Echocardiographic predictors of exercise induced pulmonary hypertension in patients with asymptomatic moderate to severe mitral regurgitation and preserved left ventricular ejection fraction.

BACKGROUND: The significant role of mitral regurgitation (MR) in development of pulmonary hypertension (PH) has been proved in previous studies. Experts suggest systolic pulmonary arterial pressure (SPAP) ⩾60 mmHg during exercise as a significant threshold of negative prognostic value in patients with MR. PURPOSE: The aim of this study was to evaluate the changes of SPAP and to ascertain the determinants of exercise induced pulmonary hypertension (EIPH) in patients with asymptomatic primary MR. METHODS: We performed a prospective study that included 50 patients with asymptomatic primary moderate to severe MR with preserved left ventricular ejection fraction (LV EF ⩾60%) at rest. They were divided into two groups according to the presence (PH group; n = 13) or absence (non-PH group; n = 37) of EIPH. Rest and stress (bicycle ergometry) echocardiography and speckle-tracking offline analysis were performed. RESULTS: An increment of SPAP from rest to peak stress was higher in PH group (p < 0.001). Multivariate regression analysis showed that MR effective regurgitation orifice area (EROA; p = 0.008) and regurgitant volume (RVol; p = 0.006) contributed significantly to SPAP at rest. Higher increment of MR EROA during stress and worse parameters of LV diastolic function at rest (E, A, E/e') correlated significantly with higher SPAP during peak stress and they had a major role in predicting EIPH according to univariate logistic regression analysis. In ROC analysis SPAP >33.1 mmHg at rest could predict EIPH with 84.6% sensitivity and 87.1% specificity (95%CI 0.849-1.000; p < 0.001). CONCLUSIONS: Parameters of MR severity (EROA and RVol) were significant determinants of SPAP at rest, while the increment of MR EROA during stress and parameters of resting LV diastolic function were the best predictors of significant EIPH.

Right Ventricle Mechanics and Function during Stress in Patients with Asymptomatic Primary Moderate to Severe Mitral Regurgitation and Preserved Left Ventricular Ejection Fraction.

Background and objectives. Mitral regurgitation (MR) is usually dynamic and increasing with exertion. Stress may provoke symptoms, cause the progression of pulmonary hypertension (PH) and unmask subclinical changes of the left and right ventricle function. The aim of this study was to evaluate changes of right ventricle (RV) functional parameters during stress and to find out determinants of RV function in patients with MR. Materials and methods. We performed a prospective study that included patients with asymptomatic primary moderate to severe MR and preserved left ventricular (LV) ejection fraction (EF) at rest (≥60%). Conventional 2D echocardiography at rest and during stress (bicycle ergometry) and offline speckle tracking analysis were performed. Results. 80 patients were included as MR (50) and control (30) groups. Conventional functional and myocardial deformation parameters of RV were similar in both groups at all stages of exercise (p > 0.05). The grade of MR (p = 0.004) and higher LV global longitudinal strain (p = 0.037) contributed significantly to the changes of tricuspid annular plane systolic excursion (TAPSE) from rest to peak stress. Changes of MR ERA from the rest to peak stress were related to RV free wall longitudinal strain (FWLS) and four chambers longitudinal stain (4CLS) at rest (p = 0.011; r = -0.459 and p = 0.001; r = -0.572, respectively). Significant correlations between LV EF, stroke volume, cardiac output and RV fractional area change, S', TAPSE, FWLS, 4CLS were obtained. However, systolic pulmonary artery pressure and RV functional, deformation parameters were not related (p > 0.05). Conclusions. Functional parameters of LV during exercise and severity of MR were significant determinants of RV function while PH has no correlation with it in patients with primary asymptomatic moderate to severe MR.

Changes of Left and Right Ventricle Mechanics and Function in Patients with End-Stage Renal Disease Undergoing Haemodialysis.

Background and objectives: Chronic kidney disease (CKD) increases the risk of cardiovascular diseases even in its early stages and is associated with structural and functional cardiac abnormalities. The aim of this study was to use speckle-tracking echocardiography (STE) to evaluate left and right ventricle mechanics and function, markers of subclinical dysfunction in patients with end-stage renal disease (ESRD) undergoing haemodialysis. Methods: Patients with ESRD undergoing regular haemodialysis and with preserved left ventricle (LV) ejection fraction (EF) (n = 38) were enrolled in this retrospective study. The control group consisted of 32 age-matched persons with normal kidney function (glomerular filtration rate (GFR) >90 mL/min/1.73 m² according to Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI)). Conventional 2D echocardiography and STE were performed in all patients. Results: 70 individuals, 31 (44.29%) males and 39 (55.71%) females, were included in the study. There were no significant differences in age, sex and body surface area between the groups. LV end diastolic diameter did not differ between the groups, while LV myocardial mass index was higher in the group of patients on haemodialysis (111.64 ± 27.99 versus 84.21 ± 16.99, p < 0.001) and LV diastolic dysfunction (LVDD) was found in 31 (81.6%) patients of this group. LV global longitudinal strain (GLS) (-22.43 ± 2.71 versus -24.73 ± 2.03, p < 0.001) and LV global circumferential strain (GCS) at the mitral valve and papillary muscles levels (-18.73 ± 3.49 versus -21.67 ± 2.22, p < 0.001; -18.64 ± 2.75 versus -20.42 ± 2.38, p = 0.005, respectively) were significantly lower in haemodialysis group patients. The parameters of the right ventricle (RV) free wall longitudinal function including RV GLS (-22.63 ± 3.04 versus -25.45 ± 2.48, p < 0.001), were reduced in haemodialysis patients compared with the controls. However, RV fractional area change (FAC) did not differ between the groups (p = 0.19). Conclusion: Patients with ESRD and preserved LV ejection fraction undergoing haemodialysis had a higher prevalence of LVDD and impaired LV longitudinal and circumferential deformation indices, as well as reduced RV longitudinal function and deformation parameters compared with the age-matched healthy controls. STE helps to detect subclinical LV and RV dysfunction in chronic haemodialysis patients.

