Echocardiographic predictors of exercise capacity in patients with heart failure and systolic dysfunction: role of mitral regurgitation

Introduction and objectives

Patients with heart failure and similar left ventricular systolic dysfunction have differing exercise capacity. The aim of this study was to identify echocardiographic predictors of exercise capacity in patients with heart failure and systolic dysfunction.

Methods

We included 150 patients with class II (70%) or III (30%) heart failure with left ventricular ejection fraction below 40%. Six-minute walking test and cardiac color Doppler-echo, including tissue Doppler of mitral and tricuspid rings, were performed. Moderate and severe mitral regurgitation were considered as significant. Two groups were divided according to the median walking distance (290 m): Group 1, <290 m and Group 2, ≥290 m.

Results

Mitral regurgitation was detected in 112 patients (75%), which was significant in 40 (27%). Group 1 showed more significant mitral regurgitation (35 vs 18%), increased left atrium area (27±1 vs 24±1 cm²), mitral E amplitude (88±5 vs 72±3 cm/s) and systolic pulmonary pressure (37±1 vs 32±1 mmHg, all P<.05). By logistic regression analysis, only the presence of significant mitral regurgitation was independently associated with less walked distance (odds ratio: 3.44 95% confidence interval 1.02-11.66, P<.05). By multiple linear regression, the only independent predictor of walked distance was left atrium area (r=0.25, beta coefficient: −6.52 ± 2, P<.01).

Conclusions

In patients with class II-III heart failure and left ventricular systolic dysfunction, the main echocardiographic predictors of exercise capacity are related to the presence of significant mitral regurgitation.Full English text available from:www.revespcardiol.org     

Relationship of ventricular longitudinal function to contractile reserve in patients with mitral regurgitation

Background

Latent left ventricular (LV) dysfunction in patients with valvular or myocardial disease may be identified by loss of contractile reserve (CR) at exercise echocardiography. Contraction in the LV longitudinal axis may be more sensitive than radial contraction to minor disturbances of LV function. We sought to determine whether tissue Doppler measurement of longitudinal function could be used to identify CR.

Methods

Exercise echocardiography was performed in 86 patients (20 women, age 53 ± 18 years), 72 with asymptomatic or minimally symptomatic mitral regurgitation, and 14 normal controls. Pulsed-wave tissue Doppler imaging (DTI) was used to measure maximum annular systolic velocity at rest and stress. Inducible ischemia was excluded by analysis of wall motion by an experienced observer. CR was defined by ≥5% improvement of stress compared with rest ejection fraction (EF). Exercise capacity was assessed from expired gas analysis.

Results

CR was present in 34 patients with mitral regurgitation (47%); peak EF in patients with and without CR was 74% ± 11% versus 54% ± 15% (P < .0001). CR could not be predicted by resting EF, volumes or sphericity, and DTI measurement of base-apex function was the only resting echocardiographic parameter to distinguish between patients with and without CR (10 ± 2 vs 8 ± 2 cm/s, P < .03). This parameter showed greater differences after stress (14 ± 4 vs 11 ± 3 cm/s, P < .001). Patients with CR showed lower peak DTI than controls, as well as lower exercise capacity and EF response to exercise. In a multiple linear regression model, rest DTI (P = .03) was an independent correlate of contractile reserve. The other correlates were age (P < .0001), resting (P < .0001) and peak end-systolic volume (P = .01), and resting (P < .0001) and peak end-diastolic volume (P < .0001); the model r² was 0.93 (P < .001).

Conclusion

In the absence of regional LV dysfunction, measurement of longitudinal axis function by DTI may be a marker of CR.     

Negative Impact of Obesity on Ventricular Size and Function and Exercise Performance in Children and Adolescents With Repaired Tetralogy of Fallot

