Impact of arterial stiffness on echocardiographic myocardial work indices in patients with isolated bicuspid aortic valve.

OBJECTIVE: Data related to the existence of left ventricular (LV) abnormalities in normal functional bicuspid aortic valve (BAV) disease is scarce. In addition, the impact of afterload and the involved mechanisms are unclear. In this work, we study the relationship between LV function assessed with myocardial work index (MWI) and arterial stiffness in a cohort of normal functioning BAV patients. METHODS: In this study, we included a total of 38 consecutive patients with isolated BAV and 44 age- and gender-matched control subjects with tricuspid aortic valve. All participants underwent transthoracic echocardiography to assess conventional parameters and global longitudinal strain (GLS). In addition, MWI was measured by the noninvasive LV pressure-strain cycle method. Aortic pulse wave velocity (PWV) and wave reflection were evaluated by applanation tonometry. RESULTS: The mean aortic PWV was significantly higher in BAV patients (6.4 ± 0.80, 7.02 ± 0.1.2, p = .01, respectively). LV-MWI related parameters such as global work efficiency (GWE) (96.261.69 and 97.051.27, p = .02) and global wasted work (GWW) (78.232.1 and 61.824.4, p = .01) were found significantly different between the BAV and control groups. However, global working index and global constructive working were not different between groups (1969 ± 259 and 2014 ± 278, p = .45; 2299 ± 290 and 2359 ± 345, p = .39, respectively). Multivariable ordinary least squares regression analysis revealed that BAV (ß = 8.4; 95% CI: 1.5-15.3; p = .04) and PVW (ß = 5.6; 95% CI: 0.7-10.5; p = .01) were significant predictors of GWV. CONCLUSION: GWW is increased and GWE is decreased in patients with BAV compared with controls, and these changes are related to arterial stiffness. The relationship between aortic PWV and GWW may help to explain the exact mechanism of subclinical myocardial dysfunction in patients with isolated BAV.

The effects of catheter ablation of outflow tract premature ventricular complexes on atrial electromechanical delay.

BACKGROUND: Consistent data from several studies have shown that catheter ablation of frequent premature ventricular complexes (PVCs) results in substantial improvement in left ventricular ejection fraction (LVEF), left ventricular diastolic function, and left atrial volume and mechanics. However, the effects of catheter ablation of PVCs on atrial electromechanical properties have not been documented yet. AIMS: In the present study, we investigated the short-term effects of radiofrequency catheter ablation (RFCA) of outflow tract PVCs on atrial electromechanical delay (EMD). METHODS: A total of 71 subjects with idiopathic outflow tract PVCs who underwent RFCA were included. Interatrial and intra-atrial EMDs were measured by tissue Doppler imaging before and 3 months after catheter ablation. RESULTS: The study population was divided into normal ejection fraction (EF) and low-EF subgroups according to their LVEF. In all study groups, substantial improvement was found in lateral electromechanical coupling time (PA), septal PA, right ventricular PA, interatrial EMD, left-sided intra-atrial EMD, and right-sided intra-atrial EMD. No treatment heterogeneity was observed when comparing low-EF and normal-EF subgroups with respect to atrial EMDs (interatrial EMD, interaction p = .29; left-sided intra-atrial EMD, interaction p = .13; right-sided intra-atrial EMD, interaction p = .88). CONCLUSION: RFCA of outflow tract PVC has a favorable early effect on intra- and inter-atrial EMDs irrespective of preprocedural LVEF.

Serum Endocan Levels Predict Drug-Eluting Stent Restenosis in Patients with Stable Angina Pectoris.

BACKGROUND: Endothelial cell-specific molecule 1 (ESM-1 or endocan) is an immunoinflammatory marker strongly associated with inflammation, vascular endothelial dysfunction and atherosclerosis. We explored the relationship between serum endocan concentrations and coronary in-stent restenosis (ISR). METHODS: Fifty consecutive patients with ISR and 50 control subjects were included in this study. Clinical data and angiographic characteristics were collected. Serum endocan concentrations were measured using an enzyme-linked immunosorbent assay. RESULTS: All included patients were divided into four quartiles based on their concentrations of endocan: quartile 1 (0.62-1.31 ng/mL), quartile 2 (1.33-1.74 ng/mL), quartile 3 (1.75-2.77 ng/mL) and quartile 4 (2.78-4.24 ng/mL). The rates of ISR were 16%, 24%, 68%, and 92%, respectively. The patients in quartile 4 had significantly higher rates of ISR than the other groups (p < 0.001). Logistic regression analysis indicated that endocan concentration [odds ratio = 8.65, 95% confidence interval 3.56-20.94; p < 0.001] was an independent predictor of ISR. Receiver operating characteristic curve analysis was used to explore the relationship between endocan and ISR. Using a cutoff value of 1.625 ng/mL, endocan predicted ISR with a sensitivity of 86% and a specificity of 78%. CONCLUSIONS: Our findings suggest that plasma endocan levels may be a novel biomarker of endothelial dysfunction in patients with ISR.

Left atrial remodeling in patients undergoing percutaneous mitral valve repair with the MitraClip system: an advanced echocardiography study.

