Novel pulmonary artery banding followed by transcatheter balloon dilatation in treatment of complex congenital heart defects

We present a novel technique of pulmonary arterial banding using a Gore-Tex strip secured by 7-0 Prolene suture as part of surgical treatment in 2 neonates with aortic coarctation and ventricular septal defects. Successful percutaneous balloon angioplasty of the main pulmonary artery in the area of pulmonary arterial band was performed at 12 and 26 months of age in one of the patients and at 3.5 months of age in the other patient. Peak systolic pressure drop across the area of previous pulmonary artery banding was 30 mmHg and 25 mmHg at 65 and 30 months of age, respectively.     

El cateterismo cardiaco derecho de esfuerzo predice eventos en los pacientes con estenosis aórtica degenerativa asintomática

Introduction and objectivesDegenerative aortic stenosis (DAS) is the most frequent valvular heart disease. It remains unclear how to identify asymptomatic DAS patients with normal left ventricular ejection fraction who have a high probability of event occurrence and would thus benefit from early intervention. Here, we describe a protocol for exercise hemodynamics in true asymptomatic patients with moderate or severe DAS and assess the prognostic value of the data obtained in this population.MethodsThis study involved a prospective single-centre registry of consecutive asymptomatic patients with moderate or severe DAS. Patients underwent cardiopulmonary exercise testing to confirm symptom absence during exercise and then right heart catheterization (RHC) at rest and during exercise. Events were defined as death, surgical aortic valve replacement, or transcatheter aortic valve implantation according to clinical guidelines.ResultsThirty-three patients underwent baseline and exercise RHC. The mean aortic valve area was 1.08 cm² and the aortic gradient was 39 mmHg. The mean pulmonary artery pressure was 21 mmHg with a pulmonary artery occlusion pressure of 14 mmHg and cardiac output of 5.6 L/min. The mean pulmonary artery pressure at peak exercise was 34 mmHg. After a mean follow-up of 27 months, 8 patients experienced an event (24%). There were no differences in baseline variables, aortic valve area, or cardiopulmonary exercise testing parameters between the event and event-free groups. Patients with an event did not have higher pulmonary or filling pressures after peak exercise but had lower pulmonary artery oxygen saturation on effort (median, 48% vs 57%, P = .03).ConclusionsExercise RHC is feasible and safe in this population. Peak pulmonary artery oxygen saturation might identify patients with increased risk of serious adverse events.     

Echocardiographic estimation of pulmonary arterial systolic pressure in acute heart failure. Prognostic implications

BackgroundPrognostic implications of echocardiographic assessment of pulmonary hypertension (PH) in non-selected patients hospitalized for acute heart failure (AHF) are not clearly defined. The aim of this study was to evaluate the association between echocardiography-derived PH in AHF and 1-year all-cause mortality.MethodsWe prospectively included 1210 consecutive patients admitted for AHF. Patients with significant heart valve disease were excluded. Pulmonary arterial systolic pressure (PASP) was estimated using transthoracic echocardiography during hospitalization (mean time after admission 96 ± 24 h). Patients were categorized as follows: non-measurable, normal PASP (PASP ≤ 35 mm Hg), mild (PASP 36-45 mm Hg), moderate (PASP 46-60 mm Hg) and severe PH (PASP > 60 mm Hg). The independent association between PASP and 1-year mortality was assessed with Cox regression analysis.ResultsAt 1-year follow-up, 232 (19.2%) deaths were registered. PASP was measured in 502 (41.6%) patients with a median of 46 [38–55] mm Hg. The distribution of population was: 708 (58.5%), 76 (6.3%), 147 (12.1%), 190 (15.7%) and 89 (7.4%) for non-measurable, normal PASP, mild, moderate and severe PH, respectively. One-year mortality was lower for patients with normal PASP (1.32 per 10 person-years), intermediate for patients with non-measurable, mild and moderate PH (2.48, 2.46 and 2.62 per 10 persons-year, respectively) and higher for those with severe PH (4.89 per 10 person-years). After multivariate adjustment, only patients with PASP > 60 mm Hg displayed significant adjusted increase in the risk of 1-year all-cause mortality, compared to patients with normal PASP (HR = 2.56; CI 95%: 1.05–6.22, p = 0.038).ConclusionsIn AHF, severe pulmonary hypertension derived by echocardiography is an independent predictor of 1-year-mortality.     

