Hepatic and cardiac iron overload among patients with end-stage liver disease referred for liver transplantation.

BACKGROUND: Iron overload is associated with fatal cardiovascular events following liver transplantation. Myocardial iron deposits were observed post-mortem in patients who died of cardiac events after transplantation at our institution. This observation prompted testing to exclude cardiac iron in subsequent transplant candidates. AIMS: To assess the results of testing for iron overload in liver transplant candidates at our institution. METHODS: Ferritin, TIBC, and serum iron were measured in cirrhotics referred for transplantation. Patients with transferrin saturation ≥50% and ferritin ≥250 ng/mL underwent liver biopsy graded for iron. Patients with 3-4+ hepatic iron deposits underwent HFE mutation analysis and endomyocardial biopsy with iron staining. RESULTS: Eight hundred and fifty-six patients were evaluated for liver transplantation between January 1997 and March 2005. Two hundred and eighty-seven patients (34%) had transferrin saturation ≥50% and ferritin ≥250 ng/mL. Patients with markers of iron overload had more advanced liver disease than those with normal iron indices. One hundred and fifty-three patients underwent liver biopsy. Twenty-six patients (17%) had 3-4+ hepatic iron staining. One patient was a C282Y heterozygote. Endomyocardial biopsy was performed in 14 patients of whom nine had cardiac iron deposition. CONCLUSIONS: Non-HFE-related cardiac iron overload can occur in advanced liver disease We therefore recommend screening for cardiac iron prior to liver transplantation.

Tissue Doppler-derived myocardial acceleration for evaluation of left ventricular diastolic function.

OBJECTIVES: Our purpose was to evaluate a tissue Doppler-based index-peak myocardial acceleration (pACC)-during isovolumic relaxation and in evaluating left ventricular (LV) diastolic function. BACKGROUND: Simple, practical indexes for diastolic function evaluation are lacking, but are much desired for clinical evaluation. METHODS: We examined eight sheep by using tissue Doppler ultrasound images obtained in the apical four-chamber views to evaluate mitral valve annular velocity at the septum and LV wall. The pACC thus derived was analyzed during isovolumic relaxation (IVRT) and during the LV filling period (LVFP). We then changed the hemodynamic status of each animal by blood administration, dobutamine, and metoprolol infusion. We compared the pACC values during IVRT and LVFP over the four different hemodynamic conditions with a peak rate of drop in LV pressure (-dP/dt(min)) and the time constant of LV isovolumic pressure decay (tau), as measured with a high-frequency manometer-tipped catheter. RESULTS: The pACC of the septal side of the mitral valve annulus during IVRT showed a good correlation with -dP/dt(min) (r = -0.80, p < 0.0001) and tau (r = -0.87, p < 0.0001). The mean left atrial pressure (LAP) correlated well with the septal side pACC during LVFP (r = 0.81, p < 0.0001). There was a weak correlation between the mitral valve annulus pACC at the LV lateral wall and mean LAP. CONCLUSIONS: The pACC during IVRT is a sensitive, preload-independent marker for evaluation of LV diastolic function. In addition, pACC during LVFP correlated well with mean LAP.

Biphasic left ventricular outflow and its mechanism in hypertrophic obstructive cardiomyopathy.

BACKGROUND: Biphasic systolic velocity in the left ventricular (LV) outflow tract (LVOT) occurs in hypertrophic obstructive cardiomyopathy (HOCM). The cause and importance of this observation remain poorly understood. METHODS: A total of 25 patients with HOCM were matched to 30 control subjects. A function derived from the relation of flow in the proximal descending aorta to that in the LVOT was used to estimate the LVOT systolic flow rate in HOCM. Patients with HOCM were grouped by absence (group I) or presence (group II) of biphasic LVOT velocity. RESULTS: Biphasic LVOT velocity was associated with biphasic estimated LVOT outflow (P =.002). The LVOT pressure gradient was inversely related to LV outflow rate at the time of the peak gradient (r = -.64, P <.001). Dobutamine increased the gradient and reduced LVOT outflow at the time of the peak gradient. In group II, mitral-septal separation occurred despite a LVOT gradient (36 mm Hg). CONCLUSION: Biphasic LVOT flow in HOCM occurs and may be caused by "afterload mismatch." The late systolic increase in flow is related to mitral-septal separation. Resolution of systolic anterior motion occurs despite a persistent LVOT pressure gradient, implying a role for forces other than pressure differences.

