Left ventricular mass monitoring in the follow-up of dialysis patients: prognostic value of left ventricular hypertrophy progression

BACKGROUND: Regression of left ventricular hypertrophy (LVH) in the setting of a well-planned intervention study has been associated with longer survival in hemodialysis patients. Whether changes in left ventricular mass (LVM) in clinical practice predict survival and cardiovascular events in these patients is still unknown. METHODS: In a prospective study in 161 hemodialysis patients we tested the prognostic value of changes in LVM on survival and incident cardiovascular events. Echocardiography was performed twice, 18 +/- 2 SD months apart. Changes in LVM occurring between the first and the second echocardiographic study were then used to predict mortality and cardiovascular events during the ensuing 29 +/- 13 months. The prognostic value of LVM changes was tested in a multivariate Cox's model with LVM index (LVMI) [expressed as LVM/height(2.71)], included as a covariate to control for regression to the mean. RESULTS: The rate of increase of LVMI was significantly (P= 0.029) higher in patients with incident cardiovascular events than in those without such events. Accordingly, cardiovascular event-free survival in patients with changes in LVMI below the 25th percentile was significantly (P= 0.004) higher than in those with changes above the 75th percentile. In a multiple Cox regression analysis, including age, diabetes, smoking, homocysteine, 1 g/m(2.7)/month increase in LVMI was associated with a 62% increase in the incident risk of fatal and nonfatal cardiovascular events [hazard ratio 1.62 (95% CI 1.13-2.33), P= 0.009]. CONCLUSION: Changes in LVMI have an independent prognostic value for cardiovascular events and provide scientific support to the use of repeated echocardiographic studies for monitoring cardiovascular risk in dialysis patients.     

Outcome and risk factors for left ventricular disorders in chronic uraemia

BACKGROUND: Left ventricular disease occurs frequently in dialysis patients.It may be manifest as concentric LV hypertrophy, LV dilatationwith or without LV hypertrophy, or systolic dysfunction. Littleis known concerning the clinical outcome and risk factors forthese disorders. METHODS: A cohort of 432 end-stage renal disease patients who survivedat least 6 months had an echo-cardiogram on initiation of dialysistherapy. Clinical, laboratory and echocardiographic data wasobtained annually during follow-up. RESULTS: On initiation of ESRD therapy 16% of patients had systolic dysfunction,41% concentric LV hypertrophy, 28% LV dilatation, and only 16%had normal echocardiograms. Median time to development of heartfailure was 19 months in patients with systolic dysfunction,38 months in concentric LV hypertrophy and 38 months in LV dilatation.The relative risks of heart failure in the three groups weresignificantly worse than in the normal group, after adjustingfor age, diabetes and ischaemic heart disease. Median survivalwas 38 months in systolic dysfunction, 48 months in concentrichypertrophy, 56 months in LV dilatation, and >66 months inthe normal group. Two hundred and seventy-five patients had a follow-up echocardiogram17 months after starting dialysis therapy together with serialmeasurement of potential risk factors prior to the echocardiogram.On follow-up echocardiogram the degree of concentric LV hypertrophywas independently related to hypertension while on dialysis,older age, and anaemia while on dialysis; the degree of LV dilatationwas related to ischaemic heart disease, anaemia, hypertensionand hypoalbuminemia while on dialysis; the degree of systolicdysfunction was associated with ischaemic heart disease andanaemia during follow-up. CONCLUSIONS: Manifestations of left ventricular disease are frequent andpersistent in chronic uraemia, and are associated with highrisks of heart failure and death. Potentially reversible riskfactors include anaemia, hypertension, hypoalbuminaemia andischaemic heart disease.     

Changes in left ventricular mass in children and adolescents during chronic dialysis