Short term effects of sildenafil citrate therapy in secondary pulmonary hypertension

ObjectivesTo study the short term effects of sildenafil citrate therapy in patients with secondary pulmonary hypertension.MethodsForty patients with known symptomatic secondary pulmonary hypertension due to valvular heart disease, chronic thromboembolic disease, chronic obstructive pulmonary disease, interstitial pulmonary fibrosis, and idiopathic dilated cardiomyopathy were included in this phase II study. Patients were allocated in a randomized, placebo controlled design to either sildenafil or placebo for 6 weeks. Baseline and 6 week follow up included assessment of hemodynamic parameters, functional class using the NYHA classification, echocardiographic measurements of pulmonary artery systolic pressure and left ventricular ejection fraction.ResultsThe mean NYHA class at 6 weeks was 2.05 ± 0.4 in the sildenafil group versus 2.6 ± 0.6 in the placebo group, p = 0.02. The mean systolic pulmonary artery pressure significantly decreased in the sildenafil group at 6 weeks (43 ± 4 mmHg), compared to placebo patients (53 ± 7 mmHg), p = 0.02. Ejection fraction was higher in the sildenafil group, 59 ± 12% versus 54 ± 14% in the placebo group, but did not reach statistically significant difference. Sildenafil was well tolerated with minimal side effects.ConclusionOur data suggest that sildenafil therapy may provide benefits to selected patients with pulmonary hypertension secondary to cardiac or pulmonary diseases.     

Evaluación mediante OCT del remodelado vascular pulmonar en insuficiencia cardiaca avanzada. Estudio OCTOPUS-CHF

Introduction and objectivesPulmonary vascular remodeling is common among patients with advanced heart failure. Right heart catheterization is the gold standard to assess pulmonary hypertension, but is limited by indirect measurement assumptions, a steady-flow view, load-dependency, and interpretation variability. We aimed to assess pulmonary vascular remodeling with intravascular optical coherence tomography (OCT) and to study its correlation with hemodynamic data.MethodsThis observational, prospective, multicenter study recruited 100 patients with advanced heart failure referred for heart transplant evaluation. All patients underwent right heart catheterization together with OCT evaluation of a subsegmentary pulmonary artery.ResultsOCT could be performed and properly analyzed in 90 patients. Median age was 57.50 [interquartile range, 48.75-63.25] years and 71 (78.88%) were men. The most frequent underlying heart condition was nonischemic dilated cardiomyopathy (33 patients [36.66%]). Vascular wall thickness significantly correlated with mean pulmonary artery pressure, pulmonary vascular resistance, and transpulmonary gradient (R coefficient = 0.42, 0.27 and 0.32 respectively). Noninvasive estimation of pulmonary artery systolic pressure, acceleration time, and right ventricle-pulmonary artery coupling also correlated with wall thickness (R coefficient of 0.42, 0.27 and 0.49, respectively). Patients with a wall thickness over 0.25 mm had significantly higher mean pulmonary pressures (37.00 vs 25.00 mmHg; P = .004) and pulmonary vascular resistance (3.44 vs 2.08 WU; P = .017).ConclusionsDirect morphological assessment of pulmonary vascular remodeling with OCT is feasible and is significantly associated with classic hemodynamic parameters. This weak association suggests that structural remodeling does not fully explain pulmonary hypertension.     

Speckle tracking echocardiography in systemic sclerosis: A useful method for detection of myocardial involvement

