Exercise hemodynamic findings in patients with exertional dyspnea

To determine whether upright bicycle exercise could provide useful information about disabling exertional dyspnea in the absence of severe abnormalities (as shown by traditional testing methods), we evaluated 13 such patients. There were 3 men and 10 women with a mean age of 49+/-15 (SD) years. We used pulmonary artery catheterization at rest and during upright bicycle exercise to evaluate these patients. All patients had normal left ventricular function except for 1, who had an ejection fraction of 45%. The mean duration to peak exercise was 9+/-6 minutes. Normal systolic pulmonary artery pressure was defined as 25+/-5 mmHg. Four patients had normal systolic pulmonary pressure, and 9 exhibited pulmonary hypertension with exercise. In those 9, the mean mixed pulmonary venous oxygen saturation at rest was 61%+/-9% and fell to 32%+/-9% at peak exercise. Six of the 9 patients also had some degree of resting pulmonary hypertension that worsened with exercise: their mean pulmonary artery systolic pressure at rest was 47+/-14 mmHg and rose to 75+/-25 mmHg at peak exertion (P = 0.01). The other 3 patients showed no pulmonary hypertension at rest; their mean pulmonary artery systolic pressure was 27+/-6 mmHg. However, this level rose to 53+/-4 mmHg at peak exertion (P = 0.04). In this pilot study of patients with dyspnea, 9 of 13 (69%) displayed marked pulmonary hypertension with exercise. The resting hemodynamic levels were normal in 3 (33%) of those with exercise pulmonary hypertension. We conclude that hemodynamic data from bicycle exercise tests can provide additional information regarding the mechanisms of exertional dyspnea.     

A prospective evaluation of outcome in patients referred for PEG placement

BACKGROUND: PEG feeding is not recommended for short-term use because the 30-day mortality after PEG placement is substantial. The primary aim of this study was to prospectively identify factors predictive of survival in patients referred for PEG placement. METHODS: All patients for whom gastroenterology consultation was sought for feeding PEG placement were prospectively studied. Demographic data, Charlson comorbidity index, and functional status were recorded at entry. After PEG placement, patients were followed for up to 12 months. RESULTS: Of the 67 patients for whom consultation was requested, 58 were eligible for the study and 50 underwent PEG placement. The 7-day and 30-day mortality rates in the PEG placement group were 4% and 20%, respectively. In multivariate analysis, only the Charlson index > or =4 was associated with decreased survival time (relative hazard = 2.9: 95% CI [1.20, 7.21], p = 0.019). Median survival in patients with Charlson comorbidity index > or =4 was significantly shorter than that in patients with Charlson index < 4 (p = 0.013). CONCLUSIONS: A Charlson comorbidity index > or =4 was significantly associated with shorter patient survival after initial consultation. Careful consideration of predictive factors of survival may improve patient selection for feeding PEG placement.     

Exercise dyspnea in patients with COPD

Dyspnea, a symptom limiting exercise capacity in patients with COPD, is associated with central perception of an overall increase in central respiratory motor output directed preferentially to the rib cage muscles. On the other hand, disparity between respiratory motor output, mechanical and ventilatory response of the system is also thought to play an important role on the increased perception of exercise in these patients. Both inspiratory and expiratory muscles and operational lung volumes are important contributors to exercise dyspnea. However, the potential link between dyspnea, abnormal mechanics of breathing and impaired exercise performance via the circulation rather than a malfunctioning ventilatory pump per se should not be disregarded. Change in arterial blood gas content may affect dyspnea via direct or indirect effects. An increase in carbon dioxide arterial tension seems to be the most important stimulus overriding all other inputs from dyspnea in hypercapnic COPD patients. Hypoxia may act indirectly by increasing ventilation and indirectly independent of changes in ventilation. A greater treatment effect is often achieved after the addition of pulmonary rehabilitation with pharmacological treatment.     