Will a handheld ultrasound scanner be applicable for screening for heart abnormalities in newborns and children?

BACKGROUND: There is significant interest in opportunities to provide echocardiography services for detection of congenital heart disease with portable, or even handheld, devices in remote areas or third world countries where conventional ultrasound systems may not be available. We tested a handheld system (HHS) (SonoHeart, SonoSite Inc, Bothell, Wash) equipped with a broadband, 7- to 4-MHz, miniaturized, curved, linear-array transducer and implemented with an improved directional Doppler flow map. METHODS: All echocardiography scanning was performed in the neonatal nursery, pediatric intensive care department, or pediatric echocardiography laboratory of our institution. We reviewed limited echocardiography view sequences sequentially obtained by the same expert examiner (D.J.S.) in 50 infants and children (age: 1 day to 6 years), with preoperative or postoperative forms of congenital heart disease. Each patient was studied twice, once with a conventional full-feature system (FFS) and then a limited scan with the HHS using similar frequency transducers. The cardiologist (D.J.S.) and blinded research laboratory reviewers (X.L., G.K.M., R.A.R.) read the FFS and HHS image sequences for diagnosis and for grading the quality of the anatomic and flow feature images. The studies were performed and reviewed with the examiner and reviewers blinded to patient diagnosis. RESULTS: The major diagnoses (eg, patent ductus arteriosus, atrio-ventricular (AV) canal, peripheral pulmonary valve stenosis, aortic coarctation, atrial septal defect, ventricular septal defect, preoperative or postoperative tetralogy of Fallot, and mitral regurgitation) were made by both readers, who were unaware of each other's diagnosis results. Furthermore, the average composite HHS cardiac anatomic feature score on a scale of 0 (not visualized) to 3 (visualized precisely) from the parasternal long-axis and 4- or 5-chamber view for cardiac anatomy were 2.67 +/- 0.49 (SD) and 2.50 +/- 0.55, respectively, versus 2.73 +/- 0.45 and 2.55 +/- 0.54 for the FFS. The mean flow feature score, comprising all views, was 2.67 +/- 0.45 (HHS) versus 2.72 +/- 0.48 (FFS). The P values for all above comparisons were >.05. Image quality of the FFS anatomic structures were, thus, not statistically different from the HHS. Although the color cosmetic was different for the HHS directional (nonvelocity) map, only 9% of 150 total findings (including structural abnormalities and flow features, none of which were critical) were missed, whereas the other 91% regurgitant, shunt, stenosis flow features or heart structure were imaged adequately by the HHS in this population. CONCLUSIONS: Implementing high-frequency transducers and programs optimized for tissue and flow imaging on the HHS should provide images of sufficient quality for targeted echocardiography examinations to determine the presence, absence, or status of congenital heart disease in newborns and young children.

Strain rate acceleration yields a better index for evaluating left ventricular contractile function as compared with tissue velocity acceleration during isovolumic contraction time: an in vivo study.

OBJECTIVE: Our study aimed to investigate whether strain rate acceleration (SRA) during isovolumic contraction time (IVCT) could serve as a sensitive indicator of myocardial function. METHODS: A total of 8 sheep underwent occlusion of left anterior descending coronary artery or diagonal branches and 2 sheep underwent left circumflex coronary artery occlusion to create septal, apical, or basal segment myocardial ischemia 19 to 27 weeks before the study. Baseline, volume-loading, dobutamine, and metoprolol infusion were used to produce 4 hemodynamic stages for each sheep. Doppler tissue imaging was acquired using a 5-MHz probe (GE/VingMed Vivid Five, GE Medical Systems, Milwaukee, Wis) on open-chest animals using the liver as a standoff at the apex. Using software (EchoPac, GE Medical Systems), SRA during IVCT was calculated and compared with tissue velocity acceleration (TVA) during IVCT from areas located in the normal and ischemic zones. Also, invasively monitored left ventricle dP/dt was measured as reference contractile function. RESULTS: Both TVA and SRA during IVCT showed higher values for normal tissue than for ischemic area (P <.0001). SRA for normal wall segments changed significantly during the 4 stages (P =.01) with corresponding changes on high-fidelity left ventricular pressure catheters (r = 0.92). TVA over normal segments showed no significant change (P =.29) in the 4 hemodynamic stages. Both TVA and SRA of the ischemic segments showed no significant change with pharmacologic maneuvers or loading conditions. CONCLUSIONS: SRA and TVA during IVCT are both useful indicators for detecting abnormal heart wall motion. However, SRA tends to be more sensitive than TVA for differentiating the response to stress conditions.

