Peritoneal Carcinomatosis in Primary Ovarian Cancer: Ultrasound Detection and Comparison with Computed Tomography

We retrospectively compared detection rates and consistency for diagnosis of peritoneal carcinomatosis (PC) of primary ovarian cancer (OC) between ultrasound (US) and computed tomography (CT) scans in 41 patients whose PC of OC (stages IIC–IV) had been diagnosed by histopathology findings. Compared with CT detection rates, those for US were significantly higher for metastases to the pelvic area (92.3% vs. 43.6%, p < 0.001) and bowel surface (64.0% vs. 16.0%, p = 0.002); however, they did not significantly differ for other sites: omentum, diaphragm, lateral peritoneum, mesenteric, hepatic and splenic surfaces. Diagnostic consistency between US and CT scans were fair to moderate for splenic (κ = 0.806), hepatic (κ = 0.485), lateral peritoneum (κ = 0.450) and diaphragm (κ = 0.338) surfaces, but poorly consistent for other parts (κ = 0.144–0.229). In summary, US can complement CT scans, especially for detecting PC of primary OC metastases in pelvic and bowel surfaces.     

Image quality of Adaptive Iterative Dose Reduction 3D of coronary CT angiography of 640-slice CT: comparison with filtered back-projection

To assess the image quality of coronary CT angiography (CCTA) of 640-slice CT reconstructed by Adaptive Iterative Dose Reduction (AIDR) three-dimensional (3D) in comparison with the conventional filtered back-projection (FBP). CCTA images of 51 patients were scanned at the lowest tube voltage possible on condition that the built-in automatic exposure control system could suggest the optimal tube current. They were, then, reconstructed with FBP and AIDR 3D (standard). Objective measurements including CT density, noise, signal-to-noise ratio (SNR), and contrast-to-noise ratio (CNR) were performed. Subjective assessment was done by two radiologists, using a 5-point scale (0:nondiagnostic-4:excellent) based on the 15-coronary segment model which was grouped into three parts as the proximal, mid, and distal segmental classes. Radiation dose was also measured. AIDR images showed lower noise than FBP images (45.0 ± 9.4 vs. 73.4 ± 14.6 HU, p < 0.001) without any significant difference in CT density (665.5 ± 131.7 vs. 668 ± 136.3 HU, p = 0.8). Both SNR (15.0 ± 2.1 vs. 9.2 ± 1.7) and CNR (16.8 ± 2.3 vs. 10.4 ± 1.8) were significantly higher for AIDR than FBP (p < 0.001). Total subjective image quality score was also significantly improved in AIDR compared with FBP (3.1 ± 0.6 vs. 1.6 ± 0.4, p < 0.001), with better interpretability of the mid and distal segmental classes (100 vs. 95 % for the mid, p < 0.001; 100 vs. 90 % for the distal, p < 0.001). Mean effective radiation dose was 2.0 ± 1.0 mSv. The AIDR 3D reconstruction algorithm reduced image noise by 39 % compared with the FBP without affecting CT density, thus improving SNR and CNR for CCTA. Its advantages in interpretability were also confirmed by subjective evaluation by experts.     

Discrepancies between Doppler and catheter gradients in ventricular septal defect: a correction of localized gradients from pressure recovery phenomenon