BACKGROUND: The goal of this study was to determine changes in left atrial (LA) function with two-dimensional speckle tracking echocardiography (2DSTE) and real-time full-volume three-dimensional echocardiography (RT3DE) after percutaneous mitral valve repair with the MitraClip system. Furthermore, we investigated whether baseline and/or changes in LA function after MitraClip repair had any impact on prognosis. METHODS: A total of 25 consecutive patients (age: 57±12 years, 76% male) with moderate-to-severe or severe mitral regurgitation (MR) were included. Patients underwent 2DSTE and RT3DE before the clip implantation and after the 12-month follow-up. Prognostic data were also recorded via the use of telephone calls and follow-up visits for 12 months after the procedure. RESULTS: Compared with the baseline, the LA reservoir strain (LA-Res) (7.66±4.3% vs 11.15±7.5%, P<.001) and LA contraction strain (LA-Pump) (4.64±4.3% vs 7.63±5.8%, P=.001) improved significantly after MitraClip repair; significant improvements were also seen in three-dimensional (3D) minimum LA volume index (LAV min) and maximum LA volume index (LAV max). On the other hand, conventional LA indices did not change. In total, eleven major adverse cardiac events (MACE) were observed at the 1-year follow-up. In univariate analyses, the preprocedural echocardiographic parameters that were associated with the MACE within 1 year after MitraClip repair were 3D-LAV min and LA-Res. Furthermore, these indices significantly correlated with improved functional parameters and MR reduction. CONCLUSION: In conclusion, a successful MitraClip procedure can reverse the process of LA remodeling within 12 months, and this can be detected by 2DSTE and RT3DE. Also, patients with preprocedural lower LA-Res and higher 3D-LAV min had the worst prognoses at the 1-year follow-up.

Comparison of Right Ventricle Systolic Function between Long-Term Anabolic-Androgenic Steroid User and Nonuser Bodybuilder Athletes: A Study of Two-Dimensional Speckle Tracking Echocardiography.

BACKGROUND: Right ventricular (RV) effects of long-term use of anabolic-androgenic steroids (AAS) are not clearly known. The aim of this study was to assess RV systolic functions by two-dimensional speckle tracking echocardiography (2DSTE) in AAS user and nonuser bodybuilders. METHODS: A total of 33 competitive male bodybuilders (15 AAS users, 18 AAS nonusers) were assessed. To assess RV systolic functions, all participants underwent standard two-dimensional and Doppler echocardiography, and 2DSTE. RESULTS: Interventricular septal thickness, left ventricle posterior wall thickness, relative wall thickness, and left ventricle mass index were significantly higher in AAS users than nonusers. While standard diastolic parameters were not statistically different between the groups, tissue Doppler parameters including RV E' and E'/A' were lower in AAS users than nonusers (10.1 ± 2.0 vs. 12.7 ± 2.1; P = 0.001, 1.1 ± 0.1 vs. 1.5 ± 0.4; P = 0.009, respectively). Tricuspid annular plane systolic excursion, RV fractional area change, and RV S' were in normal ranges. However, RV S' was found to be lower in users than nonusers (12.2 ± 2.2 vs. 14.6 ± 2.8, P = 0.011). RV free wall longitudinal strain and strain rate were decreased in AAS users in comparison with nonusers (-20.2 ± 3.1 vs. -23.3 ± 3.5; P = 0.012, -3.2 ± 0.1 vs. -3.4 ± 0.1; P = 0.022, respectively). In addition, there were good correlations between 2DSTE parameters and RV S', E', and E'/A'. CONCLUSION: Despite normal standard systolic echo parameters, peak systolic RV free wall strain and strain rate were reduced in AAS user bodybuilders in comparison with nonusers. Strain and strain rate by 2DSTE may be useful for early determination of subclinical RV dysfunction in AAS user bodybuilders.

Relation of epicardial fat thickness to the severity of heart failure in patients with nonischemic dilated cardiomyopathy.

BACKGROUND: The aim of this study was to assess whether epicardial fat thickness (EFT) is associated with the severity of heart failure in patients with nonischemic dilated cardiomyopathy (NICMP). METHODS: The study group was composed of 93 patients with NICMP and38 age- and sex-matched healty individuals as the control group. The EFT was identified during end-systole at the point on the free wall of the right ventricle. RESULTS: Patients with NICMP had significantly lower mean EFT than those in the control group (4.1 ± 0.8 vs. 6.1 ± 1.8 mm, P < 0.001). EFT was thinnest in patients with New York Heart Association (NYHA) functional class III or IV (3.5 ± 0.5, P < 0.001). There was a significant correlation between EFT, left ventricle EF (r = 0.540 P < 0.001), and B-type natriuretic peptide (BNP) (r = -0.695, P < 0.001) values in patients with NICMP. In addition, when EFT was corrected for BMI, EFT/BMI was lower in patients with NYHA functional class III-IV than patients with NYHA class I-II and control group (0.13 ± 0.01, 0.16 ± 0.02, 0.23 ± 0.04, respectively; P < 0.001). There was a significant correlation between EFT/BMI, left ventricle EF (r = 0.489, P < 0.001), and BNP (r = -0.549, P < 0.001) in patients with NICMP. In multivariate regression analysis, EFT (P = 0.009), BNP (P = 0.039), and left atrium volume index (P = 0.039) were independently associated with impaired functional status. CONCLUSION: Echocardiographic EFT is an inexpensive, simple, and readily available marker that may be used to asses the severity of chronic heart failure in patients with NICMP.

