Adverse impact of chronic subpulmonary left ventricular pacing on systemic right ventricular function in patients with congenitally corrected transposition of the great arteries

Background

Patients with congenitally corrected transposition of the great arteries (ccTGA) are at high risk of heart block requiring subpulmonary left ventricular (LV) pacing. Long-term right ventricular (RV) pacing in congenitally normal hearts is associated with LV dysfunction. We examined the effects of univentricular subpulmonary LV pacing on the systemic RV in a ccTGA cohort.

Methods

ccTGA patients with two echocardiographic studies at least 6 months apart were included. Records of 52 patients, 22 with pacing, were retrospectively reviewed. Seven patients with biventricular pacing were included for comparison.

Results

The LV-Paced Group experienced deterioration in the RV fractional area change (RVFAC) (28.7 ± 10.0 vs. 21.9 ± 9.1%; P = 0.003), systemic atrioventricular valve regurgitation (P = 0.019) and RV dilatation (end-diastolic area 32.7 ± 8.7 vs. 37.2 ± 9.0 cm²; P = 0.004). There was a corresponding deterioration in NYHA class (P = 0.013). Multivariate Cox regression analysis showed that pacing was an independent predictor of deteriorating RV function and RV dilation (hazard ratio 2.7(10–7.0) and 4.7(1.1–20.6) respectively). None of these parameters changed significantly in the Un-paced Group. The CRT Group showed improvement in RVFAC (22.0% to 30.7% (P = 0.030) and NYHA class (P = 0.030), despite having lower baseline RVFAC (22.0 ± 5.7 vs. 31 ± 9.7%; P = 0.025) and greater dyssynchrony (RV total isovolumic time 13.4 ± 2.1 vs. 9.3 ± 4.2 s/min; P = 0.016) when compared to the Un-Paced Group.

Conclusions

Univentricular subpulmonary LV pacing in patients with ccTGA predicted deterioration in RV function and RV dilatation over time associated with deteriorating NYHA class. Alternative primary pacing strategies such as biventricular pacing may need consideration in this vulnerable group already highly prone to mortality from systemic RV failure.     

Early pacing-induced systolic dyssynchrony is a strong predictor of left ventricular adverse remodeling: Analysis from the Pacing to Avoid Cardiac Enlargement (PACE) trial

Background

Right ventricular apical (RVA) pacing is associated with adverse left ventricular (LV) remodeling and biventricular (BiV) pacing may prevent it although the mechanisms remain unclear. The current study aimed to assess the role of early pacing-induced systolic dyssynchrony (DYS) to predict adverse LV remodeling.

Methods

Patients with standard pacing indications and normal LV ejection fraction were randomized either to BiV (n = 89) or RVA pacing (n = 88). Pacing-induced DYS, defined as the standard deviation of the time to peak systolic velocity (Dyssynchrony Index) > 33 ms in a 12-segmental model of LV, was measured by tissue Doppler echocardiography at 1 month.

Results

At 1 month, 59 patients (33%) had DYS which was more prevalent in RVA than BiV pacing group (52% vs. 15%, χ² = 28.3, p < 0.001), though Dyssynchrony Index was similar at baseline (30 ± 14 vs. 26 ± 11 ms, p = 0.06). At 12 months, those developing DYS had significantly lower LV ejection fraction (55.1 ± 9.7 vs. 62.2 ± 7.9%, p < 0.001) and larger LV end-systolic volume (35.3 ± 14.3 vs. 27.0 ± 10.4 ml, p < 0.001) when compared to those without DYS. Reduction of ejection fraction ≥ 5% occurred in 67% (39 out of 58) of patients with DYS, but only in 18% (21 out of 115) in those without DYS (χ² = 40.8, p < 0.001). Both DYS at 1 month (odds ratio [OR]: 4.725, p = 0.001) and RVA pacing (OR: 3.427, p = 0.009) were independent predictors for reduction of ejection fraction at 12 months.

Conclusion

Early pacing-induced DYS is a significant predictor of LV adverse remodeling and the observed benefit of BiV pacing may be related to the prevention of DYS.

Clinical trial registration

Centre for Clinical Trials number, CUHK_CCT00037 (URL: http://www.cct.cuhk.edu.hk/Registry/publictrialrecord.aspx?trialid=CUHK_CCT00037).     

Left ventricular diastolic function in relation to the urinary proteome: A proof-of-concept study in a general population

Background

In previous studies, we identified two urinary proteomic classifiers, termed HF1 and HF2, which discriminated subclinical diastolic left ventricular (LV) dysfunction from normal. HF1 and HF2 combine information from 85 and 671 urinary peptides, mainly up- or down-regulated collagen fragments. We sought to validate these classifiers in a population study.