Left ventricular hypertrophy (LVH) is an independent risk factor for cardiac mortality in adults with end-stage renal disease (ESRD). It is prevalent in pediatric patients on chronic dialysis. The objectives of this study were to evaluate left ventricular mass (LVM) in children and adolescents at the initiation of dialysis and to assess its changes during chronic dialysis therapy. In this longitudinal analysis, 29 patients aged 4–18 years had an echocardiographic evaluation within 90 days of starting dialysis therapy and a follow-up study at least 6 months later. LVH was defined as LVM index (g/m^2.7) >95th percentile for normal children and adolescents. On the initial echocardiogram 20 of 29 (69%) patients had LVH and 24 patients (83%) had abnormal LV geometry (38% eccentric LVH, 31% concentric LVH, and 14% concentric remodelling). Patients with LVH were more likely to be on antihypertensive medications (16/20) than patients without LVH (3/9) (P=0.005). Repeat echocardiogram, performed after 10±3 months on chronic dialysis, showed no significant difference in the mean LVM index (49.6±17.5 g/m^2.7 and 49.7±16.1 g/m^2.7, respectively) or in the prevalence of LVH or LV geometric pattern. However, 14 of 29 patients had a progressive increase in LVM index and 15 patients had regression. Multiple regression analysis showed that baseline LVM index (P=0.005) and interval change in indexed systolic blood pressure (P=0.027) were independent predictors for LVM index changes. In summary, LVH and abnormal LV geometry are already prevalent in children and adolescents with renal failure at the time of initiation of dialysis therapy, indicating that LVH develops during the pre-ESRD course. Early intervention to control blood pressure may be an important factor to improve and prevent progression of LVH in pediatric patients with ESRD. Received: 1 August 2000 / Revised: 5 December 2000 / Accepted: 7 December 2000     

Severe left ventricular hypertrophy in pediatric dialysis: prevalence and predictors

Left ventricular hypertrophy (LVH) has been recognized as an independent risk factor for cardiovascular morbidity and mortality in adults with end-stage renal disease. However, the prevalence and severity of LVH in children on chronic dialysis therapy is not well established. Retrospectively, 64 chronic dialysis patients, aged 20 months to 22 years, on chronic dialysis had echocardiographic evaluation of LV mass (LVM) and geometry. Forty-eight (75%) children had LVH, including 22 of 26 (85%) on hemodialysis (HD) and 26 of 38 (68%) on peritoneal dialysis (PD). The prevalence of LVH in patients on HD was significantly higher than those on PD (P=0.02). Abnormal LV geometry was found in 51 of 64 (80%) patients: 25 patients (39%) had eccentric hypertrophy, 3 (5%) had concentric remodelling, and 23 (36%) had concentric LVH. Twenty-six children (41%) had severe LVH, defined as LVM index greater than 51 g/m2.7, which is associated with a fourfold greater risk for development of cardiovascular disease in adults. Patients with severe LVH had a significantly lower hemoglobin level (P=0.027) and longer duration of renal disease prior to the start of dialysis therapy (P=0.003) than patients without LVH. Multiple logistic regression analysis revealed HD as opposed to PD as a significant independent predictor for severe LVH (P=0.036). Higher systolic blood pressure remained in the final model as an independent predictor with a borderline level of significance (P=0.065). The results indicate that severe LVH and abnormal left ventricular geometry are common in young dialysis patients. Better control of blood pressure, anemia, and hypervolemia may be important in prevention or improving LVH.     

Left ventricular function by 'conventional' and 'tissue Doppler' echocardiography in paediatric dialysis patients

Aim:   Cardiovascular abnormalities are common in children with chronic kidney disease (CKD). Left ventricular (LV) structure and functions have been extensively studied by conventional pulse-wave Doppler echocardiography (cPWD), however, tissue Doppler imaging (TDI) is a relatively new echocardiography method. The aims of this study were to evaluate LV diastolic function in paediatric dialysis patients using cPWD and TDI methods, and to compare the findings obtained with two modalities.
Methods:   This study included 38 children and adolescents on dialysis (14 haemodialysis and 24 peritoneal dialysis, duration of dialysis 58.0 ± 32.8 months) and 16 age- and sex-matched healthy subjects.
Results:   The mean left ventricular mass index (LVMI) was significantly higher in the patient group ( P  < 0.001) and the most common cardiac geometry was concentric LV hypertrophy (55%). There was no significant difference in LV systolic function between patient and control groups. However, dialysis patients had worse LV diastolic function both according to cPWD (lower E/A ratio) and TDI (lower Em/Am ratio) than the healthy subjects ( P  < 0.001 and P  = 0.001, respectively). Also, the index of LV filling pressure (E/Em ratio) obtained by the combination of cPWD and TDI was significantly higher in the patients ( P  < 0.001). Cumulative dose of calcium-based phosphate binder (CBPB), diastolic blood pressure and LVMI were the independent predictors of E/Em ratio.
Conclusion:   Our study shows that LV diastolic dysfunction is common in paediatric dialysis patients and TDI findings correlate well with cPWD findings. Similarly, higher dose intake of CBPB, hypertension and LV hypertrophy have a negative effect on LV filling pressure suggesting diastolic function.     