BackgroundUp to 25% of children with congenital heart disease are obese, which may have negative physiologic consequences for patients with repaired tetralogy of Fallot (rTOF).MethodsPatients with rTOF who underwent cardiac magnetic resonance (CMR) imaging and cardiopulmonary exercise testing from 2007 to 2018 were reviewed. Complex rTOF patients were excluded. Obese patients (body mass index [BMI] ≥ 95th percentile) were compared with normal-weight patients (BMI < 85th percentile). CMR data were indexed to actual body surface area (aBSA), height, and BSA assuming ideal body weight (iBSA).ResultsWe compared 32 obese patients matched with 64 normal-weight patients. Obese vs normal-weight patients had significantly lower right (RV; median 45% [interquartile range 42%-48%] vs 52% [47%-55%]; P < 0.0001) and left (LV; 52% [47%-56%] vs 56% [54%-60%]; P < 0.0001) ventricular ejection fractions (EFs). There were no statistically significant differences regarding aBSA-indexed volumes of the RV or LV at either end-diastole (EDV) or end-systole (ESV). However, when indexed to either height or iBSA, obese patients had significantly greater RVEDV and LVEDV, greater LV mass, and higher RV and LV stroke volumes. Obese patients had lower peak oxygen consumption and oxygen consumption at anaerobic threshold. These results did not change after adjusting for degree of pulmonary regurgitation.ConclusionsObesity is associated with increased biventricular size, decreased biventricular EFs, and impaired exercise performance after rTOF. These data suggest a potential role for cardiac rehabilitation for weight management and to optimize fitness.     

Tissue Doppler atrial conduction times and electrocardiogram interlead P-wave durations with varying severity of obstructive sleep apnea

Objectives

Obstructive sleep apnea (OSA) has been reported to be associated with an increased risk of atrial fibrillation. The aim of this study was to investigate atrial electromechanical couplings in patients with OSA and the relationship between these parameters and P-wave dispersion (Pd).

Methods

One hundred twenty-six patients were enrolled in this study. All patients underwent polysomnographic examination. The apnea-hypopnea index (AHI) was defined as the number of apneas and hypopneas per hour of sleep. An AHI score of 5 or more was diagnosed as OSA, and an AHI score of less than 5 was diagnosed as OSA (−). Thirty-nine of the patients had an AHI score of less than 5 (group 1), 42 of the patients had AHI score between 5 and 30 (mild and moderate, group 2), 45 of the patients had an AHI score more than 30 (severe, group 3). Atrial electromechanical coupling (PA), intra-atrial, and interatrial electromechanical delay were measured with tissue Doppler imaging. P-wave dispersion was calculated from 12-lead electrocardiogram.

Results

Maximum P-wave duration was higher in group 3 compared with groups 2 and 1 (126.0 ± 16.7 vs 111.0 ± 12.5 [P < .001] and 126.0 ± 16.7 vs 99.9 ± 10.0 [P < .001], respectively). Maximum P-wave duration was higher in group 2 than in group 1 (111.0 ± 12.5 vs 99.9 ± 10.0, P < .001). P-wave dispersion was higher in group 3 compared with groups 2 and 1 (50.9 ± 11.5 vs 37.0 ± 8.6 [P < .001] and 50.9 ± 11.5 vs 27.9 ± 6.8 [P < .001], respectively). P-wave dispersion was higher in group 2 than in group 1 (37.0 ± 8.6 vs 27.9 ± 6.8, P < .001). Minimum P-wave duration did not differ between the groups. Atrial PA at the left lateral mitral annulus (lateral PA), septal mitral annulus (septal PA), and right ventricular tricuspid annulus (RV PA) were significantly higher in group 3 than in group 2 (P < .001, P = .001, and P = .009, respectively). Lateral PA, septal PA, and RV PA were higher in group 2 compared with group 1 (P < .001, P = .003, and P = .009, respectively). Interatrial electromechanical delay (lateral PA − RV PA) was significantly longer in group 3 compared with groups 2 and 1 (33.6 ± 12.1 vs 22.4 ± 9.4 [P < .001] and 33.6 ± 12.1 vs 14.9 ± 9.2 [P < .001], respectively). Interatrial electromechanical delay was longer in group 2 than in group 1 (22.4 ± 9.4 vs 14.9 ± 9.2, P = .001). There was a positive correlation between AHI and Pd, lateral PA, septal PA, RV PA, interatrial electromechanical delay, and left-sided intra-atrial electromechanical delay.

Conclusion

Prolongation of electromechanical delay and increased Pd are associated with apnea-hypopnea index (AHI) and hence the severity of disease.     

Psycho-emotional Manifestations of Valvular Heart Diseases: Prospective Assessment in Mitral Regurgitation

Objective

To define the prevalence and consequences of post-traumatic stress disorder (PTSD) as an emotional response to cardiac diseases in patients with mitral regurgitation.