BackgroundSystemic sclerosis is a multisystem disorder characterized by tissue fibrosis and organ damage. Heart involvement is one of the main factors shortening survival, which may be underestimated by conventional echocardiography measurements. Two-dimensional speckle-tracking echocardiography is a powerful novel modality to assess subclinical myocardial dysfunction.AimThe aim of this study is to investigate heart involvement in systemic sclerosis patients, and to determine the usefulness of ventricular longitudinal deformation using the Two-dimensional speckle tracking technology for an early detection of ventricular dysfunction.Patients and methodsBetween May 2016 and September 2016, 25 patients with systemic sclerosis and 25 healthy subjects underwent echocardiography to assess heart abnormalities and the strain of the two ventricles using two dimensions’ speckle tracking echography.ResultsThe two groups were comparable in age and gender. Despite comparable left ventricle systolic function (left ventricular ejection fraction patients 64.58 ± 8.87 vs. in healthy 68.2 ± 7.41, P = 0.19), patients presented altered longitudinal peak systolic strain values (global longitudinal strain: patients −17.42 ± 1.62 vs. healthy −19.24 ± 8.85, P < 0.0001). Despite comparable pulmonary artery systolic pressure, there was a significant alteration in right ventricular systolic and diastolic function assessed by standard measurement. Longitudinal peak systolic strain of the right ventricle was significantly lower in patients compared with controls (P < 0.01).ConclusionVentricular deformation analysis by two dimensions’ speckle tracking echocardiography appears to be a sensitive method to detect early ventricular impairment in patients with systemic sclerosis.     

Functional improvement in a patient with cirrhosis and portopulmonary hypertension treated by sildenafil for 2 years

Portopulmonary hypertension (PPH) represents an uncommon form of pulmonary arterial hypertension (PAH) associated with portal hypertension and cirrhosis. PPH is a severe disease with a poor short-term prognosis, with a possibility of liver transplantation only for patients with mild to moderate PAH. Patients with PAH could be candidates for specific vasodilator-based treatment, the choice of which being guided by their toxicity profile. We report here the case of a 46-year-old woman with a cirrhosis (Child-Pugh C) complicated by a severe PPH (mean pulmonary arterial pressure: 49 mmHg, pulmonary vascular resistance: 688 dynes, right ventricular dysfunction), with NYHA class III dyspnea and an altered 6-min walk distance (6MWD). Treatment with sildenafil (20 mg t.i.d) was started. In the first 6 months, a functional improvement was indicated by dyspnea assessed as class II, an increased distance at the 6MWD (375 m vs. 250 m without oxygen desaturation), and a normalization of right ventricular function. After one year of therapy, the benefits were maintained (6MWD: 465 m) and transthoracic echocardiography showed a normalization of pulmonary arterial pressures. Sildenafil treatment was well tolerated. At two years, haemodynamic values measured by right heart catheterization were similar to the pre-treatment values, while clinical and functional parameters remained improved. At our knowledge, this is the first case delineating the long-term functional benefit of sildenafil monotherapy, making this drug a therapeutic option in patients with PPH and cirrhosis, the usefulness of which in the waiting period for liver transplantation needs to be evaluated.     

Une cause rare d’hypertension artérielle pulmonaire : l’amylose thoracique

Isolated thoracic involvement in amyloidosis is a rare and serious condition. Its association with pulmonary arterial hypertension (PAH) usually weakens the prognosis. We report the case of a 40-year-old man with a smoking history, hospitalized for chest pain, abdominal pain and acute respiratory distress. The cardiac ultrasound revealed a circumferential pericardial effusion as well as a pulmonary artery systolic pressure (PAPS) at 80 mmHg. Chest imaging (computed tomography scan and magnetic resonance imaging) showed a tissue process developed in the pericardial sheath (60 × 45 mm) sheathing the ascending aorta and infiltrating the trunk of the pulmonary artery and its right branch. Anatomopathological and immunohistochemical study of the process revealed AL amyloidosis. Note that the patient had no signs of extrathoracic amyloidosis. Blood and urine electrophoresis and immunoelectrophoresis as well as bone marrow mylogram and biopsy were normal. The patient was put on oral anticoagulant as he presented with PAH. A therapeutic protocol with thalidomide and dexamethasone has been initiated. The course of the disease was marked by total regression of the clinical signs, a marked decrease in the amyloid process on imaging and a normalization of the PAPS; our follow-up being three years.     