Prevalence of abnormal echocardiographic findings in cancer patients: a retrospective evaluation of echocardiography for identifying cardiac abnormalities in cancer patients

Background: Transthoracic echocardiography (TTE) is commonly used to assess cardiac morphology and function in cancer patients. The nature, distribution, and prevalence of significant echocardiographic abnormalities are unknown. We hypothesized that TTEs performed for cancer or cancer treatment indications, have a high prevalence of significant abnormalities (SA), including a large proportion of findings that may be overlooked by other imaging modalities. Methods: All TTE studies performed in a tertiary cancer center over a six‐month period, from January to June 2007, were reviewed. The TTEs were divided into studies performed for a cardiovascular indication (CV) and those done for a cancer‐related indication (CA). Reports were classified as normal, mildly abnormal, and significantly abnormal (SA) based on findings. Abnormal findings’ distributions were compared between indication groups. Results: Three thousand nine hundred and twenty‐four TTEs were performed and divided into either group CV (61.2%) or group CA (38.7%). The most common indication in the CV group was valvular diseases (29.9%). In the CA group, the majority of TTE were requested for evaluation during or after chemotherapy or radiation (94.7%). Around 41.9% of studies in group CV were classified as SA whereas 19.9% (P < 0.001) in the CA group were classified as such. The relative distributions of individual SA findings were compared between the indication groups and were not statistically different. Conclusions: One in five patients who had TTE studies for CA were found to have SA, and 81.5% of these may not have been found with other modalities. The TTE allows safe diagnosis of a wide range of abnormal findings that may be overlooked if alternative but less versatile modalities are used. (Echocardiography 2011;28:1061‐1067)     

Clinical outcome and echocardiographic findings of native and prosthetic valve endocarditis in the 1990s

Prosthetic valve endocarditis is considered to be associatedwith a more severe prognosis than native valve endocarditis.Among other factors, inappropriate visualization of vegetationsin prosthetic valve endocarditis by transthoracic echocardiographyis responsible for this observation. Since the introductionof transoesophageal echocardiography into clinical practicethe diagnostic sensitivity and specificity of the detectionof vegetations located on prosthetic valves have been enhanced.Therefore we aimed to determine and compare the prognosis ofprosthetic valve endocarditis and native valve endocarditisin the era of this improved diagnostic approach. One hundred and six episodes of infective endocarditis in 104patients were seen at our institution between 1989 and 1993.Eighty patients (77%) had native valve endocarditis and 24 (23%)had late prosthetic valve endocarditis. In the latter grouptwo patients had recurrent infective endocarditis. Patientswith prosthetic valve endocarditis were older (mean age 64 vs54 years in native valve endocarditis; P<0.00l) and the majoritywas female (62% vs 38% in native valve endocarditis; P<0.001In prosthetic valve endocarditis, infection of a valve in themitral position predominated (65% vs 30% in native valve endocarditis;P<0.0l), whereas in native valve endocarditis more than halfthe cases had isolated aortic valve endocarditis (51% vs 27%in prosthetic valve endocarditis; P<0.01). In prostheticvalve endocarditis more cases were caused by Staphylococcusaureus (31% vs 14% in native valve endocarditis; P<0.08),whereas in native valve endocarditis the most frequent organismswere streptococci (29% vs l9% in prosthetic valve endocarditis;P<0.12). Differences in the clinical features of native valveendocarditis and prosthetic valve endocarditis could not befound except for a higher rate of embolism in native valve endocarditis(40% vs l9% in prosthetic valve endocarditis; P<0.05). Vegetationscould be detected by transthoracic echocardiography more frequentlyin native valve endocarditis (71% vs 15% in prosthetic valveendocarditis; P<0.0001). Transoesophageal echocardiographyvisualized vegetations in 95% of the episodes of native valveendocarditis and in 80% of the episodes of prosthetic valveendocarditis (P<0.09). Thus, the diagnostic gain by transoesophagealechocardiography was greatest in prosthetic valve endocarditis.Patients with native valve endocarditis had significantly largervegetations than patients with prosthetic valve endocarditis(P<0.05 for length, P<0.00l for width). The median timeto diagnosis was similar in native valve endocarditis and prostheticvalve endocarditis (31 vs 28 days). Surgery was performed in 74% of patients with native valve endocarditisand in 58% of those with prosthetic valve endocarditis; themedian time delay between the diagnosis of infective endocarditisand surgery tended to be shorter in prosthetic valve endocarditisthan in native valve endocarditis (45 vs 60 days). The in-hospitalmortality and the mortality during a follow-up of 22±10 months did not significantly differ between native valveendocarditis and prosthetic valve endocarditis (21% vs 17% 28%vs 25%). In summary in the era of transoesophageal echocardiography,late prosthetic valve endocarditis does not seem to carry aworse prognosis than native valve endocarditis. This can beattributed in part to the improved diagnostic accuracy achievedby transoesophageal echocardiography leading to comparable diagnosticlatency periods in both patient groups. Finally, better characterizationof vegetations on prosthetic valves by transoesophageal echocardiographyallows early lifesaving surgery in patients with prostheticvalve endocarditis.     