Methods

We prospectively enrolled 186 patients with moderate or severe organic mitral regurgitation, presenting class I (absent) or II (minimal) dyspnea, who were compared with 80 controls of similar age (38 with completely normal cardiac function; 42 with mild mitral-valve prolapse; all with no, or at most mild, mitral regurgitation). Mitral-regurgitation severity and consequences were comprehensively measured, simultaneously with PTSD, anxiety, and depression.

Results

PTSD prevalence was higher in mitral-regurgitation patients vs controls (23% vs 9%, P <.01). Although mitral-regurgitation objective severity (regurgitant volume 77.8 ± 28.9 vs 79.0 ± 27.5 mL, P = .8) and objective consequences (left-atrial volume 59.1 ± 20.9 vs 54.02 ± 15.6 mL, P = .1; right-ventricular systolic pressure 34.1 ± 11.4 vs 32.9 ± 7.2 mm Hg, P = .6) were similar with and without PTSD (all P ≥.1), patients with PTSD were more symptomatic (class II 74 vs 38%; fatigue 71% vs 38%, both P <.0001) and had higher anxiety and depressions scores (P <.0001).

Conclusions

PTSD is prevalent in organic moderate or severe mitral-regurgitation patients but is not determined by objective mitral-regurgitation severity or consequences. PTSD is linked to anxiety and depression and to symptoms usually considered cardiac, such as dyspnea. Thus, PTSD and psycho-emotional manifestations, linked to symptoms, represent important responses to chronic-valve disease that may affect clinical outcomes.     

Validation de la reproductibilité de la mesure de la surface de l’orifice régurgitant par planimétrie dans l’insuffisance aortique : une étude préliminaire d’échocardiographie trans-œsophagienne tridimensionnelle

Background

Aortic regurgitation is mainly evaluated by trans-thoracic echocardiography using multi-parametric qualitative and semi quantitative tools. All those parameters can fail to meet expectations, resulting in an imperfect diagnostic reliability and assessment of aortic regurgitation severity can be challenging.

Objectives

We sought to evaluate feasibility and intra- and inter-observer reproducibility of aortic regurgitant orifice area measured by planimetry with tridimensional trans-esophageal echocardiography on patients with at least grade 2/4 aortic regurgitation.

Patients and methods

Consecutive patients with at least grade 2/4 aortic regurgitation measured by trans-thoracic echocardiography and referred for trans-esophageal echocardiography for any reason were included. Planimetric reconstructions of regurgitant orifice area were studied and reproducibility indexes between senior and junior observers were calculated.

Results

Twenty-three patients were included in this study. Intra- and inter-observer reproducibility were excellent with an ICC of 0.95 [0.88–0.98], P < 0.0001 and 0.91 [0.79–0.96], P < 0.0001, respectively. Mean length of the measurement was 6.6 ± 0.9 min [CI95% 6.23–7.01].

Conclusion

Planimetric measurement of the aortic regurgitant orifice using tridimensional trans-esophageal echocardiography seems to be feasible and has great intra- and inter-observer reproducibility. Reconstruction durations were compatible with a daily use. There is a need now to investigate the reliability of this measurement as compared with the reference technique.     

Biomechanical Modeling to Inform Pulmonary Valve Replacement in Tetralogy of Fallot Patients After Complete Repair

BackgroundA biomechanical model of the heart can be used to incorporate multiple data sources (electrocardiography, imaging, invasive hemodynamics). The purpose of this study was to use this approach in a cohort of patients with tetralogy of Fallot after complete repair (rTOF) to assess comparative influences of residual right ventricular outflow tract obstruction (RVOTO) and pulmonary regurgitation on ventricular health.MethodsTwenty patients with rTOF who underwent percutaneous pulmonary valve replacement (PVR) and cardiovascular magnetic resonance imaging were included in this retrospective study. Biomechanical models specific to individual patient and physiology (before and after PVR) were created and used to estimate the RV myocardial contractility. The ability of models to capture post-PVR changes of right ventricular (RV) end-diastolic volume (EDV) and effective flow in the pulmonary artery (Q_eff) was also compared with expected values.ResultsRV contractility before PVR (mean 66 ± 16 kPa, mean ± standard deviation) was increased in patients with rTOF compared with normal RV (38-48 kPa) (P < 0.05). The contractility decreased significantly in all patients after PVR (P < 0.05). Patients with predominantly RVOTO demonstrated greater reduction in contractility (median decrease 35%) after PVR than those with predominant pulmonary regurgitation (median decrease 11%). The model simulated post-PVR decreased EDV for the majority and suggested an increase of Q_eff—both in line with published data.ConclusionsThis study used a biomechanical model to synthesize multiple clinical inputs and give an insight into RV health. Individualized modeling allows us to predict the RV response to PVR. Initial data suggest that residual RVOTO imposes greater ventricular work than isolated pulmonary regurgitation.     