Syphilitic coronary artery ostial stenosis resulting in acute myocardial infarction.

Cardiovascular abnormalities are well-known manifestations of a late form of syphilis - tertiary syphilis. Since the era of antibiotics, the incidence of late manifestations of syphilis has declined almost to a rare entity. The injury of aorta (the aortitis with a dilatation of aortic root and its associated complications) is the most common between all the cardiovascular lesions. A less common manifestation of syphilitic aortitis is coronary artery ostial narrowing related to aortic wall thickening. We present the case of a 37-year-old male who was treated for an acute myocardial infarction due to bilateral coronary artery ostial stenosis secondary to syphilitic aortitis. According to the multidisciplinary decision, surgical revascularization (coronary artery bypass grafting, CABG) was performed. According to dermatologist recommendation, patient postoperative cardiovascular treatment was supplemented with intramuscular doses of benzathine penicillin recommended for tertiary syphilis. Further follow-up visits were also planned to detect possible changes of the aortic wall, dynamics of aortic regurgitation or potential anastomotic restenosis due to progression of aortitis.

Early and late diastolic strain rate vs global longitudinal strain at rest and during dobutamine stress for the assessment of significant coronary artery stenosis in patients with a moderate and high probability of coronary artery disease.

BACKGROUND: The aim of this prospective study was to assess the usefulness of global longitudinal strain (GLS), regional diastolic and systolic strain, strain rate (SR) parameters at rest and during dobutamine stress echocardiography for detecting significant coronary artery stenosis in patients with a moderate or high probability of coronary artery disease (CAD). METHODS: Dobutamine stress echocardiography and adenosine magnetic resonance imaging (AMRI) were performed on 127 patients with a moderate and high probability of CAD and left ventricle ejection fraction ≥55%. CAD was defined as ≥70% diameter stenosis on coronary angiography validated as hemodynamically significant by AMRI. Patients were grouped according to coronary angiography and AMRI results: CAD (-) n=67 (52.8%) vs CAD (+) n=60 (47.2%). RESULTS: There were no significant differences of clinical characteristics, conventional echocardiography, and deformation parameters between the two groups at rest except that GLS was higher in the CAD (-) group (-21.5±2.4% vs -16.2±2.1%, P=.00). GLS at high dobutamine doses had the highest area under the ROC curve (AUC) (AUC 0.955, sensitivity 94%, specificity 92%). Radial late diastolic SR at low doses performed best out of all diastolic parameters with an AUC of 0.789, sensitivity 76.7%, specificity 91.7%. Other deformation parameters including visual assessment were inferior. CONCLUSIONS: Global longitudinal strain is highly sensitive and specific in detecting hemodynamically significant coronary artery stenosis in moderate- to high-risk patients without known CAD. This is the first study showing that GLS is more sensitive and specific compared with early and late diastolic SR parameters or visual assessment in detecting CAD.

Dobutamine-stress echocardiography speckle-tracking imaging in the assessment of hemodynamic significance of coronary artery stenosis in patients with moderate and high probability of coronary artery disease.

BACKGROUND AND OBJECTIVE: Myocardial deformation indices are considered as sensitive markers of ischemia and may be useful in the quantification of hemodynamic significance of coronary artery disease (CAD). We sought to determine the diagnostic value of speckle-tracking echocardiography derived myocardial deformation parameters at rest and during stress to determine hemodynamically significance coronary artery stenosis in patients with moderate and high probability of CAD. MATERIALS AND METHODS: In 81 patients (mean age, 64±8.6 years) with stable CAD inducible myocardial ischemia was evaluated by dobutamine stress echocardiography (DSE) and adenosine magnetic resonance imaging (AMRI). Based on AMRI patients were divided into two groups: nonpathologic (n=41) and pathologic (n=40). Strain and strain rate (SR) parameters and their changes from the rest (BASE) to low stress (MIN), peak stress (MAX), and recovery (REC) were analyzed using 2D speckle-tracking imaging (STI). RESULTS: In the nonpathologic group, systolic longitudinal and circumferential strain increased significantly from BASE to MIN, as well as systolic SR from BASE to MIN and from MIN to MAX in longitudinal plane. In contrast, in the pathologic group, insignificant longitudinal systolic SR increase and radial and circumferential systolic SR decrease from MIN to MAX was observed. Discriminant function analysis revealed that select STI derived parameters best classify patients into predefined AMRI groups (pathologic and nonpathologic) with the accuracy respectively 90.9% and 83.3%. According to ROC analysis these myocardial deformation parameters had the greatest predictive value of significant coronary artery stenoses: longitudinal strain at high dose (AUC 0.811, sensitivity 89.4%, specificity 64.7%), longitudinal strain rate at high dose (AUC 0.855, sensitivity 88.1%, specificity 71.0% at high doses). The sensitivity and specificity of inducible wall motion abnormalities were 74.0% and 85.0% (AUC 0.798) and was lower compared with the diagnostic value of longitudinal myocardial deformation parameters. CONCLUSIONS: Left ventricular strain and strain rate analyses during DSE can be used in the assessment of hemodynamic significance of coronary artery stenosis in patients with moderate and high risk for CAD.