Methods

In 745 people randomly recruited from a Flemish population (49.8 years; 51.3% women), we measured early and late diastolic peak velocities of mitral inflow (E and A) and mitral annular velocities (e' and a') by conventional and tissue Doppler echocardiography, and the urinary proteome by capillary electrophoresis coupled with mass spectrometry.

Results

In the analyses adjusted for sex, age, body mass index, blood pressure, heart rate, LV mass index and intake of medications, we expressed effect sizes per 1-SD increment in the classifiers. HF1 was associated with 0.204 cm/s lower e' peak velocity (95% confidence interval, 0.057–0.351; p = 0.007) and 0.145 higher E/e' ratio (0.023–0.268; p = 0.020), while HF2 was associated with a 0.174 higher E/e' ratio (0.046–0.302; p = 0.008). According to published definitions, 67 (9.0%) participants had impaired LV relaxation and 96 (12.9%) had elevated LV filling pressure. The odds of impaired relaxation associated with HF1 was 1.38 (1.01–1.88; p = 0.043) and that of increased LV filling pressure associated with HF2 was 1.38 (1.00–1.90; p = 0.052).

Conclusions

In a general population, the urinary proteome correlated with diastolic LV dysfunction, proving its utility for early diagnosis of this condition.     

Distal protection device aggravated microvascular obstruction evaluated by cardiac MR after primary percutaneous intervention for ST-elevation myocardial infarction

Background

Protection of distal embolization by balloon occlusion and thrombus aspiration has not improved microvascular circulation nor decreased myocardial injury during primary percutaneous intervention (PCI) for ST-elevation myocardial infarction (STEMI) in randomized trials. In a prospective randomized trial, we investigated the mechanism of the poor effect of distal protection and thrombus aspiration (DP–TA) in 126 patients with STEMI.

Methods

Patients with first-diagnosed STEMI were randomly assigned to DP–TA pretreatment or conventional PCI (c-PCI). Primary endpoint was reduced left ventricular end-diastolic volume (LVEDV) measured by MRI at post-PCI and 6 months after PCI. Secondary end points were infarct ratio (infarct size to entire LV size) by delayed enhancement (DE), area at risk (AAR) ratio (AAR to entire LV size) by T2 high signal, microvascular occlusion index (MVO) ratio (MVO to entire LV size) by DE, and myocardial salvage index (MSI: (AAR − infarct size) ∗ 100 / AAR) using cardiac magnetic resonance imaging (MRI) within 3 days after PCI.

Results

Baseline characteristics of the patients including cardiovascular risk factors and lesion characteristics were similar between the two groups. DT–PA failed to improve LV remodeling at 6 months (LVEDV 140 ± 39 vs 133 ± 37 in c-PCI group, p = 0.418). Infarct ratio, AAR ratio and MSI were not statistically different between DP–TA group and c-PCI group. However, MVO ratio was significantly larger in DP–TA group than in c-PCI group (2.4 ± 2.7 vs 1.1 ± 1.9, p = 0.045).

Conclusion

DP–TA was potentially hazardous in primary PCI for STEMI by increasing MVO. DP–TA should not be used in STEMI.     

Coronary artery calcification correlates with the presence and severity of valve calcification

Aim

To investigate the prevalence of coronary artery calcification (CAC) in symptomatic individuals with CT evidence for left heart valve calcification, aortic valve (AVC), mitral valve (MAC) or both.

Methods

This is a retrospective study of 282 consecutive patients with calcification in either the aortic valve or mitral annulus. Calcium scoring of the coronary artery, aortic and mitral valve was measured using the Agatston score.

Results

AVC was more prevalent than MAC (64% vs. 2.5%, p < 0.001), with 34% having both. Absence of CAC was noted in 12.7% of the study population. AVC + CAC were observed in 53.5%, MAC and CAC in 2.1%, and combined AVC, MAC and CAC in 31.6%. The median CAC score was higher in individuals with combined AVC + MAC, followed by those with AVC and lowest was in the MAC group. The majority (40%) of individuals with AVC had CAC score > 400, and only in 16% had CAC = 0. The same pattern was more evident in individuals with AVC + MAC, where 70% had CAC score > 400 and only 6% had CAC score of 0. These results were irrespective of gender. There was no correlation between AVC and MAC but there was modest correlation between CAC score and AVC score (r = 0.28, p = 0.0001), MAC (r = 0.36, p = 0.0001) and with combined AVC + MAC (r = 0.5, p = 0.0001). AVC score of 262 had a sensitivity of 78% and specificity of 92% for the prediction of presence of CAC.

Conclusion

The presence and extent of calcification in the aortic valve or/and mitral valves are associated with severe coronary artery calcification.     