Study of left ventricular systolic dysfunction,left ventricular diastolic dysfunction and pulmonary hypertension in CKD 3b-5ND patients—A single centre cross-sectional study

IntroductionCardiovascular diseases are associated with increased morbidity and mortality among CKD (chronic kidney disease) population. Recent studies have found increasing prevalence of PH (pulmonary hypertension) in CKD population. Present study was done to determine prevalence and predictors of LV (left ventricular) systolic dysfunction, LVDD (left ventricular diastolic dysfunction) and PH in CKD 3b-5ND (non-dialysis) patients.MethodsA cross sectional observational study was done from Jan/2020 to April/2021. CKD 3b-5ND patients aged ≥15 yrs were included. Transthoracic 2D (2 dimensional) echocardiography was done in all patients. PH was defined as if PASP (pulmonary artery systolic pressure) value above 35 mm Hg, LV systolic dysfunction was defined as LVEF (left ventricular ejection fraction) ≤ 50% and LVDD as E/e′ ratio >14 respectively. Multivariate logistic regression model was done to determine the predictors.ResultsA total of 378 patients were included in the study with 103 in stage 3b, 175 in stage 4 and 100 patients in stage 5ND. Prevalence of PH was 12.2%, LV systolic dysfunction was 15.6% and LVDD was 43.65%. Predictors of PH were duration of CKD, haemoglobin, serum 25-OH vitamin D, serum iPTH (intact parathyroid hormone) and serum albumin. Predictors of LVDD were duration of CKD and presence of arterial hypertension. Predictors of LV systolic dysfunction were eGFR (estimated glomerular filtration rate), duration of CKD, serum albumin and urine protein.ConclusionIn our study of 378 CKD 3b-5ND patients prevalence of PH was 12.2%, LV systolic dysfunction was 15.6% and LVDD was 43.65%.     

Role of echocardiography and cardiac biomarkers in prediction of in-hospital mortality and long-term risk of brain infarction in pulmonary embolism patients

IntroductionThe aim of prospective study was to evaluate the ability of echocardiography and cardiac biomarkers to predict in-hospital mortality and the risk of brain infarction during a 12-month follow-up period (FUP) with anticoagulation in pulmonary embolism (PE) patients.MethodsEighty-eight consecutive acute PE patients (39 men, mean age 63 years) were enrolled; 78 underwent baseline echocardiography and brain magnetic resonance imaging (MRI). After a 12-month FUP, 58 underwent brain MRI. In-hospital mortality and the rates of new ischemic brain lesions (IBL) on MRI with clinical ischemic stroke (IS) events were predicted based on echocardiography (patent foramen ovale presence with right-to-left shunt – PFO/RLS; right/left ventricle diameter ratio – RV/LD; tricuspid annulus plane systolic excursion – TAPSE; tricuspid annulus systolic velocity – S_T; pulmonary artery systolic pressure – PASP) and biomarkers results (amino-terminal fragment of brain natriuretic peptide – NT-proBNP and cardiac troponin T – cTnT).ResultsOur series involved 88 patients, of whom 11 (12.5%) presented high-risk PE, 24 (27.3%) intermediate-high risk PE, 19 (21.6%) intermediate-low risk PE and 34 (38.6%) patients had low risk PE.Nine patients (10.2%) died during hospitalization including high-risk PE [6/9 (66.6%)] and intermediate-high-risk PE [3/24 (12.5%)]. cTnT [odds ratio (OR) 4.3; 95% confidence interval 0.59–31.3, P = 0.014], NT-proBNP (OR 14.2 [1.5–133.4], P = 0.02), RV/LD ≥0.79 (OR 36.6 [4.2–316.4], P = 0.001), TAPSE (OR 0.55 [0.34–0.92, P = 0.022) and PASP ≥51.5 mmHg (OR 33.3 [3.8–292.6], P = 0.022) were predictors of in-hospital mortality.Seventeen patients (19.3%) experienced IS (n = 8) or new IBL (n = 9). On multivariate analysis, PFO/RLS (OR 27.1 [3.0–245.3], P = 0.003) and S_T ≤14.5 cm/s (OR 34.1 [CI 3.4–344.0], P = 0.003) were independent predictors of IS and IBL risk.ConclusionsHigh blood troponin T, NT-proBNP, RV dilatation/systolic dysfunction and pulmonary hypertension predicted in-hospital mortality. PFO/RLS presence and S_T were predictors of clinically apparent/silent brain infarction.     