Although very high gradient levels were measured during the evaluation of ventricular septal defect (VSD) in daily practice, these measurements are generally interpreted as erroneous and thus neglected. Our aim was to assess the features of VSD’s having erroneous interventricular pressure gradients by echocardiography. A 46 patients were enrolled in the study. The patients with higher Doppler-derived interventricular gradient than brachial systolic blood pressure were compared with patients with lower gradient (group 1, n = 26; group 2, n = 20, respectively) in terms of echocardiographic characteristics of VSD. No significant relations were observed in systolic and diastolic blood pressure and interventricular synchronicity between two groups (117.1 ± 6.7 vs 110.2 ± 6.3 mmHg, p = 0.145; 74.7 ± 4.3 vs 73.2 ± 4.9 mmHg, p = 0.32; 31.2 ± 5.5 vs 33.2 ± 4.9 msn, p = 0.29, respectively). Left ventricular end-diastolic and end-systolic diameters were greater in group 2 (46.6 ± 3.5 vs 49.5 ± 4.5, p = 0.022; 30.3 ± 2.5 vs 32.9 ± 3.2, p = 0.004, respectively). Doppler-derived interventricular pressure gradients were significantly higher in group 1 (144.4 ± 13.6 vs 75.7 ± 5.1 mmHg, p < 0.001, respectively). Defect width was significantly lower (3.20 ± 0.40 vs 4.8 ± 1.8 mm, respectively, p < 0.05), and length was greater in group 1 patients (5.75 ± 0.90 vs 2.80 ± 0.80 mm, p < 0.05, respectively). There was a significant positive correlation between pressure gradient and defect length (r = 0.84, p < 0.001), and a negative correlation between pressure gradient and defect width (r = ?0.66, p < 0.001). Defect length/width was significantly greater in group 1. With the cut-off value of 1.2, defect length/width was able to predict tunnel-type VSD with sensitivity of 88.5 % and specificity of 72.7 %. Continuous-wave Doppler method may overestimate interventricular pressure gradients in patients with tunnel-type ventricular septal defect.     

New inflammatory predictors for non-valvular atrial fibrillation: echocardiographic epicardial fat thickness and neutrophil to lymphocyte ratio

The objective of this study was to investigate the relationship of echocardiographic epicardial fat thickness (EFT) and neutrophil to lymphocyte ratio (NLR) with different types of non-valvular atrial fibrillation (AF) in a clinical setting. A total of 197 consecutive patients were enrolled in the study. Seventy-one patients had paroxysmal non-valvular AF, 63 patients had persistent/permanent non-valvular AF, and 63 patients had sinus rhythm (control group). EFT was measured with echocardiography, while NLR was measured by dividing neutrophil count by lymphocyte count. EFT was significantly higher in patients with paroxysmal non-valvular AF compared with those in the sinus rhythm group (6.6 ± 0.7 vs. 5.0 ± 0.9 mm, p < 0.001). Persistent/permanent non-valvular AF patients had a significantly larger EFT compared with those with paroxysmal AF (8.3 ± 1.1 vs. 6.6 ± 0.7 mm, p < 0.001). EFT had a significant relationship with paroxysmal non-valvular AF (odds ratio 4.672, 95 % CI 2.329–9.371, p < 0.001) and persistent/permanent non-valvular AF (OR 24.276, 95 % CI 9.285–63.474, p < 0.001). NLR was significantly higher in those with paroxysmal non-valvular AF compared with those in the sinus rhythm group (2.5 ± 0.6 vs. 1.8 ± 0.4, p < 0.001). Persistent/permanent non-valvular AF patients had a significantly larger NLR when compared with paroxysmal non-valvular AF patients (3.4 ± 0.6, vs. 2.5 ± 0.6, p < 0.001). NLR (>2.1) had a significant relationship with non-valvular AF (OR 11.313, 95 % CI 3.025–42.306, b 2.426, p < 0.001). EFT and NLR are highly associated with types of non-valvular AF independent of traditional risk factors. EFT measured by echocardiography and NLR appears to be related to the duration and severity of AF.     

Optical coherence tomography guided in-stent thrombus removal in patients with acute coronary syndromes

The persistence of thrombus inside stent struts is a frequent event in patients with acute coronary syndromes (ACS) undergoing percutaneous coronary intervention (PCI), and this phenomenon might be associated with an increased risk of stent thrombosis. We sought to quantify by means of optical coherence tomography (OCT) the presence of in-stent thrombus after achievement of an optimal angiographic result in patients with ACS undergoing PCI. In addition, we evaluated the feasibility and safety of an OCT-guided strategy of in-stent thrombus removal. Eighty consecutive patients with ACS undergoing PCI were treated with two different strategies equally divided into two groups: angio-guided PCI, and OCT-guided PCI, in which additional OCT-driven in-stent balloon dilatation was adopted to reduce thrombus encroachment of the lumen. Overall in-stent thrombus area was 4.3 % with a maximal thrombus encroachment of 16.7 %. In the OCT-guided group, use of high pressure intra-stent dilatation led to a significant increase in stented area (9.6 ± 2.4 vs. 9.1 ± 2.49 mm², p = 0.002) and lumen area (9.2 ± 2.4 vs. 8.7 ± 2.3 mm², p < 0.001) and also significantly decreased in-stent thrombus area in absolute (0.35 ± 0.29 vs. 0.42 ± 0.30 mm², p = 0.001) and relative terms (3.58 ± 3.25 vs. 4.53 ± 3.01 %, p = 0.001). Values of TIMI flow, frame count and blush grade, as well as clinical outcomes were not detrimentally affected by such additional dilatations. The use of additional OCT-driven in-stent balloon dilatations is feasible, safe and might be effective in the treatment of in-stent thrombus for patients with ACS.     