Regression of significant tricuspid regurgitation after mitral balloon valvotomy for severe mitral stenosis

Background

Significant tricuspid regurgitation (TR) is occasionally associated with severe mitral stenosis and has an adverse impact on morbidity and mortality in patients undergoing mitral valve surgery. However, the effect of successful mitral balloon valvotomy (MBV) on significant TR is not fully elucidated. The aim of this study was to investigate TR after MBV in patients with severe mitral stenosis.

Methods

We analyzed the data of 53 patients with significant TR (grade ≥2, on a 1 to 3 scale) from the mitral balloon valvotomy database at our hospital. Patients were evaluated by Doppler echocardiography before valvotomy and at follow-up 1 to 13 years after MBV. Patients were divided into group A (27 patients), in whom TR regressed by ≥1 scale, and group B (26 patients), in whom TR did not regress.

Results

The Doppler-determined pulmonary artery systolic pressure was initially higher and decreased at follow-up more in group A (from 70.7 ± 23.8 to 36.5 ± 8.3 mm Hg; P < .0001) than in group B (from 48.7 ± 17.8 to 41.6 ± 13.1 mm Hg; P = NS). Compared with patients in group B, patients in group A were younger (25 ±10 vs 35 ± 11 years; P < .005), had higher prevalence of functional TR (85% vs 8%; P < .0001), and had lower incidence of atrial fibrillation (7% vs 38%; P < .005). Significant decrease in right ventricular end-diastolic dimension after MBV was noted in group A but not in group B. The mitral valve area at late follow-up was larger in group A than in group B (1.8 ± 0.3 vs 1.6 ± 0.3 cm²; P < .05).

Conclusions

Regression of significant TR after successful MBV in patients with severe mitral stenosis was observed in patients who had severe pulmonary hypertension. This improvement in TR occurred even in the presence of organic tricuspid valve disease.     

Color Doppler regurgitant jet area for evaluating eccenteric mitral regurgitation: An animal study with quantified mitral regurgitation

Objectives. The purpose of the present study was to rigorously evaluate the accuracy of the color Doppler jet area planimetry method for quantifying chronic mitral regurgitation.Background. Although the color Doppler jet area has been widely used clinically for evaluating the severity of mitral regurgitation, there have been no studies comparing the color jet area with a strictly quantifiable reference standard for determining regurgitant volume.Methods. In six sheep with surgically produced chronic mitral regurgitation, 24 hemodynamically different states were obtained. Maximal color Doppler jet area for each state was obtained with a Vingmed 750. Image data were directly transferred in digital format to a microcomputer. Mitral regurgitation was quantified by the peak and mean regurgitant flow rates, regurgitant stroke volumes and regurgitant fractions determined using mitral and aortic electromagnetic flow probes.Results. Mean regurgitant volumes varied from 0.19 to 2.4 liters/ min (mean [±SD] 1.2 ± 0.59), regurgitant stroke volumes from 1.8 to 29 ml/beat (mean 11 ± 6.2), peak regurgitant volumes from 1.0 to 8.1 liters/min (mean 3.5 ± 2.1) and regurgitant fractions from 8.0% to 54% (mean 29 ± 12%). Twenty-two of 24 jets were eccentric. Simple linear regression analysis between maximal color jet areas and peak and mean regurgitant flow rates, regurgitant stroke volumes and regurgitant fractions showed correlation, with r = 0.68 (SEE 0.64 cm²), r = 0.63 (SEE 0.67 cm²), r = 0.63 (SEE 0.67 cm²) and r = 0.58 (SEE 0.71 cm²), respectively. Univariate regression comparing regurgitant jet area with cardiac output, stroke volume, systolic left ventricular pressure, pressure gradient, left ventricular/ left atrial pressure gradient, left atrial mean pressure, left atrial vwave pressure, systemic vascular resistance and maximal jet velocity showed poor correlation (0.08 < r < 0.53, SEE > 0.76 cm²).Conclusions. This study demonstrates that color Doppler jet area has limited use for evaluating the severity of mitral regurgitation with eccentric jets.     