Guideline-based early rehabilitation after myocardial infarction. A pragmatic randomised controlled trial.

OBJECTIVES: To determine the effectiveness of individualised educational behavioural treatment delivered by cardiac nurses in hospital compared to usual care for patients following acute myocardial infarction. METHODS: One hundred and fourteen consecutive patients were randomised to receive the intervention or usual care. Outcome assessment was by self-report questionnaire (the Hospital Anxiety and Depression Scale and Dartmouth COOP Health Status), interview at 1 month, and self-report at 3 and 12 months. The primary outcome was improvement in the Dartmouth COOP total score from baseline to 3 months. RESULTS: Four patients needed to be treated to give an additional patient with improvement in health status at 3 months (number needed to treat [NNT] 4, 95% confidence intervals [CIs] 3 to 12). The intervention group were more confident about returning to activities 1 month after discharge from hospital. Treated patients had fewer further treatment needs. CONCLUSIONS: An individualised educational behavioural treatment delivered by cardiac nurses in hospital may have substantial benefits. A large-scale pragmatic RCT is needed.

Real-time 3-dimensional Doppler echocardiography for the assessment of stroke volume: an in vivo human study compared with standard 2-dimensional echocardiography.

BACKGROUND: Invasive monitors and noninvasive 2-dimensional echocardiography are the standard clinical methods for stroke volume (SV) and cardiac output computation. We studied the use of real-time color Doppler 3-dimensional (3D) echocardiography (3DE) for the assessment of SV in human beings. METHODS: In all, 55 pediatric and adult patients with good transthoracic windows and a normal aortic valve were studied. Real-time 3DE color Doppler volumes incorporating the left ventricular outflow tract and aortic valve were taken. SV was calculated from the color Doppler data in the 3DE DICOM dataset. This was compared with 2-dimensional echocardiography SV calculation from the pulsed wave velocity through the aortic valve along with the left ventricular outflow tract diameter. RESULTS: Five patients were excluded because of mismatching of the 3D color Doppler segments in the 3D volume. The 3D Doppler volumes from the remaining 50 patients were analyzed. There was good correlation between the patients' averaged 3DE SV calculations and the 2-dimensional echocardiography pulsed wave SV estimation (y = 0.84x + 7.8, r2 = 0.90). CONCLUSION: Real-time 3D Doppler echocardiography can be used to accurately calculate SV and cardiac output, compared with conventional pulsed Doppler measurement, in pediatric and adult patients from transthoracic imaging.

Strain rate imaging: an in vitro "validation" study using a physiologic balloon model mimicking the left ventricle.

BACKGROUND: Strain rate imaging (SRI) can be implemented from digital ultrasound loops of tissue Doppler imaging (TDI) data and is performed as an autocorrelation solution of the distance between intramyocardial targets. As such, it should have better resolution along longer distances of wall segments that are imaged at the length of individual ultrasound scan lines. METHODS: We used a new left ventricular double-balloon phantom with a tissue-mimicking gel between the walls. Mounted in a water bath and connected to a pulsatile flow pump at four-stroke volume (30-50 ml/beat), the high frame rate, digital, multiple two-dimensional/tissue/TDI loops of balloon wall motion were recorded using a GE VingMed system FiVe (3.5 MHz phased array transducer), with the model scanned longitudinally from the apex. The strain rate (SR) values were measured at the apex and the lateral wall using an offline measurement program, and mean SR values for every 100 msec were calculated by averaging three determinations at each point. The excursions of the apex and lateral wall also were measured directly by high speed digital video imaging, and consecutive velocity profiles were calculated every 100 msec. A total of 40 data points for four-stroke volumes were analyzed. RESULTS: While our balloon model had enough gel targets between the walls to produce a good mimic of myocardial speckle with walls that thickened and thinned, samples immediately across the apex and apex SR values (Hz) varied substantially. In contrast, systematic signals could be obtained from lines imaged >15 degrees from the true apex and crossing a longer length of myocardium. At the lateral wall, there was a close correlation between the video velocities and SR values, as well as a close overlap of the phasic patterns. CONCLUSIONS: SRI produces more reliable data from wall segments parallel to scan lines.