Regression of Left Ventricular Hypertrophy After Arteriovenous Fistula Closure in Renal Transplant Recipients: A Long-Term Follow-Up

The long-term effects of hemodialysis arteriovenous fistula (AVF) closure on left ventricular (LV) morphology are unknown. Using echocardiography, we prospectively studied 17 kidney transplant recipients before, 1, and, 21 months after AVF closure (mean fistula flow 1371 +/- 727 mL/min). Eight kidney transplant recipients with a patent AVF, matched for age, time after AVF creation, and time after transplantation, served as controls. LV mass index (LVMI) decreased from 139 +/- 44 g/m2 before AVF closure to 127 +/- 45 g/m2 and 117 +/- 40 g/m2 at 1 and 21 months post-closure, respectively (p < 0.001), but remained unchanged in controls. LV hypertrophy prevalence (LVMI > 125 g/m2) decreased from 65% before, to 41% early, and 18%, late, after surgery (p = 0.008), mostly from a decrease in LV end-diastolic diameter. Consequently, the prevalence of LV concentric remodeling (relative wall thickness > 0.45 without hypertrophy) increased from 12% before, to 35% early, and 65% late, after surgery (p = 0.003). Diastolic arterial blood pressure increased from 78 +/- 15 mmHg before, to 85 +/- 13 mmHg early, and 85 +/- 10 mmHg late, after surgery (p < 0.015). In conclusion, closure of large and/or symptomatic AVF induces long-term regression of LV hypertrophy. However, residual concentric remodeling geometry as well as diastolic blood pressure increase may blunt the expected beneficial cardiac effects of the procedure.     

Stentless and stented aortic valve replacement in elderly patients: Factors affecting midterm clinical and hemodynamical outcome.

OBJECTIVE: To report on the midterm results of aortic valve replacement (AVR) with stented and stentless bioprosthesis in an elderly population by analyzing the factors affecting survival and hemodynamical performance. METHODS: In a retrospective study, 145 patients with a Toronto stentless prosthesis are compared with 110 patients with a stented Carpentier-Edwards valve. The 5- to 10-year clinical outcome, transprosthetic gradients, and early and late left ventricular mass (LVM) regression are analyzed in view of specific prosthesis- and patient-related factors. RESULTS: Actuarial survival at 5 years is 82% after stentless AVR versus 68% after stented AVR (p < 0.001) in elderly patients. However, there was no difference in survival at 8 years, being 55.9% and 59.5%, respectively. Univariate analysis revealed that advanced age at the time of operation, NYHA class IV, use of a stented xenograft, presence of patient-prosthesis mismatch (PPM) (IEOA < or = 0.85 cm2/m2), and severe preoperative left ventricular (LV) hypertrophy (LVMI > 180 g/m2) affected survival adversely. But multivariate analysis determined only age, NYHA class IV and excessive LV hypertrophy as independent predictors of late mortality. Stented and stentless xenografts were equally effective in terms of transprosthetic gradients and LVMI regression. The use of a stentless valve significantly reduced the occurrence of PPM (18% vs 41%, p < 0.01). Early LVMI regression at 1 year was optimized by the avoidance of PPM, indicated by a higher absolute (43.7+/-28.3 g/m2 vs 58.6+/-33.8 g/m2, p = 0.003) and relative (25.0+/-12.7% vs 31.4+/-14.9%, p=0.004) mass regression. However, late LV remodeling was predominantly affected by systemic hypertension and severe preoperative LV hypertrophy, resulting in the incomplete LVMI resolution in 61.3% and 66.7% of these patients, respectively. Conclusion: In elderly patients, aortic valve replacement appears to be equally effective with a stentless or stented bioprosthesis. Midterm clinical outcome is mainly determined by patient-related factors such as age, advanced NYHA class, and severity of preoperative LV hypertrophy. Regarding post-AVR left ventricular remodeling, patient-prosthesis mismatch influences the early phase, whereas arterial hypertension affects the late regression more. However, the left ventricular remodeling is continuously compromised by the preoperative presence of excessive hypertrophy, despite the efficacy of the aortic valve replacement.     

Prognostic value of ultrasonographic measurement of carotid intima media thickness in dialysis patients.