Hipertensión pulmonar tromboembólica crónica: tratamiento mediante tromboendarterectomía quirúrgica

Background and objectives

Pulmonary thromboendarterectomy (PTE) is considered the potential curative treatment for chronic thromboembolic pulmonary hypertension (CTEPH). We analysed the results of the PTE application in our institution.

Patients and methods

From February 1996 to December 2007, 30 patients with CTEPH underwent video-assisted PTE. Preoperative hemodynamic data were: systolic pulmonary artery pressure (SPAP) 87±17 mmHg, mean pulmonary artery pressure (MPAP) 51±11 mmHg, pulmonary total resistance 1067±485 dynes·s·cm^–5, pulmonary vascular resistance 873±389 dynes·s·cm^–5 and cardiac index 2.2±0.5 l/min/m². We analysed the influence of several factors on hospital mortality and survival, and we performed partial analysis of mortality since 2004.

Results

PTE resulted in significant improvements in SPAP (P<0.001), MPAP (P=0.001) and cardiac index (P<0.001). Hospital mortality was 17% (5/30) (95% confidence interval, 6%-35%). From 2004, it dropped to 5% (1/20) (95% confidence interval, 0%-25%). Hospital mortality was influenced by preoperative pulmonary total resistance, preoperative pulmonary vascular resistance, postoperative SPAP, reduction of SPAP, reduction of MPAP, reperfusion pulmonary oedema and residual postoperative pulmonary hypertension (P=0.036; P=0.018;P=0.013; P=0.050; P=0.050; P=0.030; P=0.045). Survival after PTE, including hospital mortality, was 76±9% at 10 years. Through long-term follow-up, functional status (P=0.001), 6 min walking distance (P=0.001), end-diastolic right ventricle size (P<0.001), and tricuspid regurgitation (P<0.001) significantly improved.

Conclusions

PTE effectively reduces pulmonary hypertension and offers CTEPH patients a substantial improvement in survival and quality of life.     

Prevalence,Echocardiographic Correlations,and Clinical Outcome of Tricuspid Regurgitation in Patients with Significant Left Ventricular Dysfunction

Purpose

We initiated this study to evaluate the prevalence and clinical significance of tricuspid regurgitation in patients with left ventricular dysfunction.

Pulmonary valve replacement in chronic pulmonary regurgitation in adults with congenital heart disease: Impact of preoperative QRS-duration and NT-proBNP levels on postoperative right ventricular function

Background

Chronic severe pulmonary regurgitation (PR) causes progressive right ventricular (RV) dysfunction and heart failure. Parameters defining the optimal time point for surgery of chronic PR are lacking. The present study prospectively evaluated the impact of preoperative clinical parameters, cardiorespiratory function, QRS duration and NT-proBNP levels on post operative RV function and volumes assessed by cardiac magnetic resonance imaging (CMR) in patients with chronic severe PR undergoing pulmonary valve replacement.

Methods and results

CMR was performed pre- and 6 months postoperatively in 27 patients (23.6 ± 2.9 years, 15 women) with severe PR. Postoperatively, RV endsystolic (RVESVI) and enddiastolic volume indices (RVEDVI) decreased significantly (RVESVI pre 78.2 ± 20.4 ml/m² BSA vs. RVESVI post 52.2 ± 16.8 ml/m²BSA, p < 0.001; RVEDVI pre 150.7 ± 27.7 ml/m²BSA vs. RVEDVI post 105.7 ± 26.7 ml/m²BSA; p < 0,001). With increasing preoperative QRS-duration, postoperative RVEF decreased significantly (r =−0.57; p < 0.005). Preoperative QRS-duration smaller than the median (156 ms) predicted an improved RVEF compared to QRS-duration ≥ 156 ms (54.9% vs 46.8%, p < 0.05). Multivariate analysis identified preoperative QRS duration as an independent predictor of postoperative RVEF (p < 0.005). NT-proBNP levels correlated with changes in RVEDI (r = 0.58 p < 0,005) and RVESVI (r = 0.63; p < 0,0001). Multivariate analysis identified NT-proBNP levels prior to PVR as an independent predictor of volume changes (p < 0.05).