Associations between N-terminal pro-B-type natriuretic peptide and cardiac function in adults with corrected tetralogy of Fallot

Background

Amino-terminal B-type natriuretic peptide (NT-proBNP) may detect early cardiac dysfunction in adults with tetralogy of Fallot (ToF) late after corrective surgery. We aimed to determine the value of NT-proBNP in adults with ToF and establish its relationship with echocardiography and exercise capacity.

Methods and results

NT-proBNP measurement, electrocardiography and detailed 2D-echocardiography were performed on the same day in 177 consecutive adults with ToF (mean age 34.6 ± 11.8 years, 58% male, 89% NYHA I, 29.3 ± 8.5 years after surgical correction). Thirty-eight percent of the patients also underwent a cardiopulmonary-exercise test. Median NT-proBNP was 16 [IQR 6.7–33.6] pmol/L, and was elevated in 55%. NT-proBNP correlated with right ventricular (RV) dilatation (r = 0.271, p < 0.001) and RV systolic dysfunction (r = − 0.195, p = 0.022), but more strongly with LV systolic dysfunction (r = − 0.367, p < 0.001), which was present in 69 patients (39%). Moderate or severe pulmonary regurgitation was not associated with higher NT-proBNP. Tricuspid and pulmonary regurgitation peak velocities correlated with NT-proBNP (r = 0.305, p < 0.001 and r = 0.186, p = 0.045, respectively). LV twist was measured with speckle-tracking echocardiography in 71 patients. An abnormal LV twist (20 patients, 28%) was associated with elevated NT-proBNP (p = 0.030). No relationship between NT-proBNP and exercise capacity was found.

Conclusions

NT-proBNP levels are elevated in more than 50% of adults with corrected ToF, while they are in stable clinical condition. Higher NT-proBNP is most strongly associated with elevated pulmonary pressures, and with LV dysfunction rather than RV dysfunction. NT-proBNP has the potential to become routine examination in patients with ToF to monitor ventricular function and may be used for timely detection of clinical deterioration.     

MitraClip in CRT non-responders with severe mitral regurgitation

Background

Severe mitral regurgitation (MR) ≥ 3 + and left ventricular dyssynchrony in heart failure patients are markers of CRT non response. The MitraClip (MC) implantation is a therapy for MR ≥ 3 + in patients with high surgical risk of mitral valve reconstruction.

Methods and results

We investigated 42 patients with CRT and MR ≥ 3 + who received an MC device at our center. One and two year mortality rates were compared with the predicted mortality by Seattle Heart Failure Model (SHFM) and meta-analysis global group in chronic heart failure (MAGGIC), using the baseline characteristics of patients at the time of MC implantation.The median time interval between CRT and MC implantation was 20.1 (4.5–43.3) months. In 19 patients we observed a functional regurgitation with normal leaflets and in 23 patients a degenerative mechanism for mitral regurgitation. There was no change in mean QRS duration by biventricular pacing or MC implantation. The use of MC led to significant reductions in: median N-terminal pro-brain natriuretic peptide (NT-proBNP) level (pg/ml) from 3923 to 2636 (p = 0.02), tricuspid regurgitation pressure gradient (TRPG) from 43 to 35 mm Hg (p = 0.019) and in left ventricular end-diastolic volume (LVEDV) by MC (p = 0.008). At the 2 year follow-up interval the all-cause mortality was 25%.

Conclusion

MC implantation leads to an improvement of NT-proBNP level, TRPG and LVEDV in both functional and degenerative MR but does not influence QRS duration. Two year all-cause mortality was 25% and did not differ significantly from that predicted by SHFM and MAGGIC.     

The increasing detection of asymptomatic left ventricular dysfunction in patients with type 2 diabetes mellitus without overt cardiac disease: Data from the SHORTWAVE study

Aims

Type 2 diabetes mellitus (DM) is associated with higher risk of heart failure. Over the last three decades several studies demonstrated the presence of asymptomatic systolic and/or diastolic left ventricular (LV) dysfunction (asymLVD) in patients with normal LV ejection fraction (LVEF). Purpose of our study was to assess the prevalence and factors associated with asymLVD in DM patients by echocardiographic indexes more sensitive than LVEF and transmitral flow detected by pulsed Doppler.

Methods

386 DM patients without overt cardiac disease were enrolled from January to October 2011. Stress-corrected midwall shortening (sc-MS) and mitral annular peak systolic velocity (S′) were considered as indexes of systolic function of circumferential and longitudinal myocardial fibers, respectively. Early diastolic velocity of transmitral flow was divided by early diastolic Tissue Doppler velocity of mitral annulus for identifying diastolic LVD.

