas rebreathing technique. The study was conducted in 35 adult female patients (mean age 48 years, range 30-67) submitted to chemotherapy for metastatic breast cancer with DXR and paclitaxel. DXR was administered at a dose of 60 mg/m2 and paclitaxel at a dose of 200 mg/m2 every 3 weeks for a maximum of 8 cycles. Heart function evaluation was performed before initiating chemotherapy, after 3 cycles, 1 month after the completion of chemotherapy and when clinically requested. The mean cumulative dose of DXR, in patients who had received at least 4 or more cycles, was 320 mg/m2 of body surface area with a range of 240 to 480 mg/m2. The data obtained with 2D echocardiography (left ventricular end diastolic and systolic dimensions and ejection fraction) were compared with hemodynamic parameters obtained by the inert gas rebreathing technique (cardiac output, stroke volume, cardiac index and stroke index). Hemodynamic monitoring showed a progressive decrease of all parameters during DXR treatment, which became statistically significant at the end of the treatment. A significant reduction of ejection fraction due to an increase in the end systolic dimension of the left ventricle, without significant modification of the end diastolic dimensions, was observed. A good correlation was found between data obtained with the echocardiographic method and those obtained by the inert gas rebreathing technique. Two patients showed symptoms of congestive heart failure, the deterioration of cardiac function was simultaneously detected by both methods. These data confirm that cardiac function deterioration is detectable at a cumulative dose lower than 550 mg/m2 and that the inert gas rebreathing method for the determination of hemodynamic parameters could represent an alternative tool, in addition to conventional echocardiographic examination, in the evaluation of anthracycline-induced cardiotoxicity.

Respiratory changes in transvalvular flow velocities versus two-dimensional echocardiographic findings in the diagnosis of cardiac tamponade.

BACKGROUND: The purpose of this study was to compare the sensitivity, specificity and positive predictive value of the respiratory changes in the transvalvular flow velocities to those of right atrial collapse and right ventricular collapse in the diagnosis of cardiac tamponade. METHODS: Standard two-dimensional and Doppler echocardiography were performed with respiratory monitoring in 56 consecutive patients with mild to severe pericardial effusion. Sixteen patients met the clinical criteria for cardiac tamponade and underwent pericardiocentesis or surgical drainage. Forty patients were found to have no tamponade and were followed up for at least 2 weeks and none of them showed clinical worsening. RESULTS: The sensitivity, specificity and predictive value were, respectively, 77, 80 and 62% for an inspiratory decrease > 22% in the peak velocity of the early mitral flow; 75, 89 and 73% for an inspiratory reduction > 20% in the peak velocity of the aortic flow; 50, 69 and 36% for an inspiratory increase > 30% in the peak velocity of the early tricuspid flow; 87, 85 and 64% for an inspiratory increase > 25% in the peak velocity of the pulmonary flow. Right atrial collapse and right ventricular collapse had a sensitivity of 100 and 75%, a specificity of 33 and 85%, and a predictive value of 37 and 66%, respectively. CONCLUSIONS: In the diagnosis of cardiac tamponade: 1) right atrial collapse is the most sensitive sign but lacks any specificity; 2) except for the tricuspid valve, the respiratory variations in the transvalvular flow velocities have a reliability and a predictive value comparable with those of right ventricular collapse; 3) the predictive value is not very high, indicating that at both techniques false positive results are not negligible.

The prognostic value of early left ventricular longitudinal systolic dysfunction in asymptomatic subjects with cardiovascular risk factors.

BACKGROUND: Early diagnosis of left ventricular (LV) dysfunction represents a major challenge in asymptomatic subjects with cardiovascular (CV) risk factors. Tissue Doppler imaging (TDI) has emerged as an important tool with clinical relevance in several cardiac diseases. HYPOTHESIS: To evaluate the prognostic ability of TDI in detecting early longitudinal ventricular dysfunction in a large group of asymptomatic subjects with CV risk factors (RsF), normal LV systolic function, and normal diastolic function. METHODS: A total of 554 subjects (mean age 55 ± 13 years, 39% men) formed our study population: controls, 144 healthy subjects; group 1, 163 subjects with 1 CV RsF; group 2, 147 subjects with 2 CV RsF; group 3, 100 subjects with ≥3 CV RsF. All subjects underwent a comprehensive standard echo-Doppler evaluation, including posterior wall TDI study. Follow-up data were available in all the studied samples (mean 28 ± 16 mo). RESULTS: Upon follow-up, 18 individuals (3.2%) developed a first overt CV event. The presence of a peak systolic velocity <7.5 cm/second showed a significant additional predictive value compared with the presence of CV RsF (P<0.001). CONCLUSIONS: Tissue Doppler imaging is able to identify early longitudinal LV systolic abnormalities in the presence of apparently normal systolic and diastolic function. It demonstrated a significant additional prognostic value compared with the simple presence of coexisting CV RsF. These findings could be clinically relevant in identifying asymptomatic subjects with CV RsF who need early, tailored preventive treatment.