Hépatopathies et maladies vasculaires pulmonaires

About 70% patients waiting for liver transplantation have a dyspnea. Two pulmonary vascular disorders can be associated with portal hypertension or chronic liver diseases: portopulmonary hypertension (PoPH) related to pulmonary small arteries remodeling and obstruction and hepatopulmonary syndrome (HPS) characterized by pulmonary capillaries dilatations and proliferations. PoPH is defined by the combination of pulmonary arterial hypertension (PAH) (mean pulmonary artery pressure [PAP] ≥ 25 mmHg, with normal pulmonary artery wedge pressure ≤ 15 mmHg and pulmonary vascular resistance [PVR] > 3 Wood units [WU]) and portal hypertension. HPS is a triad of intrapulmonary vascular dilatations, hypoxemia (increased alveolar-arterial oxygen gradient) and liver disease or isolated portal hypertension. The pathophysiology of both syndromes is complex and poorly understood. PoPH and HPS have a negative impact on functional and vital prognosis in patients with portal hypertension. Liver transplantation is the established treatment standard in HPS. PoPH treatment is improved over the years with the use of specific PAH treatment despite the lack of randomized assay in this indication. Liver transplantation could be considered in PoPH leading to stabilization, improvement or recovery in selected patients (mean PAP < 35 mmHg without severe right ventricular dysfunction and PVR < 4 WU).     

Biomarcadores da classe funcional na insuficiência cardíaca sistólica. Relevância da copeptina

IntroductionFunctional class is an important predictor of prognosis in chronic heart failure (CHF). However, it is often subjective and poorly reproducible.ObjectiveWe sought to identify diagnostic markers of high functional class.MethodsWe prospectively studied 37 patients with symptomatic CHF and ejection fraction < 40%. The study protocol included clinical evaluation, echocardiography (M-mode, 2D, Doppler and tissue Doppler) and laboratory tests including copeptin, vasopressin and NT-proBNP. We compared patients in NYHA class II with those in NYHA class > II. Overall mortality was assessed at 18 months.ResultsMortality was higher in the more advanced symptomatic stages (p < 0.05). Patients in NYHA class > II had higher creatinine, copeptin and NT-proBNP levels (p < 0.05). E/E’, E-septum distance, pulmonary artery systolic pressure (PASP) and inferior vena cava (IVC) dimensions were also significantly greater (p < 0.05). The biomarkers copeptin (area under the curve [AUC] = 0.76, p < 0.01) and NT-proBNP (AUC = 0.81, p < 0.01) and the echocardiographic parameters PASP (AUC = 0.88, p < 0.01) and IVC inspiratory diameter (AUC = 0.91, p < 0.01) showed the best performance for diagnosis of functional class > II. In multivariate regression analysis only PASP and serum creatinine were independent predictors of NYHA functional class > II.ConclusionCopeptin and NT-proBNP have high sensitivity and specificity in the diagnosis of functional classes with prognostic impact and may be useful in defining a standardized functional classification.The structural and hemodynamic echocardiographic changes associated with NYHA class > II were left ventricular filling pressure, PASP and central venous pressure.     

SFE/SFHTA/AFCE consensus on primary aldosteronism,part 1: Epidemiology of PA,who should be screened for sporadic PA?

Depending on the study, the prevalence of primary aldosteronism (PA) in patients with hypertension varies from 6 to 18%. Prevalence is higher in each of the following conditions, any one of which requires screening for PA: severe hypertension (systolic blood pressure [BP] ≥ 180 mmHg and/or diastolic BP ≥ 110 mmHg); resistant hypertension (systolic BP ≥ 140 mmHg and/or diastolic BP ≥ 90 mmHg despite adherence to a tritherapy including a thiazide diuretic); hypertension associated with hypokalemia (either spontaneous or associated with a diuretic); Hypertension or hypokalemia associated with adrenal incidentaloma. It should be borne in mind that PA can induce hypertension without hypokalemia or, less frequently, hypokalemia without hypertension. Finally, as cardiovascular and renal morbidity in PA is greater than in essential hypertension of equivalent level, screening for PA is indicated when cardiovascular or renal morbidity is more severe than predicted from BP level.     