Portal Vein Pulsatility Ratio Provides a Measure of Right Heart Function in Chronic Heart Failure

Portal vein flow was recorded by color Doppler sonography in 31 patients with chronic heart failure and 18 control subjects. Compared with patients showing a forward flow (Group A), those with reversed portal vein flow (Group B) had higher prevalence of tricuspid regurgitation (75% vs. 43%), hepatic congestion (100% vs. 30%) and ascites (50% vs. 18%), and showed higher right atrial pressure (25.3 ± 3.01 mmHg vs. 11.8 ± 5.75 mmHg, p < 0.01). In controls, portal vein pulsatility ratio was 0.66 ± 0.08, in Group A it was 0.46 ± 0.28 (p < 0.01), in Group B −0.60 ± 0.19 (p < 0.01). Portal vein pulsatility ratio negatively correlated with right atrial pressure (r = −0.87; p < 0.01). In Group A, hepatic congestion, ascites and tricuspid regurgitation were associated with a higher portal vein pulsatility. This study indicates that portal vein pulsatility ratio reflects the level of impairment of the right heart.     

Role of Lung Ultrasound in Adjusting Ultrafiltration Volume in Hemodialysis Patients

Chronic fluid over-hydration is common in dialysis patients. It is associated with mortality and cardiovascular events. Optimal methods for adjusting fluid volume status and ideal dry weight remain uncertain. The purpose of this study was to evaluate the usefulness of ultrasound in quantifying body water. In 35 hemodialysis patients, we performed ultrasound of the chest, pre-tibial skin tissue thickness (TT), heart and inferior vena cava (IVC) before and after dialysis. We compared B-line scores of lungs, IVC diameters and cardiac functions in pre-dialysis and post-dialysis groups. We then estimated the correlations between ultrasound parameters and ultrafiltration volumes. Ultrafiltration parameters were adjusted prospectively for subsequent dialysis. As a result, both extravascular and intravascular water decreased during ultrafiltration. The median numbers of B-line scores (10 [0–42] vs. 4 [0–30]; p < 0.001); mitral valve blood flow velocities E (0.83 ± 0.23 m/s vs. 0.70 ± 0.20 m/s; p < 0.001), A (0.93 ± 0.28 vs. 0.89 ± 0.23 m/s; p < 0.001) and E/e' (12.47 ± 4.92 vs. 10.37 ± 4.0; p < 0.001); IVC diameters at end-expiration (17.51 ± 3.33 mm vs. 14.26 ± 3.45 mm; p < 0.001); and right pre-tibial TT (2.86 ± 1.36 mm vs. 2.43 ± 1.24 mm; p < 0.001) decreased during dialysis. Ultrafiltration volume was most associated with B-line score (adjusting for age and sex) (β?=?–3.340; p?=?0.003). In addition, the B-line score after dialysis was significantly associated with left ventricular ejection fraction (r?=?–0.393; p?=?0.019) and TT (r?=?–0.447; p?=?0.007). Ultrafiltration volume was prospectively increased then if the B-line score was >6 in the previous dialysis. All patients tolerated the protocol well without any symptoms. Ultrafiltration volume was most associated with lung water, reflected by variation in B-line score. It was not associated with cardiac function, IVC diameter, IVC collapse rate or TT. Lung ultrasound is a useful imaging tool for dialysis patients.     