High-resolution carotid ultrasonography is considered a fundamental technique for the investigation of the vascular system. However, it is still very unclear whether ultrasonographic studies of carotid arteries are useful for the prediction of cardiovascular events in patients with end-stage renal disease. The prediction power of carotid ultrasonography for all-cause and cardiovascular mortality was tested in a cohort of 138 patients receiving chronic dialysis treatment (91 receiving hemodialysis treatment and 47 receiving continuous ambulatory peritoneal dialysis treatment; follow-up, 29.8 +/- 15.0 mo), and the relationship between this parameter and alterations in left ventricular mass (LVM) and geometry was examined. On univariate analysis, intima media thickness (IMT) was directly related to LVM as well as to the absolute and relative thicknesses of LV walls but independent of LV end-diastolic volume. Data analysis based on LV geometry patterns revealed that patients with concentric hypertrophy were those with the highest IMT. The internal diameter of the common carotid artery (DCCA) was also related to concentric hypertrophy, but the strength of this relationship was of borderline significance (P = 0.06). During the follow-up period, 63 patients died: 32 (51%) of them of cardiovascular causes. IMT was significantly higher (P = 0.006) in patients who died of cardiovascular causes (1.10 +/- 0.21 mm) than in patients who survived (0.99 +/- 0.24 mm), In a Cox regression model, this parameter turned out to be an independent predictor of cardiovascular death, and it retained an independent effect in a model that included LVM. Treatment modality failed to independently predict this outcome. The risk of cardiovascular death was progressively higher from the first IMT tertile onward. DCCA failed to predict cardiovascular outcomes. IMT in dialysis patients is associated with LV concentric hypertrophy and is an independent predictor of cardiovascular death. IMT may be usefully applied for risk stratification in the dialysis population.     

Effect of parathyroidectomy on anemia and cardiac function in uremic patients with secondary hyperparathyroidism

Objective To explore the effect of total parathyroidectomy (PTX) with forearm autograft on the anemia and cardiac function in uremic patients with secondary hyperparathyroidism (SHPT). Methods The clinical data of 130 uremic patients who received PTX with forearm autograft in the First Affiliated Hospital of Zhejiang University from October 2010 to December 2015 were retrospectively analyzed. The changes of anemia and echocardiogram before and after operation were compared. According to the presence of left ventricular hypertrophy (LVH) before operation, the patients were divided into LVH group and non-LVH group. Echocardiographic indexes before and one year after operation of the two groups were compared. Results (1) Three months and one year after operation, hemoglobin and hematocrit increased while erythropoietin average usage decreased significantly (P＜0.01). (2) Compared with preoperative period, the dry weight was significantly increased one year after operation, and the cardiac function indexes including left ventricular end diastolic diameter (LVDd), interventricular septum end diastolic thickness (IVSd), left ventricular posterior wall end diastolic thickness (LVPWd), interventricular septum systolic thickness (IVSs), left ventricular systolic diameter (LVDs), left ventricular myocardial mass (LVM), and left ventricular myocardial mass index (LVMI) decreased significantly (P＜0.05). (3) In the non-LVH group, only IVSs decreased one year after operation (P＜0.05). In the LVH group, LVDs, LVDd, LVPWd, LVM, LVMI and IVSs were decreased significantly one year after operation than those in preoperative period (P＜0.05). Conclusions PTX with forearm autograft is an effective treatment for uremic patients with SHPT significantly improving anemia and left ventricular structure and function, especially for patients with ventricular hypertrophy in preoperative.     

Alterations of left ventricular hypertrophy in and survival of patients receiving hemodialysis: follow-up of an interventional study.

Left ventricular (LV) hypertrophy (LVH) is a risk factor for mortality in patients with end-stage renal disease (ESRD). Whether the attenuation of LVH has a positive effect on survival of patients with ESRD has not been documented. The aim of this study was to determine the effect of parallel treatment of hypertension and anemia on LV mass (LVM) and to determine the effect of LVM changes on survival. A cohort of 153 patients receiving hemodialysis was studied. The duration of follow-up was 54 +/- 37 mo. All patients had echocardiographic determination of LV dimensions and LVM at baseline and regular intervals until the end of the follow-up period. During the study, BP decreased from (mean +/- SD) 169.4 +/- 29.7/90.2 +/- 15.6 to 146.7 +/- 29/78 +/- 14.1 mmHg (P < 0.001), and hemoglobin increased from 8.65 +/- 1.65 to 10.5 +/- 1.45 g/dl (P < 0.001). The LV end-diastolic diameter and mean wall thickness decreased from 56.6 +/- 6.5 to 54.8 +/- 6.5 mm (P < 0.001), and from 10.4 +/- 1.6 to 10.2 +/- 1.6 mm (P < 0.05), respectively. The LVM decreased from 290 +/- 80 to 264 +/- 86 g (P < 0.01). Fifty-eight deaths occurred, 38 attributed to cardiovascular (CV) disease and 20 attributed to non-CV causes. According to Cox analyses after adjustment for age, gender, diabetes, history of CV disease, and all nonspecific CV risk factors, LVM regression positively affected the survival. The hazard risk ratio associated with a 10% LVM decrease was 0.78 (95% confidence interval, 0.63 to 0.92) for all-causes mortality and 0.72 (95% confidence interval, 0.51 to 0.90) for mortality due to CV disease. These results show that a partial LVH regression in patients with ESRD had a favorable and independent effect on patients' all-cause and CV survival.     