感染性心内膜炎的临床表现与超声心动图诊断

对40例感染性心内膜炎（IE）患者的临床资料进行分析，结果显示，采用超声心动图检查能检出瓣膜赘生物者38例（95％），血培养阳性者仅8例（20％），发热和栓塞的发生率分别为55％和30％。瓣膜赘生物多发生于左心系统（37例），尤以主动脉瓣多见（22例）。8例血培养阳性者以金黄色葡萄球菌多见（3例），草绿色链球菌已降为从属地位（1例）。瓣膜返流、心力衰竭和栓塞是1E最常见的并发症。     

Comparison of echocardiographic findings in patients with nonfunctioning adrenal incidentalomas

Adrenal incidentalomas (AIs) are usually discovered incidentally after imaging unrelated to adrenal glands. We aimed to evaluate standard risk factors for systemic atherosclerosis and echocardiographic changes in patients with nonfunctioning AIs and compare them with normal subjects. We evaluated 70 patients diagnosed with AIs and 51 healthy controls. Mean levels were determined for HbA1c, LDL, uric acid, fasting plasma insulin, HOMA, and neutrophil-to-lymphocyte ratio (NLR), and these values were found to be significantly higher in the patients than the controls. The mean left atrial diameter, interventricular septum thickness, posterior wall thickness, left ventricular mass, E-wave deceleration time, isovolumetric relaxation time, and the median ratio of the early transmittal flow velocity to the early diastolic tissue velocity (E/Em) were higher in patients with AIs compared to controls. The mitral annular early diastolic velocity was lower in patients with AIs. The mean aortic diastolic diameter, stiffness index (SI), and aortic strain were higher, and aortic distensibility was lower in the patients. The mean right ventricular diameter, right atrial major-axis diameter, and right atrial minor-axis diameter were statistically higher in the patient group than the controls. A negative correlation was found between the NLR and aortic strain and aortic distensibility, while a positive correction was found between the NLR and SI. We found altered left ventricular (LV) and right ventricular (RV) echocardiographic findings in patients with AIs without known cardiovascular disease. Aortic stiffness was also increased. These changes may be related to an increase in cardiovascular risk factors in AI patients.     

Clinical and exercise echocardiographic findings in patients with mitral valve prolapse