Results

asymLVD was detected in 262 patients (68%). 106 (27%) had isolated systolic asymLVD, 61 (16%) isolated diastolic asymLVD; in 95 (25%) systolic and diastolic asymLVD coexisted. Patients with asymLVD were older, had lower glomerular filtration rate, higher levels of glycated hemoglobin, C reactive protein, LV mass, relative wall thickness and prevalence of valve calcifications. Older age (HR 1.1 [1.02–1.18], p = 0.01), aortic valve calcifications (HR 6.3 [1.31–30.31], p = 0.02), LV concentric geometry defined as relative wall thickness ≥0.43 (HR 15.44 [2.96–80.44], p = 0.001) were independent predictors of asymLVD at multivariate analysis.

Conclusions

Using suitable echocardiographic indexes, asymLVD is detectable in two/third of DM patients without overt cardiac disease and is predicted by older age, cardiac valve calcifications and LV concentric remodeling.     

Blood flow characteristics in the ascending aorta after aortic valve replacement—a pilot study using 4D-flow MRI

Background

Aortic remodeling after aortic valve replacement (AVR) might be influenced by the postoperative blood flow pattern in the ascending aorta. This pilot study used flow-sensitive four-dimensional magnetic resonance imaging (4D-flow) to describe ascending aortic flow characteristics after various types of AVR.

Methods

4D-flow was acquired in 38 AVR patients (n = 9 mechanical, n = 8 stentless bioprosthesis, n = 14 stented bioprosthesis, n = 7 autograft) and 9 healthy controls. Analysis included grading of vortex and helix flow (0–3 point scale), assessment of systolic flow eccentricity (1–3 point scale), and quantification of the segmental distribution of peak systolic wall shear stress (WSS_peak) in the ascending aorta.

Results

Compared to controls, mechanical prostheses showed the most distinct vorticity (2.7 ± 0.5 vs. 0.7 ± 0.7; p < 0.001), while stented bioprostheses exhibited most distinct helicity (2.6 ± 0.7 vs. 1.6 ± 0.5; p = 0.002). Instead of a physiologic central flow, all stented, stentless and mechanical prostheses showed eccentric flow jets mainly directed towards the right-anterior aortic wall. Stented and stentless prostheses showed an asymmetric distribution of WSS_peak along the aortic circumference, with significantly increased local WSS_peak where the flow jet impinged on the aortic wall. Local WSS_peak was higher in stented (1.4 ± 0.7 N/m²) and stentless (1.3 ± 0.7 N/m²) compared to autografts (0.6 ± 0.2 N/m²; p = 0.005 and p = 0.008) and controls (0.7 ± 0.1 N/m²; p = 0.017 and p = 0.027). Autografts exhibited lower absolute WSS_peak than controls (0.4 ± 0.1 N/m² vs. 0.7 ± 0.2 N/m²; p = 0.003).

Conclusions

Flow characteristics in the ascending aorta after AVR are different from native aortic valves and differ between various types of AVR.     

Growth differentiation factor-15 in Takotsubo cardiomyopathy: Diagnostic and prognostic value

Background

Growth differentiation factor-15 (GDF-15), a stress responsive cytokine, has emerged as a marker of adverse outcome in various cardiovascular diseases. Since GDF-15 has not been evaluated in patients with Takotsubo cardiomyopathy (TTC), the present study sought to investigate the diagnostic and prognostic value in this patient cohort.

Methods

A total of 22 patients presenting with TTC were matched for age and gender with 22 ST-segment elevation myocardial infarction (STEMI) patients. GDF-15 concentrations were measured at admission and 1 day thereafter. The primary clinical endpoint of the TTC cohort was the composite of death, cardiogenic shock, or new congestive heart failure within 6 months.

Results

TTC patients showed significantly higher GDF-15 values on admission compared to patients presenting with STEMI (median 3047 ng/l [interquartile range 2256–7572] versus median 1527 ng/l [interquartile range 1152–2677]; p = 0.002). TTC patients with a biventricular ballooning pattern and patients experiencing major adverse cardiac events during the first 6 months after acute presentation showed significantly higher GDF-15 concentrations on admission (p = 0.008 and p = 0.005, respectively). Biventricular ballooning was identified as a predictor for elevated GDF-15 values on admission (p = 0.03). High GDF-15 levels on admission were the only significant predictor for the combined clinical endpoint in multivariable regression analysis (p = 0.02).

Conclusion

TTC patients showed markedly high, but transient elevation of GDF-15 levels. Biventricular ballooning was associated with particularly high GDF-15 concentrations. Elevated GDF-15 values on admission were a strong predictor of adverse clinical outcome.     