Differences in Cardiac Structure Assessed by Echocardiography Between Renal Transplant Recipients and Chronic Kidney Disease Patients

BackgroundCardiovascular disease (CVD) is the leading cause of death in predialysis chronic kidney disease (CKD) and dialysis patients as well as in renal transplant recipients (RTRs). Left ventricular hypertrophy (LVH) starts early during the course of CKD and is a strong predictor of CVD in this population. Regression of LVH after a successful renal transplantation remains a debatable issue among investigators, whereas there is little data comparing echocardiographic measurements between patients with predialysis CKD and RTRs.AimThe aim of this study was to compare echocardiographic measurements of LV structure and function between predialysis CKD patients and RTRs of similar renal function level.Patients and MethodsWe conducted a case control study with individual (1:2) matching from the Renal Transplant and the predialysis CKD Outpatient Clinic. For each of the 36 RTRs, two matched for gender, age and estimated glomerular filtration rate (eGFR) predialysis CKD outpatients (72 patients) were included. All patients underwent transthoracic echocardiography and LV mass, LV mass index [LVM and LVMI = LVM/BSA g/m²] and indices of systolic function were measured. In a subgroup of 12 RTRs we retrospectively assessed and compared the LVMI measurements at three different time points, during predialysis, dialysis and post transplant period.ResultsThe prevalence of LVH was 33% in RTRs and 52% in CKD patients (ns). RTRs had significantly lower LVM and LVMI levels compared with predialysis CKD patients (P = .006 and P = .008) while the other echocardiographic indices did not differ. In the subgroup of 12 RTRs, post-transplant LVMI levels (105 ± 25 g/m²) were significantly lower in comparison with predialysis (147 ± 57 g/m²) and dialysis LVMI levels (169 ± 72 g/m²) (P = .01, P = .01, respectively).ConclusionRTRs had significantly lower LVMI compared with predialysis CKD patients of similar age, renal function, hemoglobin and blood pressure level.     

Influence of long-term amelioration of anemia and blood pressure control on left ventricular hypertrophy in hemodialyzed patients.

The course of left ventricular hypertrophy was investigated in anemic hemodialysis patients treated with recombinant human erythropoietin (r-huEPO). 12 patients, aged 60.8 +/- 9.9 years (mean +/- SD) were treated for 18.8 +/- 2.7 months. Left ventricular size was estimated by echocardiography performed before treatment and at least 12 months after relieving anemia. Patients had signs of left ventricular and/or asymmetric septal hypertrophy when compared with a nonanemic and normotensive control group matched for sex and age. At baseline, hemoglobin (Hb) was 8.6 +/- 0.7 g/dl; interventricular septum thickness (IVST) was 1.75 +/- 0.34 cm, left ventricular posterior wall thickness (LVPWT) 1.32 +/- 0.19 cm, left ventricular muscle mass index (LVMI) 222.7 +/- 41 g/m2 and blood pressure (BP) 146.4 +/- 10/81.6 +/- 6 mm Hg. Hb rose to 11.4 +/- 1.2 g/dl (p less than 0.001); IVST and LVMI decreased to 1.42 +/- 0.35 cm (p less than 0.02) and 155.4 +/- 25.1 g/m2 (p less than 0.001); LVPWT and BP remained unchanged (1.30 +/- 0.26 cm and 146.8 +/- 16.9/81.2 +/- 7.8 mm Hg) at the end of the study. During the observation period, two groups of 5 and 7 patients differed from each other. The group of 5 patients had higher BP values (158.9 +/- 9.8/86.5 +/- 5.3 vs. 140.0 +/- 9.5/79.2 +/- 6.8 mm Hg, p less than 0.01), and the period with Hb values above 10 g/dl was shorter (14.5 +/- 2.4 vs. 17.8 +/- 2.4 months, p less than 0.05). These 5 patients failed to show a significant decrease in IVST and LVMI.(ABSTRACT TRUNCATED AT 250 WORDS)     

Time-dependent changes in cardiac growth after kidney transplantation: the impact of pre-dialysis ventricular mass.