To assess the relationship between left ventricular functional reserve and prognosis in patients with idiopathic mitral valve prolapse, ergometer exercise echocardiography was performed in 10 normal subjects and 30 patients with mitral valve prolapse having either mild, or no mitral regurgitation. These 30 patients with mitral prolapse were followed for 2 to 8 (mean 4.5) years. Increment of % fractional shortening during maximum exercise at the initial study in patients with mitral valve prolapse and normal subjects were 7 +/- 7 and 11 +/- 3%, respectively. Based on increment of % fractional shortening, patients with mitral valve prolapse were divided into 2 groups; Group I: 13 cases with delta% fractional shortening less than 5%, Group II: 17 cases with delta% fractional shortening greater than or equal to 5%. The incidence of cardiac symptoms was higher in Group I than in Group II (85 vs 41%, p less than 0.05). ST-T changes and life-threatening arrhythmias were more frequently observed in Group I. During the follow-up period, M-mode echocardiographic measurements did not vary in Group II, but left ventricular and left atrial dimensions increased significantly (p less than 0.05, p less than 0.01, respectively) and % fractional shortening decreased significantly (p less than 0.01) in Group I without any change in mitral regurgitation severity. Thus, some patients with mitral valve prolapse not having significant mitral regurgitation may develop progressive deterioration of the cardiac function, which may be predicted by exercise echocardiography.     

Prognostic evaluation of patients with systolic dysfunction: functional and echocardiographic evaluation

INTRODUCTION AND OBJECTIVES: Multiple clinical and echocardiographic parameters have been shown to have prognostic value in cases of left ventricular dysfunction. The purpose of this paper was to evaluate the relative predictive power of such parameters. METHODS: Ninety-one patients with systolic dysfunction were prospectively studied. Functional status was evaluated using the New York Heart Association classification and the 6-minute walking test. Other clinical and biochemical parameters were assessed, and an anatomic and functional echocardiographic study was performed. RESULTS: Mean follow-up was 16.5 months (SD: 6.95). Eighteen patients died and two underwent heart transplantation (cardiac death 22%). Multiple regression analysis showed that the only independent predictor of death was functional status. Functional classes I and II showed a 16-month mortality rate of 10%, class III 40% and class IV 83%. The mortality rate was 67% for patients who walked < 300 meters and 0% for those who reached > 500 meters. When echocardiographic results were analyzed separately, the only independent predictors of outcome were left atrial diameter and the E wave deceleration time. Deceleration times < 100 ms or atrial diameters > 5 cm were associated with a mortality rate of 46%. The correlation between E wave deceleration time and the walking test was r = 0.55, p < 0.0001. CONCLUSIONS: Functional status is the main predictor of outcome in patients with systolic dysfunction, whether assessed subjectively or estimated objectively by a walking test. Among echo-Doppler parameters, the deceleration time of the E wave and left atrial diameter gave similar prognostic information, although with less statistical significance. They can confirm or substitute the prognosis obtained by the functional classification.     

Correlation of echocardiographic and clinical findings in patients with pericardial effusion.

Clinical data and echocardiographic findings were correlated in 20 patients with pericardial effusion. Moderate to large effusions were associated with increased motion of the entire heart within the pericardial sac. A correlation was found between the estimated volume of fluid and the diastolic excursion and velocity of the right ventricular and left ventricular walls (P less than 0.01). For any given volume of fluid as estimated from the echocardiogram neoplastic effusions resulted in greater increments in wall motion (P less than 0.02). Patterns of "pseudo" mitral valve prolapse occurred and were correlated with the extent and timing of cardiac swinging and heart rate. A diminished E-F slope of the mitral valve echo and notch on the right ventricular epicardial echo during early systole were found in all four patients with pericardial tamponade. These preliminary observations suggest that echocardiographic examination of patients with pericardial effusion may provide clues to the presence or absence of tamponade in addition to providing an estimate of the quantity of fluid in the pericardial sac.     