Conclusion

Valve replacement in severe pulmonary regurgitation causes significant reduction of RV volumes. Both, preoperative NT-proBNP level elevation and QRS prolongation indicate patients with poorer outcome regarding RV function and volumes.     

Right ventricular function in adults with repaired tetralogy of Fallot assessed with cardiovascular magnetic resonance imaging: detrimental role of right ventricular outflow aneurysms or akinesia and adverse right-to-left ventricular interaction

OBJECTIVES: We examined the relationship among biventricular hemodynamics, pulmonary regurgitant fraction (PRF), right ventricular outflow tract (RVOT) aneurysm or akinesia, and baseline and surgical characteristics in adults with repaired tetralogy of Fallot (rTOF). BACKGROUND: The precise relationship of pulmonary regurgitation with biventricular hemodynamics has been hampered by limitations of right ventricular (RV) imaging. METHODS: We assessed 85 consecutive adults with rTOF and 26 matched healthy controls using cardiovascular magnetic resonance imaging. RESULTS: Patients had higher right ventricular end-diastolic volume index (RVEDVi) (p < 0.001), right ventricular end-systolic volume index (RVESVi) (p < 0.001), right ventricular mass index (RVMi) (p < 0.001), and lower right ventricular ejection fraction (RVEF) (p < 0.001) and left ventricular ejection fraction (LVEF) (p = 0.002) compared to controls. The PRF (range 0% to 55%) independently predicted RVEDVi (p < 0.01) and the latter predicted RVESVi (p < 0.01) and RVMi (p < 0.01). The RVOT aneurysm/akinesia was present in 48/85 (56.9%) of patients and predicted RV volumes (RVEDVi, p = 0.01, and RVESVi, p = 0.03). There was a negative effect of RVOT aneurysm/akinesia and RVMi on RVEF (p < 0.01 and p = 0.02, respectively). There was only a tendency among patients with transannular or RVOT patching toward RVOT aneurysm/akinesia (p = 0.09). The LVEF correlated with RVEF (r = 0.67, p < 0.001). CONCLUSIONS: Pulmonary regurgitation and RVOT aneurysm/akinesia were independently associated with RV dilation and the latter with RV hypertrophy late after rTOF. The RVOT aneurysm/akinesia was common but related only in part to RVOT or transannular patching. Both RV hypertrophy and RVOT aneurysm/akinesia were associated with lower RVEF. Left ventricular systolic dysfunction correlated with RV dysfunction, suggesting an unfavorable ventricular-ventricular interaction. Measures to maintain or restore pulmonary valve function and avoid RVOT aneurysm/akinesia are mandatory for preserving biventricular function late after rTOF.     

Comparison of stroke work between repaired tetralogy of Fallot and normal right ventricular physiologies

Adult patients who underwent tetralogy of Fallot repair surgery (rTOF) confront life-threatening ailments due to right ventricular (RV) myocardial dysfunction. Pulmonary valve replacement (PVR) needs to be performed to restore the deteriorating RV function. Determination of correct timing to perform PVR in an rTOF patient remains subjective, due to the unavailability of quantifiable clinical diagnostic parameters. The objective of this study is to evaluate the possibility of using RV body surface area (BSA)-indexed stroke work (SW_I) to quantify RV inefficiency in TOF patients. We hypothesized that RV SW_I required to push blood to the lungs in rTOF patients is significantly higher than that of normal subjects. Seven patients with rTOF pathophysiology and eight controls with normal RV physiology were registered for this study. Right ventricular volume and pressure were measured using cardiac magnetic resonance imaging and catheterization, respectively. Statistical analysis was performed to quantify the difference in SW_I between the RV of the rTOF and control groups. Right ventricular SW_I in rTOF patients (0.176 ± 0.055 J/m²) was significantly higher by 93.4% (P = 0.0026) than that of controls (0.091 ± 0.030 J/m²). Further, rTOF patients were found to have significantly higher (P < 0.05) BSA normalized RV end-systolic volume, end-systolic pressure, and regurgitation fraction than control subjects. Ejection fraction and peak ejection rate of rTOF patients were significantly lower (P < 0.05) than those of controls. Patients with rTOF pathophysiology had significantly higher RV SW_I compared with subjects with normal RV physiology. Therefore, RV SW_I may be useful to quantify RV inefficiency in rTOF patients along with currently used clinical end points such as RV volume, pressure, regurgitation fraction, and ejection fraction.     