Improved coronary artery blood flow following the correction of systolic dyssynchrony with cardiac resynchronization therapy

Background

Coronary blood flow (CBF) is improved by cardiac resynchronization therapy (CRT) and impaired by right ventricular apical (RVA) pacing in patients with heart failure. However, the underlying mechanism remains unclear.

Methods

Twenty-nine non-ischemic heart failure patients who responded to CRT underwent transthoracic echocardiography examination including both left anterior descending (LAD) CBF and tissue Doppler imaging in 3 pacing modes: intrinsic conduction, RVA pacing and biventricular (BiV) pacing. LAD velocity-temporal integral (LAD-VTI) and duration were measured. Systolic dyssynchrony was assessed with the standard deviation of a 12-left ventricular segmental model (Ts-SD).

Results

BiV pacing improved while RVA pacing reduced CBF compared to intrinsic conduction (all p < 0.05). Both Ts-SD and ventricular septal velocity deteriorated during RVA pacing but improved during BiV pacing (all p < 0.05). When systolic dyssynchrony was induced, lower LAD-VTI (9.5 ± 3.4 versus 12.7 ± 5.1 cm, p = 0.001) and shorter LAD diastolic duration (483 ± 92 versus 542 ± 106 ms, p = 0.010) were detected than synchronous status. Systolic dyssynchrony was inversely related to septal velocity (r = − 0.41), p<0.001 and LAD-VTI (r = − 0.30, p = 0.007), with the latter found to be moderately correlated to septal velocity (r = 0.30, p = 0.007).

Conclusion

Regional LAD flow was improved in patients subjected to BiV but worsened in those treated with RVA pacing in non-ischemic heart failure CRT responders. Systolic dyssynchrony was more commonly observed in patients subjected to RVA pacing. Reduction of septal velocity with dyssynchrony may directly lead to reduced LAD flow. Improvement of septal velocity by CRT and hence LAD flow may be an important mechanism in determining the response to CRT.     

Effect of ischemic postconditioning on microvascular obstruction in reperfused myocardial infarction. Results of a randomized study in patients and of an experimental model in swine

Background

Ischemic postconditioning (PCON) appears as a potentially beneficial tool in ST-segment elevation myocardial infarction (STEMI). We evaluated the effect of PCON on microvascular obstruction (MVO) in STEMI patients and in an experimental swine model.

Methods

A prospective randomized study in patients and an experimental study in swine were carried out in two university hospitals in Spain. 101 consecutive STEMI patients were randomized to undergo primary angioplasty followed by PCON or primary angioplasty alone (non-PCON). Using late gadolinium enhancement cardiovascular magnetic resonance, infarct size and MVO were quantified (% of left ventricular mass). In swine, using an angioplasty balloon-induced anterior STEMI model, MVO was defined as the % of area at risk without thioflavin-S staining.

Results

In patients, PCON (n = 49) in comparison with non-PCON (n = 52) did not significantly reduce MVO (0 [0–1.02]% vs. 0 [0–2.1]% p = 0.2) or IS (18 ± 13% vs. 21 ± 14%, p = 0.2). MVO (> 1 segment in the 17-segment model) occurred in 12/49 (25%) PCON and in 18/52 (35%) non-PCON patients, p = 0.3. No significant differences were observed between PCON and non-PCON patients in left ventricular volumes, ejection fraction or the extent of hemorrhage. In the swine model, MVO occurred in 4/6 (67%) PCON and in 4/6 (67%) non-PCON pigs, p = 0.9. The extent of MVO (10 ± 7% vs. 10 ± 8%, p = 0.9) and infarct size (23 ± 14% vs. 24 ± 10%, p = 0.8) was not reduced in PCON compared with non-PCON pigs.

Conclusions

Ischemic postconditioning does not significantly reduce microvascular obstruction in ST-segment elevation myocardial infarction.Clinical Trial Registrationhttp://www.clinicaltrials.gov. Unique identifier: NCT01898546.     

Left anterior descending coronary artery flow impaired by right ventricular apical pacing: The role of systolic dyssynchrony

Introduction

Right ventricular (RV) pacing may affect myocardial perfusion and coronary blood flow; however, it remains unknown whether this is related to systolic dyssynchrony induced by RV pacing. This prospective study was aimed to assess the relationship between dyssynchrony and the changes of coronary blood flow.

Methods

Seventy patients with sinus node dysfunction were prospectively enrolled. Coronary flow was evaluated by measuring diastolic velocity time integral (VTI) and duration at the distal-portion of left anterior descending coronary artery (LAD) with transthoracic echocardiography at baseline and follow-up. Systolic dyssynchrony was assessed with tissue Doppler imaging by time standard deviation to peak systolic velocity of 12 left ventricular segments (Ts-SD, cutoff value ≥ 33 ms).