Frequency, determinants and outcome of pulmonary hypertension in patients with aortic valve stenosis

IntroductionThe frequency, causes and prognostic implications of pulmonary hypertension (PHT) in patients with severe aortic stenosis (AS) are not well defined. The objectives of this study were to determine the frequency of PHT [pulmonary artery systolic pressure (PASP) > 50 mm Hg] in patients with severe AS, identify the factors associated with PHT and assess the relationship between PHT and clinical outcome.MethodsPatients with severe AS (aortic valve area ≤ 1.0 cm²) and an echocardiographic estimate of PASP were identified by using the institutional echocardiography laboratory database. Patients with atrial fibrillation, mitral valve stenosis or a mitral prosthesis were excluded from analysis. The associations between clinical and echocardiographic parameters and PHT and the relationship between PHT and outcome were examined.ResultsDuring the study period, 216 patients fulfilled the inclusion criteria (age: 75 ± 11 years; 43% men), and PHT was present in 64 patients (29.6%). By multivariate analysis, reduced left ventricular (LV) systolic function (LV ejection fraction ≤ 45% and lower stroke volume) and impaired LV diastolic function (mitral inflow E/A ratio ≥ 1.5 and greater left atrium size) were independent predictors of PHT. Mortality was higher among patients with PHT managed medically (adjusted hazard ratio, 1.87; 95% confidence interval, 1.06–3.30; P = 0.011), whereas patients with PHT who underwent aortic valve replacement had an excellent outcome.ConclusionsPHT is common in patients with AS and is related to the severity of LV systolic and diastolic dysfunction. PHT is associated with poorer outcome in medically treated patients.     

Pontage coronaire chez les patients en dysfonction systolique sévère du ventricule gauche : résultats à court et à long terme

BackgroundIschemic heart disease with severe left ventricular systolic dysfunction is a poor prognosis. Coronary artery bypass grafting is the gold treatment in this population, despite high surgical risk.AimThe aim of our study is to evaluate the short- and long-term outcomes of coronary artery bypass grafting in patients with ischemic heart disease and severe left ventricular systolic dysfunction (LVEF ≤ 35%).MethodsBetween May 1995 and December 2010, 171 patients with ischemic heart disease and severe left ventricular systolic dysfunction (LVEF ≤ 35%) underwent isolated coronary artery bypass grafting. Hospital mortality, postoperative morbidity, all-cause death, cardiovascular death, and major adverse cardiovascular events (heart failure, recurrent angina, myocardial infarction, stroke) were evaluated. The mean follow-up was 9.3 ± 5 years.ResultsHospital mortality was 9.9%. Postoperative morbidity was 36.9%. Overall survival at 1-, 5- and 10-years was 97.4%, 90.5% and 43.4%, respectively. Freedom from cardiovascular death at 1-, 5- and 10-years was 98.1%, 91.8% and 55.4%, respectively. Freedom from recurrent angina at 1-, 5- and 10-years was 95.5%, 84.8% and 44.9%, respectively. Freedom from heart failure at 1-, 5- and 10-years was 89.9%, 86,8% and 53.3%, respectively. Freedom from major adverse cardiovascular events at 1-, 5- and 10-years was 88%, 82.1% and 38.2%, respectively.ConclusionBased on our findings, coronary artery bypass grafting can be performed in patients with ischemic heart disease and severe left ventricular systolic dysfunction with acceptable hospital morbidity and mortality and long-term survival.     

Pulmonary hypertension and left heart function: insights from tissue Doppler imaging and myocardial performance index