Dobutamine-induced increase of right ventricular contractility without increased stroke volume in adolescent patients with transposition of the great arteries: Evaluation with magnetic resonance imaging

Objective: Prognosis in patients with surgically corrected (Senning or Mustard) transposition of the great arteries (TGA) depends mainly on right ventricular (RV) function and RV functional reserve. We examined the role of dobutamine stress in the early detection of RV dysfunction in asymptomatic or slightly symptomatic patients with TGA using magnetic resonance imaging (MRI). Design and patients: Twelve asymptomatic or slightly symptomatic patients with chronic RV pressure overload, surgically corrected (Mustard or Senning) TGA (age 22.8 (±3.4) years; New York Heart Association (NYHA) class I/II) and nine age matched healthy volunteers (age 27.3 (±4.4) years) were included. MRI was applied both at baseline and during dobutamine stress (start dose 5 μg/kg/min to maximum dose 15 μg/kg/min) to determine RV and left ventricular (LV) stroke volumes (SV) and ejection fraction (EF). Results: At baseline only RVEF was significantly higher in controls than in patients (71 (±9) vs. 57 (±10)%, p < 0.001), other RV parameters were not significantly different between the two examined groups: RVSV (86 (±21) vs. 72 (±27) ml, p = ns), RV end-diastolic volume (EDV) (123 (±37) vs. 123 (±33) ml, p = ns), and heart rate (61 (±10) vs. 69 (±14) bpm, p = ns), respectively. During dobutamine stress RVEF increased significantly both in controls and patients (20 (±16) vs. 17 (±18)%, p < 0.01 and p < 0.02 vs. rest, respectively), but stress RVEF was significantly higher in controls than in patients (85 (±3) vs. 66 (±7)%, p < 0.0001). RVSV increased significantly in controls (22 (±19)%, p < 0.02), and there was no significant increase in RVSV in patients (?10 (±28)%, p = ns). The controls showed no change in RVEDV (2 (±17)%, p = ns), but in patients a significant decrease in RVEDV (?24 (±15)%, p < 0.001) was observed. Maximal heart rate was significantly higher in patients than in controls (122 (±20) vs. 101 (±14) bpm, p < 0.02). Conclusion: In asymptomatic or slightly symptomatic patients with surgically corrected TGA dobutamine had a positive inotropic effect on RV, but the increased contractility was not accompanied by an appropriate increase in SV. Our data suggest inadequate RV filling in this category of patients, possibly due to rigid atrial baffles and compromised atrial function or decreased compliance due to RV hypertrophy.     

Evaluation of Myocardial Stiffness in Hypertensive Patients by Intrinsic Wave Propagation of the Myocardial Stretch

The objective of the study was to evaluate myocardial stiffness in hypertensive patients by measuring the intrinsic velocity propagation (IVP) of the myocardial stretch and to explore the correlation between IVP and cardiac systolic and diastolic functions. Eighty-one hypertensive patients and 53 healthy patients were prospectively enrolled in this study. IVP was measured using high-frame rate tissue Doppler (350−450 frames per second). IVP was significantly higher in hypertensive patients than in the control group (1.53 ± 0.39 m/s vs. 1.40 ± 0.19 m/s, p = 0.031). In the hypertensive group, IVP was significantly higher in patients with electrocardiogram (ECG) strain than in those without ECG strain (1.63 ± 0.46 m/s vs. 1.45 ± 0.32 m/s, p = 0.047). Moreover, IVP exhibited a good correlation with interventricular septal thickness at end-diastole (r = 0.434, p < 0.001), left ventricular posterior wall thickness at end-diastole (r = 0.439, p < 0.001), E/A ratio (r = 0.245, p = 0.004) and global longitudinal systolic strain (r = 0.405, p < 0.001). IVP was significantly higher in hypertensive patients, which indicates elevated myocardial stiffness in this cohort of patients. This novel measurement exhibited great potential for use in clinical practice to assess myocardial stiffness in patients with hypertension non-invasively.     