Assessment of atrial conduction time by tissue Doppler echocardiography and P-wave dispersion in patients with mitral annulus calcification

The aim of our study was to investigate atrial conduction time in patients with mitral annulus calcification (MAC) using P-wave dispersion (PWD) and electromechanical coupling measured with the surface electrocardiogram and the tissue Doppler echocardiography. Fifty-nine patients with MAC and 43 control subjects underwent resting the surface electrocardiogram and tissue Doppler echocardiography. The difference between the maximum (Pmax) and minimum P-wave durations was calculated and defined as PWD. Interatrial and intraatrial electromechanical delays were measured with tissue Doppler echocardiography. Both Pmax and PWD were higher in patients with MAC compared with controls (111.4 ± 15.8 vs 97.3 ± 18.8 milliseconds; P < .0001 and 46.4 ± 14.6 vs 31.4 ± 13.1 milliseconds; P < .0001, respectively). Both interatrial and intraatrial conduction time were also delayed in patients with MAC compared with controls (29.8 ± 13.3 vs 17.6 ± 12.5 milliseconds; P < .0001; 9.4 ± 5.1 vs 6.8 ± 4.0 milliseconds; P < .008, respectively). Left atrial (LA) diameter was significantly higher in patients with MAC compared with controls (35.4 ± 5.0 mm vs 32.3 ± 4.2 mm; P < .001). The LA diameter correlated significantly with both interatrial conduction times and PWD (r = 0.56; P < .0001 and r = 0.47; P < .0001, respectively). There is a delay in both intraatrial and interatrial electromechanical coupling intervals in patients with MAC.     

A Middle School Intervention to Improve Health Behaviors and Reduce Cardiac Risk Factors

Objective

This study aimed to measure the impact of a school-based multidisciplinary intervention program on risk factors for atherosclerosis in sixth-grade middle school students. We also measured health behaviors before and after the intervention using a validated questionnaire.

Methods

A prospective study was performed in which students served as historical controls. Sixth-grade students from 23 middle schools in 12 cities with varying populations were exposed to a program promoting healthful activity and nutrition habits through educational and environmental change. Along with a modified School-Based Nutrition Monitoring behavioral questionnaire, physiologic risk factors were studied, including body mass index, systolic and diastolic blood pressures, cholesterol panel, and random blood glucose, which were measured before the 10-week program and again 1 to 3 months after program completion.

Results

Of 4021 sixth graders (male, 49%) at 23 middle schools completing a before and after behavioral survey, 2118 students, aged 11.56 ± 0.47 years, consented to participate in the screening. The mean total cholesterol value decreased from 161.64 ± 28.99 mg/dL to 154.77 ± 27.26 mg/dL (P < .001). The low-density lipoprotein value decreased from 89.37 ± 25.08 mg/dL to 87.14 ± 24.25 mg/dL (P < .001). The high-density lipoprotein value decreased from 52.15 ± 13.35 md/dL to 49.95 ± 13.28 mg/dL (P < .001). The measure of triglycerides decreased from 113.34 ± 73.19 mg/dL to 101.22 ± 63.93 mg/dL (P < .001). The random glucose value decreased from 97.51 ± 16.00 to 94.94 ± 16.62 (P < .001). The mean systolic blood pressure decreased from 109.47 ± 15.26 mm Hg to 107.76 ± 10.87 mm Hg (P < .001), and the mean diastolic blood pressure decreased from 64.78 ± 8.57 mm Hg to 63.35 ± 7.81 mm Hg (P < .001). These changes in physiologic measures seemed to correlate with self-reported increases in vegetable and fruit consumption, increases in physical activity, and less screen time.