BACKGROUND: As a consequence of a leftward shift of the interventricular septum and of pericardial restraint, related to the degree RV dilatation, left heart function would be influenced after pulmonary hypertension and right heart failure. METHODS AND RESULTS: We enrolled 70 patients with pulmonary artery systolic pressure (PASP) more than 30 mmHg: 40 patients with PASP between 30 and 60 mmHg (Group 2), 30 patients with PASP more than 60 mmHg (Group 3). Another 70 patients with normal heart performance and PASP less than 30 mmHg served as the control group (Group 1). Myocardial performance index (MPI), isovolumic contraction time (IVCT), and isovolumic relaxation time (IVRT) were obtained by tissue Doppler imaging (TDI). PASP correlated negatively to peak systolic velocity of lateral tricuspid annulus (RV-Sm) and RVEF. The MPI of RV and LV in patients with severe pulmonary hypertension (Group 3) became higher as the result of the prolongation of IVRT. The higher E/Em (peak early-diastolic mitral-inflow velocity divided by early-diastolic velocity of mitral annulus) in pulmonary hypertension indicated diastolic dysfunction of LV. The decline of left ventricular ejection fraction, and also right ventricular ejection fraction, suggested LV systolic dysfunction after pulmonary hypertension. The LV-MPI truly reflected LV systolic and diastolic dysfunction in patients with pulmonary hypertension. In multiple linear regression analysis, LV-MPI was independently associated only with RV-MPI (Beta 0.47, P < 0.0001). CONCLUSION: The result infers that the systolic and diastolic function of LV declined, following pulmonary hypertension.     

Mitochondrial complex II participates in normoxic and hypoxic regulation of α-keto acids in the murine heart

α-Keto acids (α-KAs) are not just metabolic intermediates but are also powerful modulators of different cellular pathways. Here, we tested the hypothesis that α-KA concentrations are regulated by complex II (succinate dehydrogenase = SDH), which represents an intersection between the mitochondrial respiratory chain for which an important function in cardiopulmonary oxygen sensing has been demonstrated, and the Krebs cycle, a central element of α-KA metabolism. SDH subunit D heterozygous (SDHD^+/−) and wild-type (WT) mice were housed at normoxia or hypoxia (10% O₂) for 4 days or 3 weeks, and right ventricular pressure, right ventricle/(left ventricle + septum) ratio, cardiomyocyte ultrastructure, pulmonary vascular remodelling, ventricular complex II subunit expression, SDH activity and α-KA concentrations were analysed. In both strains, hypoxia induced increases in right ventricular pressure and enhanced muscularization of distal pulmonary arteries. Right ventricular hypertrophy was less severe in SDHD^+/− mice although the cardiomyocyte ultrastructure and mitochondrial morphometric parameters were unchanged. Protein amounts of SDHA, SDHB and SDHC, and SDH activity were distinctly reduced in SDHD^+/− mice. In normoxic SDHD^+/− mice, α-ketoisocaproate concentration was lowered to 50% as compared to WT animals. Right/left ventricular concentration differences and the hypoxia-induced decline in individual α-KAs were less pronounced in SDHD^+/− animals indicating that mitochondrial complex II participates in the adjustment of cardiac α-KA concentrations both under normoxic and hypoxic conditions. These characteristics are not related to the hemodynamic consequences of hypoxia-induced pulmonary vascular remodelling, since its extent and right ventricular pressure were not affected in SDHD^+/− mice albeit right ventricular hypertrophy was attenuated.     

Efficacy and safety of high dose versus low dose streptokinase for treatment of submassive pulmonary embolism

Pulmonary embolism (PE) remains a major cause of morbidity and mortality in the general population, the established treatment for PE is anticoagulation. It has previously been demonstrated that thrombolytic therapy can be lifesaving in patients with massive PE (haemodynamic instability and right heart failure). However, the use of thrombolytic therapy in patients with submassive PE (haemodynamically stable) remains a controversial topic. Recent clinical studies, however, support evidence that thrombolysis may favorably affect the outcomes in a wider spectrum of high risk PE patients presenting with right ventricular dysfunction (RVD) as evidenced by decreased right ventricular end diastolic diameter (RVEDD), disappearance of paradoxical septal motion (PSM), and tricuspid regurge (TR) as well as decrease in the pulmonary artery pressure. The aim of this study was to evaluate the efficacy and safety of high dose streptokinase (SK) in 1 h versus low dose SK in 24 h in patients with submassive PE and RVD (high risk PE). The study included 60 patients (28 males and 32 females, mean age 45.5 ± 13.6 years) with submassive PE (positive spiral CT chest) and RVD (proved by echocardiography). Those without contraindications to SK were randomly assigned to receive either high dose (group I) or low dose (group II) of SK. Those with contraindication(s) to SK received anticoagulation (group III). Echocardiography was done before and 72 h after treatment. Right ventricular dysfunction (RVEDD, PSM, and TR) and mean pulmonary artery pressure (PAP) improved significantly 72 h after treatment in groups I and II, while a slight improvement in PAP was observed after treatment in group III. No significant difference was noticed between groups I and II regarding the effect of treatment on RVD or PAP. Statistically nonsignificant difference was found between groups I and II regarding the complications of SK, however a slightly higher risk of bleeding was observed in group I (high dose SK). No significant difference was found between the three groups regarding the mortality. These data suggest that SK can rapidly and safely reverse the pulmonary hypertension and RVD in contrast to anticoagulation. Both protocols of SK are equieffective in rapid reversal of RVD and pulmonary hypertension. Both protocols were safe as proved by absence of difference in mortality over anticoagulant group.     