Association between changes in coronary artery circulation and cardiac venous retention: a lesson from cardiac computed tomography

To use computed tomography (CT) image data to measure a potential association between the implantation of coronary artery bypass grafts (CABG) and changes in the coronary venous system has not yet been examined. In 112 (aged 59.4 ± 9.0; 45F) patients (pts.), a 64-slice CT angiography was performed. Patients were divided into 2 groups: CABG (56 pts.) and control (56 pts.)—without changes in coronaries. In each case, ten multi-planar reconstructions (MPR) and 3D volume rendering reconstructions using a 2 mm layer with ECG-gating, helical pitch: 12.8; rotation time: 0.4 s and average tube voltage: 135 kV at 380 mA. The visualization of the coronary veins was independently graded by 2 experts trained in CT. In the CABG group, the average number of visible coronary veins was 5.3 ± 1.3, while in the control group it was 3.1 ± 1.1 (p < 0.001). Statistical differences were also observed for the following coronary veins: posterolateral (control 2.1 ± 1.9 vs. CABG 2.9 ± 1.9; p < 0.05), lateral (control 2.2 ± 1.7 vs. CABG 3.1 ± 1.3; p < 0.01) and anterolateral (control 0.5 ± 0.9 vs. CABG 1.3 ± 1.0; p < 0.001). Implantation of CABG influences the coronary venous system. In patients after CABG, the number of identifiable coronary veins is significantly higher as compared to that in subjects without changes in coronaries. This might suggest an association between changes in coronary artery circulation and cardiac venous retention.     

Impact of chronic liver disease in intensive care unit acquired pneumonia: a prospective study

Purpose

To assess the impact of chronic liver disease (CLD) on ICU-acquired pneumonia.

Methods

This was a prospective, observational study of the characteristics, microbiology, and outcomes of 343 consecutive patients with ICU-acquired pneumonia clustered according to the presence of CLD.

Results

Sixty-seven (20 %) patients had CLD (67 % had liver cirrhosis, LC), MELD score 26 ± 9, 20 % Child–Pugh class C). They presented higher severity scores than patients without CLD both on admission to the ICU (APACHE II, LC 19 ± 6 vs. other CLD 18 ± 6 vs. no CLD 16 ± 6; p < 0.001; SOFA, 10 ± 3 vs. 8 ± 4 vs. 7 ± 3; p < 0.001) and at onset of pneumonia (APACHE II, 19 ± 6 vs. 17 ± 6 vs. 16 ± 5; p = 0.001; SOFA, 11 ± 4 vs. 9 ± 4 vs. 7 ± 3; p < 0.001). Levels of CRP were lower in patients with LC than in the other two groups (day 1, 6.5 [2.5–11.5] vs. 13 [6–23] vs. 15.5 [8–24], p < 0.001, day 3, 6 [3–12] vs. 16 [9–21] vs. 11 [5–20], p = 0.001); all the other biomarkers were higher in LC and other CLD patients. LC patients had higher 28- and 90-day mortality (63 vs. 28 %, p < 0.001; 72 vs. 38 %, p < 0.001, respectively) than non-CLD patients. Presence of LC was independently associated with decreased 28- and 90-day survival (95 % confidence interval [CI], 1.982–17.250; p = 0.001; 95 % confidence interval [CI], 2.915–20.699, p = 0.001, respectively).

Conclusions

In critically ill patients with ICU-acquired pneumonia, CLD is associated with a more severe clinical presentation and poor clinical outcomes. Moreover, LC is independently associated with 28- and 90-day mortality. The results of this study are important for future trials focused on mortality.     

Effects of distal protection on left ventricular function in acute anterior myocardial infarction: a Doppler echocardiographic study

Whether distal protection devices (DPDs) during percutaneous coronary intervention (PCI) can improve myocardial function in patients with acute myocardial infarction (AMI) is still under debate. Using tissue Doppler imaging (TDI), we evaluate the global and regional left ventricular systolic and diastolic functions in patients with anterior AMI using DPDs compared with conventional PCI. Ninety-six patients with anterior AMI were randomly assigned to either PCI with DPDs (DPD, n = 46) or traditional PCI (control, n = 50) groups. At the 3- and 6-month follow-ups, the DPD group had a higher left ventricular ejection fraction than the control group (51.6 ± 3.6 vs. 49.3 ± 5.3% and 53.0 ± 3.7 vs. 50.8 ± 5.2%, respectively; both P < 0.05). Moreover, peak systolic (S _a) and early diastolic (E _a) mitral annular velocities obtained by TDI were significantly higher in the DPD group than in the control group (S _a: 7.57 ± 0.53 vs. 7.12 ± 0.62 cm/s and 7.71 ± 0.63 vs. 7.32 ± 0.59 cm/s; E _a: 7.23 ± 0.78 vs. 6.89 ± 0.86 cm/s and 7.49 ± 0.69 vs. 7.04 ± 0.85 cm/s, respectively; all P < 0.05). However, systolic and diastolic regional myocardial velocities significantly improved in the DPD group from the 1-month follow-up compared with those in the control group (all P < 0.05). Patients who received treatment with DPDs experienced enhanced improvement of cardiac function. Thus, anterior AMI patients can benefit from DPDs during PCI.     