BACKGROUND: Left ventricular hypertrophy (LVH) is common in chronic kidney disease (CKD), including kidney transplant recipients. However, time-related left ventricular mass changes (DeltaLVM) from pre-dialysis stage to beyond the first post-transplant year have not been clearly identified. METHODS: We studied a cohort of 60 stages 4-5 CKD patients without overt cardiac disease, who underwent three echocardiograms during follow-up: at pre-dialysis stage, on dialysis and after kidney transplantation (KT). Multiple linear regression was used to model DeltaLVM from baseline study. Cox proportional analysis was used to determine risk factors associated with either de novo LVH or>20% DeltaLVMI over time. RESULTS: Patients with baseline LVH (n=37; 61%) had a higher body mass index (BMI) than those without LVH (n=23; 39%) (P=0.013). BMI, haemoglobin levels (P=0.047) and non-use of angiotensin-converting enzyme inhibitors (ACEI) (P=0.057) were associated with baseline left ventricular mass index (LVMI). Twelve out of 23 patients (52%) with normal LVM at baseline, developed either de novo LVH or>20% DeltaLVMI at follow-up. On the other hand, 29 (78%) of those with initial LVH maintained this abnormality, and 8 (22%) normalized LVM post-transplantation. Factors associated with DeltaLVMI were age (P=0.01), pre-dialysis LVMI (P<0.0001), serum creatinine (P=0.012) and the use of ACEI post-transplantation (P=0.009). In Cox analysis, pre-dialysis LVMI was associated with de novo LVH or>20% DeltaLVMI over time (hazard ratio 1.009; 95% confidence interval 1.004 to 1.015; P=0.001). CONCLUSIONS: Successful KT may not completely normalize LVM post-transplantation. Pre-dialysis LVMI, traditional risk factors and no use of ACEI may perpetuate cardiac growth following KT.     

Reduced systolic myocardial function in children with chronic renal insufficiency

Increased left ventricular (LV) mass in children with chronic renal insufficiency (CRI) might be adaptive to sustain myocardial performance in the presence of increased loading conditions. It was hypothesized that in children with CRI, LV systolic function is impaired despite increased LV mass (LVM). Standard echocardiograms were obtained in 130 predialysis children who were aged 3 to 18 yr (59% boys) and had stages II through IV chronic kidney disease and in 130 healthy children of similar age, gender distribution, and body build. Systolic function was assessed by measurement of fractional shortening at the endocardial (eS) and midwall (mS) levels and computation of end-systolic stress (myocardial afterload). The patients with CRI exhibited a 6% lower eS (33.1 +/- 5.5 versus 35.3 +/- 6.1%; P < 0.05) and 10% lower mS (17.8 +/- 3.1 versus 19.7 +/- 2.7%; P < 0.001) than control subjects in the presence of significantly elevated BP, increased LVM, and more concentric LV geometry. Whereas the decreased eS was explained entirely by augmented end-systolic stress, mS remained reduced after correction for myocardial afterload. The prevalence of subclinical systolic dysfunction as defined by impaired mS was more than five-fold higher in patients with CRI compared with control subjects (24.6 versus 4.5%; P < 0.001). Systolic dysfunction was most common (48%) in patients with concentric hypertrophy and associated with lower hemoglobin levels. CRI in children is associated with impaired intrinsic LV contractility, which parallels increased LVM.     