Results

Adequate data for analysis was available from 65 patients. At follow-up (mean follow up time: 127 ± 45 days), LAD velocity-time integral (LAD-VTI: 12.1 ± 4.2 vs. 10.7 ± 4.6 cm, p < 0.001) was decreased and there was deterioration of left ventricular systolic function (left ventricular ejection fraction: 65 ± 7% vs. 62 ± 7%). However, these changes were only detected in those with RV pacing induced systolic dyssynchrony. Significant reduction of LAD-VTI (defined as ≥ 5%) occurred in 34 (52%) patients which was more prevalent in those with pacing-induced systolic dyssynchrony than those without (85.3% versus 16.1%, χ² = 31.1, p < 0.001). Though similar at baseline, LAD-VTI was significantly lower in the dyssynchrony group at follow up (p < 0.001). Cox-regression analysis showed that pacing-inducing systolic dyssynchrony [hazard ratio (HR): 3.62, p = 0.009] and higher accumulative pacing percentage (HR: 1.02, p = 0.002) were independently associated with reduction of LAD-VTI. ROC curve demonstrated that accumulative pacing percentage ≥ 35% was 97% sensitive and 84% specific in revealing significant reduction (area under the curve: 0.961, p < 0.001).

Conclusions

RV pacing induced dyssynchrony is associated with reduced coronary flow and this may account for, in part, the deleterious effect of RV pacing on ventricular function over time.     

Effets de la réduction de la précharge sur les paramètres échographiques de la fonction systolique et diastolique du ventricule gauche de l’enfant en insuffisance rénale terminale : étude comparative avant et après hémodialyse

Purpose

Contrasting data exist about the hemodialysis induced changes of ventricular diastolic and systolic functions in adults. Few data in children with end-stage renal disease (ESRD) are reported. The aim of the present study was to evaluate the effect of a single hemodialysis (HD) session on left ventricular (LV) systolic and diastolic function using conventional pulsed-Doppler echocardiography and pulsed tissue Doppler imaging (TDI) in hemodialysis children.

Methods

Thirty-five children with chronic renal failure (15 males, aged 12.8 ± 3.8 years) on maintenance hemodialysis underwent conventional 2D and Doppler Echo together with measurement of longitudinal mitral annular motion velocities. Echocardiographic parameters were obtained 30 minutes before and 30 minutes after HD. Paired data were compared.

Results

Hemodialysis led to reduction in LV end-diastolic volume (p = 0.001), end-systolic volume (p = 0.05), left atrium area (p < 0.0001), peak early (E wave) transmitral flow velocity (p = 0.005), peak S velocity of pulmonary vein flow (p = 0.002), aortic time velocity integral (p < 0.0001) and aortic ejection time (p < 0.0001). No significant change in Tei Index was observed after HD. Regarding TDI measures, velocities were not affected by preload reduction. Only the early diastolic velocities on the septal side of the mitral annulus decreased significantly (p = 0.001) and the systolic velocities on the lateral side of the mitral annulus increased significantly (p = 0.042) after hemodialysis.

Conclusions

Most of Doppler-derived indices of diastolic function are preload-dependant. TDI velocities and Tei Index were not or minimally affected by preload reduction in hemodialysis children.     

Diastolic ventricular interaction in patients after atrial switch for transposition of the great arteries: A speckle tracking echocardiographic study

Background

We tested the hypothesis that diastolic ventricular interaction occurs after atrial switch operation for transposition of the great arteries (TGA) and that subpulmonary LV diastolic function is influenced by septal geometry.

Methods

Twenty-nine patients (male 19) after atrial switch operation for TGA aged 20.8 ± 4.1 years and 27 healthy controls were studied. Two-dimensional longitudinal systolic strain, systolic (SRs), early diastolic (SRe), and late diastolic (SRa) strain rates of both ventricles were determined using speckle tracking echocardiography. Early diastolic trans-atrioventricular velocity (E) and myocardial early diastolic myocardial velocity (e) at the ventricular free wall-annular junction were measured. Geometry of the morphologic left ventricle was quantified by the diastolic eccentricity index (EI).

Results

In both systemic and subpulmonary ventricles, SRe and SRa were significantly lower and trans-atrioventricular E/e ratios higher in patients than controls (all p < 0.001). In patients, RV SRe correlated with left ventricular (LV) SRe (r = 0.49, p = 0.008), and RV SRa correlated with LV SRa (r = 0.46, p = 0.01). Significant leftward shifting of the septum in patients was reflected by the greater LV EI (p < 0.001). In patients, LV EI correlated with age- and sex-adjusted z score of LV end-diastolic volume. As a group, LV EI correlated negatively with LV SRe (r =−0.62, p < 0.001) and LV SRa (r = − 0.51, p < 0.001), and positively with mitral E/e ratio (r = 0.33, p = 0.02).