Accuracy of MDCT in the preoperative definition of Peritoneal Cancer Index (PCI) in patients with advanced ovarian cancer who underwent peritonectomy and hyperthermic intraperitoneal chemotherapy (HIPEC)

Purpose

To evaluate the accuracy of MDCT in the preoperative definition of Peritoneal Cancer Index (PCI) in patients with advanced ovarian cancer who underwent a peritonectomy and hyperthermic intraperitoneal chemotherapy (HIPEC) after neoadjuvant chemotherapy to obtain a pre-surgery prognostic evaluation and a prediction of optimal cytoreduction surgery.

Materials and methods

Pre-HIPEC CT examinations of 43 patients with advanced ovarian cancer after neoadjuvant chemotherapy were analyzed by two radiologists. The PCI was scored according to the Sugarbaker classification, based on lesion size and distribution. The results were compared with macroscopic and histologic data after peritonectomy and HIPEC. To evaluate the accuracy of MDCT to detect and localize peritoneal carcinomatosis, both patient-level and regional-level analyses were conducted. A correlation between PCI CT and histologic values for each patient was searched according to the PCI grading.

Results

Considering the patient-level analysis, CT shows a sensitivity, specificity, PPV, NPV, and an accuracy in detecting the peritoneal carcinomatosis of 100 %, 40 %, 93 % 100 %, and 93 %, respectively. Considering the regional level analysis, a sensitivity, specificity, PPV, NPV, and diagnostic accuracy of 72 %, 80 %, 66 %, 84 %, and 77 %, respectively were obtained for the correlation between CT and histology.

Conclusion

Our results encourage the use of MDCT as the only technique sufficient to select patients with peritoneal carcinomatosis for cytoreductive surgery and HIPEC on the condition that a CT examination will be performed using a dedicated protocol optimized to detect minimal peritoneal disease and CT images will be analyzed by an experienced reader.     

Color M-Mode Doppler Flow Propagation Velocity Is a Relatively Preload-Independent Index of Left Ventricular Filling

Standard Doppler indexes of transmitral filling vary in response to alterations in left ventricular (LV) relaxation or preload. To determine whether color M-mode Doppler flow propagation velocity (v_p ), a new index of LV relaxation, is affected by preload, we obtained LV volumes, standard Doppler filling indexes, and v_p in 20 patients at baseline, during Trendelenburg’s position, inverse Trendelenburg’s position, and after inhalation of amyl nitrite. LV end-diastolic volume decreased from 111 ± 41 mL at baseline and 116 ± 43 mL during Trendelenburg’s position, to 104 ± 40 during inverse Trendelenburg’s maneuver and 92 ± 33 mL after inhalation of amyl nitrite (P < .0001). Peak early filling velocity decreased from 79 ± 19 cm/s and 90 ± 20 cm/s to 73 ± 22 cm/s and 64 ± 20 cm/s, respectively (P < 0.0001). In contrast, no significant changes were found in v_p (48 ± 24 and 50 ± 26 cm/s vs 48 ± 25 and 48 ± 25 cm/s). We conclude that v_p is not affected significantly by preload. Thus v_p may provide a more reliable and independent assessment of LV relaxation. (J Am Soc Echocardiogr 1999;12:129-37.)     