An unexpected complication of the MitraClip device: one of the arms gets stuck inside the guide catheter in the left atrium.

Percutaneous edge-to-edge mitral valve repair using the MitraClip (Abbot Vascular, USA) system is a promising technique for mitral regurgitation treatment in select high-risk surgical patients. Although the safety and efficacy of the technique have been demonstrated, a few complications of the MitraClip device have been reported. In this report, we present a rare complication that recently occurred during the performance of a MitraClip procedure in a patient with severe functional mitral regurgitation. One MitraClip arm got stuck inside the guide catheter in the left atrium and a decision was made to discontinue percutaneous intervention because the problem could not be resolved.

PE with ST-segment elevation in leads V1-3 and AVR treated successfully by catheter directed high-dose bolus thrombolytic therapy during CPR.

A 55-year-old man presented with the emergency department after having a short syncopal episode and angina during the exertion for 1 month. His initial electrocardiogram showed minimal ST-segment changes on precordial leads. While waiting for the laboratory tests, abruptly, the patient went into cardiopulmonary arrest. After a short resuscitation, a new electrocardiogram revealed ST-segment elevations in leads V1-3 and AVR, mimicking an anteroseptal myocardial infarction. Although, the angiography showed severe coronary artery disease, coronary flow was normal and main branches of pulmonary artery were almost fully occluded by large pulmonary emboli. Recombinant tissue plasminogen activator bolus (25 mg) was given 2 times at 5-minute intervals immediately into pulmonary artery by pig-tail catheter under the cardiopulmonary resuscitation. The patient had an excellent response to high-dose bolus thrombolytic therapy. We conclude that in the case of massive pulmonary embolism with small chance of resuscitation, the catheter-directed high-dose bolus injection of recombinant tissue plasminogen activator could enrich the therapeutical possibilities.

Delineation of an octopus-like thrombus attached to the eustachian valve.

Eustachian valve (EV) is a vestige of the valve of the inferior vena cava which directs the umbilical vein blood through open foramen ovale in fetal life. Following birth it gradually regresses, but it may persist in variable size, shape, and thickness as a functionless and benign structure. However, there are reports suggesting that persistent EV may not be completely innocent. It has been accused of being a predisposing cause of patent foramen ovale and paradoxical embolism and also interfering with transseptal interventional procedures. It may serve as a site of infective vegetations and be mistaken as a tumor or thrombus. In the present case, an octopus-like thrombus attached to the EV was delineated with the utility of two-dimensional and real time three-dimensional transesophageal echocardiography. EV was considered to play an essential role in preventing potential pulmonary embolism.

Concomitant Gerbode-like defect and anterior mitral leaflet perforation after aortic valve replacement for endocarditis.

We present a case of concomitant left ventricle (LV) to right atrial shunt (Gerbode-like defect) and anterior mitral leaflet perforation in a 32-year-old male after aortic valve replacement for infective endocarditis of bicuspid aortic valve. This case emphasises that intra-operative transesophageal echocardiography is a sine qua non for valvular surgical procedures.

Relation of Plasma Fibrinogen Level With the Presence, Severity, and Complexity of Coronary Artery Disease.

BACKGROUND: Relation of plasma fibrinogen levels with extent, severity, and complexity of coronary artery disease (CAD) in patients with stable angina pectoris (SAP) has not been adequately investigated. The aim of this study was to evaluate whether plasma fibrinogen level is associated with coronary complexity, severity, and extent assessed by SYNTAX (Synergy between percutaneous coronary intervention with TAXUS and Cardiac Surgery) score (SS). METHODS: We enrolled 134 consecutive patients with SAP who underwent coronary angiography. Baseline serum fibrinogen levels were measured, and SS was calculated from the study population. The patients were classified into 3 groups by tertiles of SS (SS, control group = 0; intermediate group < 22; and high group ≥ 22). RESULTS: Plasma fibrinogen levels demonstrated a stepwise increase from control group to high SS group. There was a strong correlation between fibrinogen and the SS ( r = .535, P < .001). Area under the receivers operating characteristic curve of fibrinogen was 0.72 (95% confidence interval [CI] 0.61-0.82; < .001) for predicting a high SS. Fibrinogen value higher than 411 mg/dL has a sensitivity of 75% and a specificity of 64% in prediction of high SS. In multivariate analyses, plasma fibrinogen was observed to be an independent predictor for high SS in patients with stable CAD (odds ratio [OR] 1.01; 95% CI, 1.01-1.02; P < .001). CONCLUSION: Plasma fibrinogen is a readily measurable systemic inflammatory marker and is independently associated coronary severity and complexity in patients with CAD.