Conclusions

Systemic RV diastolic dysfunction occurs after atrial switch operation and correlates with subpulmonary LV diastolic dysfunction. The observed diastolic ventricular interaction may potentially be mediated through alteration of septal geometry.     

Anévrismes infectieux de l’aorte. À propos d’une série de dix patients

Purpose

Infectious aortic aneurysms are rare, being responsible of less than 3% of aortic aneurysms. In this study, we report the clinical characteristics and the outcome of patients presenting with infectious aortic aneurysms in an internal medicine unit.

Methods

Diagnosis of infection-related aortic aneurysm was obtained using: computed tomographic scan; and blood cultures, cultures and molecular biology testing of aortic wall and intra-aneurismal thrombus.

Results

The 10 consecutive patients included in this study consisted in eight men and two women with a mean age of 61.7 years. Patients presented with fever (n = 9), asthenia (n = 2), abdominal (n = 4) or chest pain (n = 1), lumbar pain (n = 3). Computed tomographic scan showed aneurysm involving both thoracic and abdominal aorta (n = 1), abdominal (n = 8) or thoracic aorta (n = 1). Isolated microorganisms were: positive Gram cocci (70%) and negative Gram bacilli (30%). All patients underwent both medical and surgical therapy. Outcome was favorable in nine patients; the remaining patient died from aneurismal aortic rupture.

Conclusion

Clinical manifestations revealing infectious aortic aneurysms are variable, including aneurysm rupture as well as atypical abdominal pain with inflammatory syndrome. These latter presentations are more common in patients, who are hospitalized in internal medicine. Our study underlines that this clinical pattern should not be ignored, in order to avoid both diagnostic and therapeutic delay that could lead to life-threatening complications and poor prognosis.     

Revisiting a classical clinical sign: Jugular venous ultrasound

Background

Increased jugular venous pressure, reflecting the increased right atrial pressure, is a classical sign of heart failure (HF) but clinical assessment may be difficult.

Methods

In ambulatory patients with HF and control subjects, jugular vein diameter (JVD) was measured using a linear high-frequency ultrasound probe (10 MHz) at rest, during a Valsalva manoeuvre and during deep inspiration. JVD ratio was calculated as diameter during Valsalva to that at rest.

Results

211 patients (mean age 70 years; mean left ventricular ejection fraction 43%) and 20 controls were included. JVD (median and inter-quartile [IQR] range) at rest was 0.17 (0.15–0.20) cm in controls and 0.23 (0.17–0.33) cm in patients with HF (p = 0.012), JVD ratio was 6.3 (4.3–6.8) in controls and 4.4 (2.7–5.8) in patients with HF (p = 0.001).With increasing quartiles of plasma NT-proBNP, JVD at rest rose (0.20 (0.15–0.23) cm, 0.21 (0.16–0.29) cm, 0.25 (0.18–0.35) cm and 0.34 (0.20–0.53) cm (P = < 0.001), whilst JVD ratio decreased (5.4 (4.2–6.4), 4.4 (3.5–6.3), 3.9 (2.4–5.4) and 2.8 (1.7–4.7); p = < 0.001). JVD ratio correlated with log (NT-proBNP) (r = − 0.39, p = < 0.001), LV filling pressures (E/E′, r = − 0.33, p = < 0.001) and left atrial volume (r = − 0.21, p = 0.002). In a multivariable regression model, only trans-tricuspid gradient and TAPSE were independently associated with JVD ratio (R² = 0.27).

Conclusions

Distension of the JV at rest relative to the maximum diameter during a Valsalva manoeuvre (JVD ratio) identifies patients with heart failure who have higher plasma NT-proBNP levels, right ventricular dysfunction and raised pulmonary artery pressure     

Angiographic assessment of myocardial perfusion in Tako-Tsubo syndrome

Objectives

To angiographically assess myocardial perfusion in patients with Tako-Tsubo syndrome (TTS) in comparison with control individuals and patients with ST-elevation myocardial infarction (STEMI).

Background

Coronary microvascular dysfunction has been proposed as the pathophysiological mechanism underlying TTS.

Methods

We retrospectively selected consecutive TTS patients showing typical left ventricular (LV) apical dysfunction admitted to our Department in the period 2007–2011 (n = 25). We also enrolled an age and gender-matched control group showing normal coronary arteries (CTR, n = 25), patients with STEMI undergoing primary percutaneous intervention with myocardial reperfusion (SR, n = 25) or microvascular obstruction (SMVO, n = 25). TIMI flow, TIMI frame count (TFC) and both qualitative and quantitative myocardial blush grade in LV apex were assessed. Specifically, myocardial perfusion was quantitatively evaluated using ‘Quantitative Blush Evaluator’ (QuBE), an open source software previously validated in the setting of STEMI.