二尖瓣及主动脉瓣置换术后患者远期的超声心动图特征及其临床意义

目的了解二尖瓣和主动脉瓣置换术后患者远期的超声心动图特征,并探讨其临床意义。方法将1999年1月至2008年6月间四川大学华西医院施行的二尖瓣及主动脉瓣机械瓣双瓣膜置换术、且完成了术后≥5年超声心动图评价的204例患者纳入研究,其中男60例,女144例;年龄15～74（48．42±11．00）岁。术后随访时间5～13（6．34±2．05）年。观察所有患者术前、术后超声心动图指标,并进行比较。结果与术前相比,患者术后左心房径（LA）、左心室径（LV）明显缩小（P〈0．05）,右心室径（RV）、左心室射血分数（LVEF）及左心室缩短分数（LVFS）增加（P〈0．05）。以二尖瓣狭窄为主的患者术后LA、LV、左心房面积（LAA）、左心房容积（LAV）、二尖瓣平均跨瓣压差（MPGmv）、二尖瓣速度时间积分（VTImv）及二尖瓣压力降半时间（PHTmv）均明显减小或降低（P〈0．05）,而二尖瓣有效瓣口面积（EOAmv）、有效瓣口面积指数（EOAImv）明显增加（P〈0．05）;以二尖瓣反流为主的患者术后LA、LV明显缩小（P〈0．05）。以主动脉瓣狭窄为主的患者术后LV、室间隔厚度（IVS）、左心室质量（LVM）、左心室质量指数（LVMI）、主动脉瓣最大前向血流速度（Vav）及平均跨瓣压差（MPGav）均明显减小或降低（P〈0．05）,主动脉瓣有效瓣口面积（EOAav）、有效瓣口面积指数（EOAIav）明显增加（P〈0．05）,而左室后壁厚度（LVPW）变化不明显（P〉0．05）;以主动脉瓣反流为主的患者术后LV、LVM、LVMI、EOAav及EOAIav均明显减小（P〈0．05）,而Vav、MPGav明显增加（P〈0．05）。在二尖瓣部位,与置入25mm瓣膜患者相比,置入27mm瓣膜患者Emv、MPGmv及VTImv均较低（P〈0．05）;在主动脉瓣部位,与置入21mm瓣膜患者相比,置入23mm瓣膜患者Vav、MPGav及VTIav均较低（P〈0．05）。术后远期二尖瓣部位中度人工心脏瓣膜．患者不匹配（PPM）38例（21．3％）,重度PPM4例（2．3％）;术后远期主动脉瓣部位中度PPM50例（24．5％）,重度PPM43例（21．1％）。接受三尖瓣成形术的患者其术后远期三尖瓣反流（TR）程度构成比明显改善（P〈0．05）,而未接受三尖瓣成形术患者其术后远期TR程度构成比明显恶化（P〈0．05）。结论与术前相比,双瓣膜置换术患者术后远期的左心功能及血流动力学指标均得到明显改善,但远非正常;与二尖瓣部位相比,主动脉瓣部位PPM的问题更为突出;由于术后远期TR残流或加重的情况较为普遍,左心手术时积极考虑同期三尖瓣成形手术是必要的。     

Predictors of left ventricular hypertrophy in patients with chronic kidney disease

The aim of the present study is to determine the prevalence and predictors of left ventricular hypertrophy in patients with stage 3 or 4 chronic kidney disease. Thirty-four patients were included. In addition to hematological and biochemical evaluations, echocardiography and ambulatory blood pressure monitoring were performed both at the beginning and at the end of the first year. Echocardiographic left ventricular mass was calculated and indexed to body surface area to calculate left ventricular mass index (LVMI). Left ventricular hypertrophy was diagnosed if LVMI >131 g/m(2) in male and >100 g/m(2) in female patients. During the follow-up period, estimated glomerular filtration rate decreased from 36.6+/-11.7 to 31.0+/-14.0 mL/min (p = 0.03), while LVMI increased from 130.2+/-35.6 to 140.5+/-30.5 g/m(2) (p = 0.055). Left ventricular hypertrophy was detected in 67.6% of the patients at the baseline and in 89.7% at the end of the study (p = 0.011). The independent predictors of the final LVMI were age (p = 0.035), baseline day-time systolic blood pressure (p = 0.01), baseline C-reactive protein (p = 0.001), and the decrease in glomerular filtration rate during the follow-up (p = 0.002). Left ventricular hypertrophy is quite frequent among patients with stage 3 or 4 chronic kidney disease, and its prevalence increases while glomerular filtration rate decreases during the follow-up. The early detection of left ventricular hypertrophy and both prevention of the deterioration of renal function and aggressive blood pressure control may help to achieve a decrease in cardiovascular morbidity and mortality in these patients.     

Homocysteine and left ventricular hypertrophy in children with chronic renal failure

Hyperhomocysteinemia is recognized as an independent risk factor for cardiovascular disease, especially atherosclerosis, in adult patients with chronic renal failure (CRF). However, there is little information about the relationship between plasma homocysteine levels and left ventricular hypertrophy. The aim of this study was to determine plasma homocysteine levels and risk factors for left ventricular hypertrophy and to investigate the relationship between plasma homocysteine concentration and left ventricular mass index (LVMI) in children with CRF. The homocysteine level was measured by high-performance liquid chromatography and LVMI was calculated using echocardiographic findings in 27 children with CRF and 16 healthy controls. The mean LVMI and mean plasma homocysteine concentration in the CRF group, especially in patients with end-stage renal disease, were statistically higher than the control group (P<0.05). There was no correlation between LVMI and plasma homocysteine concentration. There was a positive correlation between plasma homocysteine concentration and serum creatinine level. There was a positive correlation of LVMI with creatinine and blood pressures (systolic, diastolic, and mean arterial pressure). There was a negative correlation of LVMI with hemoglobin level in multiple linear regression analysis. In our view homocysteine does not have a direct effect on left ventricular structure and left ventricular hypertrophy is the end organ damage associated with hypertension, anemia, and CRF. More prospective studies are needed to better clarify the inter-relationships of plasma homocysteine level and left ventricular structure in children with CRF.     