Assessment of right ventricular function by myocardial performance index in diabetic patients

BackgroundAssessment of right ventricular (RV) function remains difficult because of the RV complex shape. Data regarding RV performance in patients with diabetes are incomplete The aim of this study was to assess the feasibility of pulsed wave tissue Doppler imaging and myocardial performance index (MPI) for the assessment of right ventricular function in diabetic patients without coronary artery disease.MethodsThe study included 20 diabetic patients, 20 diabetic hypertensive and 20 gender and age matched healthy subjects underwent standard echocardiography with tissue Doppler imaging (TDI) to assess RV function. Patients with myocardial ischemia, impaired left ventricular systolic function, valvular heart disease or other diseases which could alter the right ventricular performance were excluded.ResultsMyocardial performance index was significantly higher in diabetes compared to control group (0.41 ± 0.05 versus 0.27 ± 0.04, p = 0.001). Peak myocardial systolic velocity (Sa), early diastolic myocardial velocity (Ea), and late diastolic myocardial velocity (Aa) were significantly lower in patients with diabetes mellitus (DM) compared to the control group (p = 0.0001). Isovolumetric relaxation time (IVRT) was significantly higher in DM group compared to control group (p = 0.003). MPI was significantly higher in diabetic hypertensive group versus DM alone group (0.46 ± 0.050 versus 0.41 ± 0.05, p = 0.01). There was no correlation between MPI and blood glucose level and duration of diabetes.ConclusionMyocardial performance index is a useful noninvasive tool for the detection of early right ventricular systolic and diastolic dysfunction in diabetic patients, regardless of coexisting hypertension.     

Prévalence d’une sténose carotidienne chez le nonagénaire : résultats d’une enquête hospitalière

AimCarotid artery stenosis increases with age and may cause brain ischemia if arterial hypotension occurs. We performed a monocentric pilot study to investigate its prevalence in the very elderly and to assess its potential influence on blood pressure (BP) goals during antihypertensive treatment.MethodsAll patients ≥ 90 years of a primary care medical ward were prospectively included over 15 months. Ultrasound exams of the precerebral arteries were offered to all elderly patients for routine evaluation of their cardiovascular risk. Frequencies of stenosed common, internal and external carotid arteries (CCA, ICA, ECA) were analyzed together with clinical BP and antihypertensive therapy. Patients with circulatory shock and readmissions were excluded.ResultsSixty-three patients aged 92 ± 3 years (78% female) hospitalized for a median of 11 days were included. On admission, 76% were on antihypertensive drugs vs. 86% at discharge. Mean admission BP was 149/77 vs. 129/72 mmHg at discharge; systolic BP < 140 mmHg 36% vs 64% (P < 0.05). Mean intima-media thickness (ACC, right/left) was 8.7/9.4 mm. Prevalence of plaque or stenosis < 60% was: CCA 19.0%, ICA 19.0%, ECA 31.7%, bulb 74.6%; of stenosis ≥ 60%: CCA 0%, ICA 7.9%, ECA 19.0%, ICA bilateral 1.6% (unilateral occlusion 3.1%, no bilateral). Coincidence of systolic BP < 120 mmHg and ACI stenosis ≥ 60% had a probability of 1–2%.ConclusionConcerning the risk of brain ischemia due to carotid artery stenosis, a BP goal < 140 mmHg should be safe for most nonagenarians. If individual BP goals are lower, searching for significant stenosis by ultrasound may be useful.