Impact of right ventricular dyssynchrony on left ventricular performance in patients with pulmonary hypertension

Pulmonary hypertension has been associated with right ventricular (RV) dyssynchrony which may induce left ventricular (LV) dysfunction and dyssynchrony through ventricular interdependence. The present study evaluated the influence of RV dyssynchrony on LV performance in patients with pulmonary hypertension. One hundred and seven patients with pulmonary hypertension (age 63 ± 14 years, systolic pulmonary arterial pressure 60 ± 19 mmHg) and LV ejection fraction (EF) >35 % were evaluated. Ventricular dyssynchrony was assessed with speckle tracking echocardiography and defined as the standard deviation of the time to peak longitudinal strain of six segments of the RV (RV-SD) and the LV (LV-SD) in the apical 4-chamber view. Mean RV-SD and LV-SD assessed with longitudinal strain speckle tracking echocardiography were 51 ± 28 and 47 ± 21 ms, respectively. The patient population was divided according to the median RV-SD value of 49 ms. Patients with RV-SD ≥49 ms had significantly worse NYHA functional class (2.7 ± 0.7 vs. 2.3 ± 0.7, p = 0.004), RV function (tricuspid annular plane systolic excursion: 16 ± 4 vs. 19 ± 4 mm, p < 0.001), LVEF (50 ± 10 vs. 55 ± 8 %, p = 0.001), and larger LV-SD (57 ± 18 vs. 36 ± 18 ms, p < 0.001). RV-SD significantly correlated with LV-SD (r = 0.55, p < 0.001) and LVEF (r = ?0.23, p = 0.02). Multiple linear regression analysis showed an independent association between RV-SD and LV-SD (β = 0.35, 95 %CI 0.21–0.49, p < 0.001). RV dyssynchrony is significantly associated with LV dyssynchrony and reduced LVEF in patients with pulmonary hypertension.     

Tissue doppler myocardial performance index in patients with heart failure and its relationship with haemodynamic parameters

The myocardial performance index (MPI) reflects both the systolic and diastolic function of the heart, and is easily applied in practice. In this study, we aimed to determine the relationship between MPI and invasive haemodynamic parameters in heart failure patients. A total of 126 patients with heart failure were selected, all of whom were referred for diagnostic cardiac catheterisation, and were divided into two groups. Group I consisted of 59 patients (32 men and 27 women, mean age 61 ± 10; functional capacity New York Heart Association (NYHA) Class I; and left ventricular end-diastolic pressure (LVEDP) <16 mmHg). Group II included 67 patients (34 men and 33 women, mean age 60 ± 9; NYHA Class ≥ II; LVEDP ≥ 16 mmHg). The following parameters were measured in all patients: ejection fraction with Simpson method, the peak mitral early (E) and late (A) diastolic velocities, E/A ratio, deceleration time (DT) and tissue Doppler from four different areas of the mitral annulus (septum, lateral, inferior and anterior). In order to measure MPI with two methods (standard Doppler and tissue Doppler), isovolumetric contraction time (IVCT), isovolumetric relaxation time (IVRT) and ejection time (ET) were measured from four areas and mean values of MPI were calculated. There was no difference between the two groups in E/A ratios, DT and IVRT (p > 0.05). Group II patients had longer IVCT and ET, when compared with group I patients (p < 0.05). MPI, measured by both standard pulsed wave Doppler and tissue Doppler methods, was significantly higher in group II patients, when compared with the values obtained from group I patients (Group I: 0.50 ± 0.2 and 0.50 ± 0.14; group II: 0.98 ± 0.3 and 1.2 ± 0.32; p < 0.001). According to receiver operating characteristics curve analysis, the cut-off value for MPI measured by tissue Doppler was 0.74. The sensitivity and specificity of this value were measured as 92.5 and 91.5 %, respectively. MPI measured by standard Doppler method was 0.67, and its sensitivity and specificity were 85.1 and 83.1 %, respectively. We found a strong relationship between MPI and LVEDP (r = 0.83, p < 0.001; r = 0.96, p < 0.001), especially when measured by tissue Doppler. In addition, we observed a significant relationship between the MPI values measured by tissue Doppler and those measured by standard traditional methods (r = 0.85, p < 0.001). We showed that MPI was reliable for the evaluation of global cardiac functions in patients with heart failure, as measured with both pulsed-wave Doppler and tissue Doppler. We assert that, in order to differentiate between those patients with symptomatic heart failure from the asymptomatic cases, MPI as measured with the tissue Doppler method is an improvement on MPI as measured using traditional methods.     