Inappropriate left ventricular mass in children and young adults with chronic renal insufficiency

Increased left ventricular (LV) mass (M) in children with chronic renal insufficiency (CRI) might represent an adaptive mechanism to compensate for increased workload. We hypothesized that in children with CRI, pre-dialysis, values of left ventricular mass (LVM) exceed compensatory values for individual cardiac load. Complete anthropometric characteristics, biochemical profile and echocardiograms were obtained for 33 children with CRI, pre-dialysis (age 1–23 years, mean 12.2 ± 5.0 years), and 33 age- and gender-matched healthy controls. LV dimensions, wall thicknesses and volume were measured. Endocardial and midwall shortening, ejection fraction, LVM, LVM index, relative wall thickness, circumferential wall stress and excess LVM (as ratio of observed LVM to value predicted from body size, gender and cardiac workload) were analysed. Patients with CRI showed higher values of LVM index, resulting in higher prevalence of LV hypertrophy (36.3% vs 9%, P < 0.05). The ratio of excess LVM was greater in patients with CRI than in healthy controls (126 ± 19% and 103 ± 13%, respectively, P < 0.001). LV ejection fraction, midwall fractional shortening and stress-corrected midwall shortening were lower in patients with CRI than in controls. We concluded that, in children with CRI, the values of LVM are higher than those needed to sustain individual cardiac load than in healthy controls, a condition associated with LV hypertrophy and reduced systolic performance.     

The Prevalence of Hypertension, Valve Calcification and Left Ventricular Hypertrophy and Geometry in Peritoneal Dialysis Patients

Background/Aims: Cardiac valve calcification (CVC) and left ventricular (LV) abnormalities are common indicators of a poor prognosis in dialysis patients. We determined the prevalence of hypertension, CVC, LV hypertrophy (LVH) and LV geometry in peritoneal dialysis (PD) patients. Methods: Eighty-seven patients (50 female; mean age 42 ± 13 years; mean dialysis duration 46 ± 24 months) on strict salt and volume restriction, none of whom were receiving antihypertensives, were included in the study. Blood pressure (BP), biochemical parameters, CVC, LVH and LV geometry were determined. Results: Most patients were normotensive. CVC of the mitral and aortic valves and of both valves were noted in 22, 23 and 15% of patients, respectively. Patients with CVC had significantly higher diastolic BP (p = 0.023), cardiothoracic index (CTI; p = 0.037) and LV mass index (LVMI; p = 0.002). LVH, noted overall in 44% of cases, was present in 62 and 36% of the patients with and without CVC, respectively (p = 0.028). Of the whole group, only 50.6% had normal LV geometry. LVH was associated with lower serum albumin (p = 0.002), higher CTI (p = 0.027) and more frequent CVC (p = 0.028). LVMI was greater in patients with CVC (p = 0.002). Conclusion: Strict salt restriction and the achievement of ideal dry weight result in normotension in PD patients. CVC is associated with LVH, both of which are lower in normotensive patients.     

Influence of left ventricular geometry on regional systolic and diastolic function in patients with essential hypertension

OBJECTIVE: In essential hypertension, especially in concentric hypertrophy, global diastolic function is impaired. But, whether the left ventricular (LV) geometric pattern influences regional systolic and diastolic function or not, is unknown. This study was aimed to evaluate the influence of left ventricular geometric pattern on regional systolic and diastolic function in hypertensive patients. DESIGN: Ninety untreated mild to moderate hypertensive patients were studied. M-mode parameters, standard Doppler and PW tissue Doppler indices were measured. Patients were divided into four groups according to left ventricular mass index and relative wall thickness: normal geometry (n = 16), concentric remodeling (n = 16), eccentric hypertrophy (n = 32) and concentric hypertrophy (n = 26). RESULTS: Age, gender, body mass index, systolic and diastolic blood pressure were similar among groups. E/A ratio was significantly lower in the concentric hypertrophy group compared with the normal geometry group. Em velocity and Em/Am ratio in basal septum and Em velocity in basal inferior were statistically lower in the concentric hypertrophy group compared with the normal geometry group. In the concentric hypertrophy group, the number of segments with diastolic dysfunction was significantly higher compared with the normal geometry group. LV ejection fraction and regional S velocity could be compared among groups. CONCLUSION: LV regional diastolic function is being impaired in concentric hypertrophy. LV regional systolic function does not show a difference according to the LV geometric pattern.