Haemodynamic and echocardiographic findings after aortoventriculoplasty

Aortoventriculoplasty (AVP) is an established operative procedurefor the enlargement of different types of severe left ventricularoutflow tract obstruction. Between 1974 and 1985 75 aortoventriculoplastieswere carried out in 72 patients ranging from 5 to 34 years ofage. Three patients had to be reoperated upon due to significantright ventricular outflow tract obstruction, outgrown prosthesis,and dissecting aortic aneurysm. There were 7 early deaths (mortalityrate 9.3%) and one late death (1.3%) following A VP. Out ofthe last 55 patients only 2 died (3.6%). In contrast to theunsatisfactory haemodynamic results of previous conventionaloperations. AVP reduced the mean residual gradient at rest acrossthe left ventricular outflow tract from 84 ± 23 mmHg(range 50–160 mmHg) to 12 ± 12 mmHg (range 0.65mmHg). Except in 2 patients, no gradient increased more than15 mmHg with isoproterenol. In the cross-sectional echocardiogram, the left ventricularoutflow tract was enlarged from 1.9 ± 0.42 to 3.1$0.39cm after AVP, whereas the aortic annulus had been expanded from2.4 ± 0.36 to 3.2±0.35 cm (n = 17). The mean lengthof the inner patch covering the septal incision measured 2.1cm ± 0.4 cm (n = 37). Our recatheterization studies afterAVP revealed equally good haemodynamic results in all typesof left ventricular outflow tract obstruction which cannot berelieved by conventional surgery.     

Long-term evaluation of patients with apical hypertrophic cardiomyopathy: Correlation between quantitative echocardiographic assessment of apical hypertrophy and clinical-electrocardiographic findings

Apical hypertrophic cardiomyopathy (AHCM) is characterized byprimary hypertrophy localized exclusively in the apex of theleft ventricle. Previous studies have indicated that AHCM resultsin a unique combination of cross-sectional echocardiographic(CSE) and ECG findings (‘giant’ Twave inversionand high R wave voltage in the precordial leads). The aims ofthis study were: (1) to assess the degree of AHCM in a quantitativefashion (2) to evaluate the possible relationship between apicalhypertrophy, quantitatively determined, and ECG findings inpatients with AHCM (3) to verify the changes in echocardiographicand ECG parameters over time (4) to define the relationshipbetween the severity of AHCM and the clinical course of suchpatients. Eleven selected patients with AHCM were studied for an average6 year follow-up period; there were seven men and four women(age from 18 to 62 years, mean 49). Apical hypertrophy was assessedquantitatively by determining the muscle cross-sectional areain the apical region, which was considered an index of myocardialmass. From the end-diastolic apical four chamber view, endocardialand epicardial contours were digitized in order to obtain thetotal muscle cross-sectional area of the left ventricle. Thewalls of the left ventricle were then divided into three regions(basal, intermediate, apical). The final value of each cross-sectionalmuscle area was obtained from the mean measurements of fourindependent and blinded observers. In AHCM the apical musclecross-sectional area (AMA) ranged from 10.3 to 17.9 cm², mean13.2 ±2.6 cm². The comparison between CSE and ECG findingsshowed that patients with giant negative T wave inversions (Twave >10 mm) and high R wave voltages (R wave >25 mm)had a more severe degree of apical hypertrophy. However, therewas incomplete agreement between CSE and ECG findings. During follow-up, negative T wave amplitude increased from 8.5±3.4 to 11.9 ±3.6 mm (mean 4.2 ±2.7) in10 patients (P>0.01) and there was a mild increase of precordialR wave (from 28.0 ±5.9 to 29.3 ± 5.2 mm, mean1.5 ± 1.6) (P–ns). The AMA change over time, from13.2 ± 26 to 13.8 ± 2.3 was not significant. Allpatients were alive at the most recent evaluation, and witlioutsignificant symptomatic deterioration. This study demonstrates a wide spectrum in the degree of severityof apical hypertrophy among patients with AHCM. Furthermore,ECG findings are not uniform and are not significantly relatedto the severity of the hypertrophy itself Therefore, AHCM shouldbe considered as a part of the morphological spectrum of hypertrophiccardiomyopathy rather than a separate entity with univocal CSEand ECG findings. Follow-up data indicate that despite ECG results worsening overtime, a significant progression in apical left ventricular wallthickness does not occur. Changes in negative T wave amplitudeare not related to symptoms and are not predictive of the functionalseverity of AHCM. Finally, the clinical outcome of patientswith AHCM seems not be dependent on the entity of apical hypertrophy.