Results

In TTS, TIMI flow on the LAD was significantly lower and TFC significantly higher compared to CTR and SR (p = 0.008 for both), while it did not significantly differ compared to SMVO (p = 0.06). In TTS, MBG was significantly lower than that in CTR and SR (p = 0.001 for both), while it was significantly higher than that in SMVO (p < 0.001). In TTS, QuBE score was significantly lower than that in CTR and SR (p = 0.001 for both) and higher than in SMVO (p = 0.02).

Conclusions

Our data indicate that myocardial perfusion assessed during angiography is more impaired in patients with TTS than in patients with STEMI exhibiting myocardial reperfusion, while it is less impaired than in patients with STEMI exhibiting MVO.     

Serum endotoxin and inflammatory mediators in patients with cirrhosis and hepatic encephalopathy

Background

Recent observations suggest that inflammatory response may be important in the pathogenesis of hepatic encephalopathy. The aim of the study was to measure arterial ammonia, tumour necrosis factor-alpha, Interleukin-6, Interleukin-18, and serum endotoxin levels and their correlation with different grades of hepatic encephalopathy.

Methods

120 patients with cirrhosis were enrolled: 20 patients each of cirrhosis with grades I, II, III and IV hepatic encephalopathy, cirrhosis with and without minimal hepatic encephalopathy and healthy controls were tested for arterial ammonia, tumour necrosis factor-alpha, Interleukin-6, Interleukin-18 and serum endotoxin levels.

Results

Median arterial ammonia, tumour necrosis factor-alpha, Interleukin-6, Interleukin-18 and serum endotoxin levels were significantly higher in patient with hepatic encephalopathy and minimal hepatic encephalopathy as compared to patients without minimal hepatic encephalopathy and healthy controls. Arterial ammonia (r = 0.72, p = 0.03), tumour necrosis factor alpha (r = 0.87, p = 0.02), Interleukin-6 (r = 0.50, p = 0.05), Interleukin-18 (r = 0.76, p = 0.02) and serum endotoxin (r = 0.91, p = 0.01) correlated with higher grades of hepatic encephalopathy.

Conclusion

In hepatic encephalopathy arterial ammonia, inflammatory mediators, and serum endotoxin are elevated and correlate with encephalopathy grade.     

First-in-man evidence of the mechanistic effects of biventricular pacing on coronary physiology

BackgroundNormal coronary blood flow is principally determined by a diastolic backward travelling decompression (suction) wave. Dyssynchronous heart failure may attenuate suction. We hypothesised that biventricular pacing, by restoring left ventricular (LV) synchronisation and improving LV relaxation, might increase this suction wave and coronary flow.MethodsTen patients with congestive heart failure (nine men; mean age 65 years [SD 12]; mean ejection fraction 26% [SD 7] with left bundle branch block (LBBB, mean QRS duration 174 ms [SD 18]) underwent atriobiventricular pacing at 100 beats per min. LV pressure was measured and wave intensity calculated from invasive coronary flow velocity and pressure, with native conduction (LBBB) and during biventricular pacing at atrioventricular (AV) delays of 40 ms (BiV-40), 120 ms (BiV-120), and separately pre-identified haemodynamically optimal AV delay (BiV-Opt). Data are given as median (IQR).FindingsCompared with LBBB, BiV-Opt enhanced coronary flow velocity time integral (VTI) by 15% (7–25, p=0·007), LV dP/dt_max by 17% (9–22, p=0·005), and _negdP/dt_max by 17% (9–22, p=0·005). The cumulative intensity of the diastolic backward decompression (suction) wave increased by 26% (18–54, p=0·005). Much of the increase in coronary flow VTI occurred in diastole (69% [41–84], p=0·047). The systolic compression waves also increased: forward by 36% (6–49; p=0·022) and backward by 38% (20–55, p=0·022). BiV-120 generated a smaller LV dP/dt_max (by 12% [5–23], p=0·013) and _negdP/dt_max (by 15% [8–40], p=0·009) increase than did BiV-OPT, with LBBB as reference; BiV-Opt and BiV-120 were not significantly different in coronary flow VTI or waves. BiV-40 was no different from LBBB.InterpretationWhen biventricular pacing improves left ventricular contraction and relaxation, it increases coronary blood flow velocity, predominantly by increasing the dominant diastolic backward decompression wave.FundingBritish Heart Foundation.