Clinical correlates of endothelial function in chronic heart failure

Objective

There is a close link between heart failure and endothelial dysfunction. Brachial flow-mediated dilation (FMD) is a validated non-invasive measure of endothelial function. The aim of this study was to investigate the clinical correlates of FMD in patients with chronic heart failure (CHF).

Design, setting, patients

We evaluated 60 CHF outpatients (age 62?±?14?years; 49 males, NYHA class 2.2?±?0.7, left ventricular ejection fraction, LVEF, 33?±?8%) taking conventional medical therapy (ACE-inhibitors and/or ARBs 93%, beta-blockers 95%) and in stable clinical conditions.

Main outcome measures

The maximum recovery value of FMD was calculated as the ratio of the change in diameter (maximum-baseline) over the baseline value.

Results

As compared with patients with a higher FMD, those with FMD below the median value (4.3%) were more frequently affected by ischemic cardiopathy (50 vs. 23%; p?=?0.032) and diabetes mellitus (20 vs. 3%; p?=?0.044), had a higher NYHA class (2.5?±?0.5 vs. 1.9?±?0.7; p?<?0.001) and NT-proBNP (2,690?±?3,690 vs. 822?±?1,060; p?=?0.001), lower glomerular filtration rate estimated by Cockcroft-Gault (GFRCG: 63?±?28 vs. 78?±?25; p?=?0.001) and LVEF (29?±?8 vs. 37?±?9; p?=?0.001), as well as more frequently showing a restrictive pattern (40 vs. 7%; p?=?0.002). In a multivariate regression model (R ²?=?0.48; p?<?0.001), FMD remained associated only with the NYHA class (p?=?0.039) and diabetes mellitus (p?=?0.024).

Conclusions

This study demonstrates that a better functional status and absence of diabetes mellitus are associated to higher FMD regardless of the etiology of the cardiac disease.     

The impact of high-normal blood pressure on left ventricular mechanics: a three-dimensional and speckle tracking echocardiography study

To assess the presence of subclinical left ventricular myocardial dysfunction in subjects with high-normal blood pressure (BP) and untreated arterial hypertension, using three-dimensional (3D) echocardiography strain analysis. This cross-sectional study included 49 subjects with optimal BP, 50 subjects with high-normal BP, and 50 newly diagnosed untreated hypertensive patients matched by gender and age. All the subjects underwent 24 h blood pressure monitoring and complete two-dimensional and 3D echocardiography examination. The enrolled subjects were grouped according to 24 h systolic BP values, dividing the subjects with optimal BP from those with high-normal BP and the hypertensive patients (cut-off values were 120 and 130 mmHg, respectively). 3D global longitudinal strain was significantly lower in the high-normal BP group and the hypertensive patients, in comparison with the optimal BP group (?20.5 ± 3.3 vs. ?18.7 ± 2.8 vs. ?17.6 ± 2.7 %, p < 0.001). Similar results were obtained for 3D global circumferential strain (?18.6 ± 3 vs. ?17.1 ± 2.9 vs. ?16 ± 2.5 %, p < 0.001), as well for 3D global radial strain (49.4 ± 9.5 vs. 44.7 ± 8.1 vs. 43.5 ± 7.8 %, p = 0.002), and global area strain (?31.2 ± 4.8 vs. ?28.7 ± 4.2 vs. ?27.1 ± 4.5 %, p < 0.001). LV twist was increased in the hypertensive patients in comparison with the high-normal and the optimal BP groups (10.1° ± 2.4° vs. 10.8° ± 2.6° vs. 13.8° ± 3.1°, p < 0.01), whereas untwisting rate significantly and gradually decreased from the optimal BP group, across the high-normal BP group, to the hypertensive patients (?135 ± 35 vs. ?118 ± 31 vs. ?102 ± 27°/s, p < 0.001). 3D echocardiography revealed that the subjects with high-normal BP suffered subclinical impairment of LV mechanics similar as the hypertensive patients.