Conclusions

Project Healthy Schools, a middle school intervention to improve childhood cardiovascular risk factors, is feasible and seems to be effective. The results showed significant improvements in risk factors associated with early atherosclerosis among sixth-grade students, including total cholesterol, low-density lipoprotein cholesterol, triglycerides, and systolic and diastolic blood pressures. Further study with a larger group of students and a longer follow-up period would be valuable.     

Hemodynamic predictors of early intoleranceand long-term effects of propranolol in dilated cardiomyopathy

Background:

Fifty-six patients with dilated cardiomyopathy (DCM) (aged 14–68 years) andbackground therapy of angiotensin-converting enzyme inhibitors, diuretics, and digoxin were given an initial challenge of propranolol in gradually increasing doses. These patients were studied noninvasively and hemodynamically and subjected to right ventricle biopsy.

Methods and Results:

Forty-four patients tolerated propranolol and received the drug for 6 months; 12 patients deteriorated after starting the drug with worsening of congestive heart failure and/or hypotension. The patients who did not tolerate propranolol had higher left ventricular end-diastolic dimension (73 ± 8 vs 66 ± 8 mm, P < .05), and severe mitral regurgitation was more common. Hemodynamically these patients had higher heart rate, right ventricular end-diastolic pressure, mean pulmonary artery pressure, mean pulmonary artery wedge pressure, and left ventricular end-diastolic pressure (102 ± 16 vs 89 ± 12 beats/min, 15 ± 7 vs 9 ± 4, 39 ± 16 vs 31 ± 12, 28 ± 8 vs 21 ± 8, 28 ± 8 vs 22 ± 8 mmHg, respectively, P < .01). These patients had a significantly lower cardiac index (1.9 ± 0.6 vs 2.5 ± 0.6 L/min/m², P < .01). Forty patients completed 6 months follow-up evaluation and were further subjected to repeat noninvasive and hemodynamic study. There was a significant improvement in New York Heart Association class, cardiothoracic ratio, and left ventricular end-diastolic dimension (68% vs 62%, 66 ± 8 vs 62 ± 7 mm, respectively, P < .01), while the ejection fraction (EF) rose from 23 to 35% (P < .001). Hemodynamically, there was a significant decrease in heart rate, right ventricular end-diastolic pressure, mean pulmonary artery pressure, mean pulmonary artery wedge pressure, and left ventricular end-diastolic pressure (91 ± 14 vs 71 ± 5 beats/min, 9 ± 4 vs 5 ± 3, 32 ± 11 vs 22 ± 7, 25 ± 9 vs 17 ± 8, 21 ± 7 vs 14 ± 4 mmHg, P < .05). The cardiac index rose from 2.3 ± 0.6 to 3.2 ± 0.7 L/min/m² (P < .01).

Conclusions:

Propranolol in dilated cardiomyopathy is associated with significant intolerance. Those who tolerate propranolol seem to have long-term beneficial effects. This study is limited as it is uncontrolled and nonrandomized.     

Does chronic mitral regurgitation influence Doppler pressure half-time-derived calculation of the mitral valve area in patients with mitral stenosis?

Background

In patients with mitral stenosis (MS), Doppler pressure half-time (PHT) may be influenced by hemodynamic variables other than the anatomic mitral valve orifice narrowing. This study was undertaken to assess whether the presence of concomitant mitral regurgitation (MR) affects mitral valve area (MVA) estimation by PHT.

Methods

Consecutive patients (n = 166) with noncalcific MS, in sinus rhythm, were studied. Group 1 (n = 106) had no or mild MR, and group 2 (n = 60) had moderate or severe MR. MVA was assessed by using the PHT method and planimetry.

Results

There was a strong correlation between planimetry and PHT MVA in both groups (group 1: r = 0.86, P < .001; group 2: r = 0.73, P < .001). However, compared with planimetry MVA, PHT underestimated MVA by ≥20% in 18 patients (17%) in group 1 and 21 patients (35%) in group 2 (P < .01). Overestimation by ≥20% occurred in 12 patients (11%) in group 1 and in 7 (12%) in group 2. Group 2 subanalysis (group 2A: moderate MR, n = 16; group 2B: severe MR, n = 44) revealed that linear regression weakened with increasing severity of MR (group 2A: r = 0.824, P < .001, group 2B: r = 0.70, P < .001). PHT underestimation of MVA occurred in 31% and 36% of patients in Groups IIA and IIB, respectively (P = NS).

Conclusions

PHT appears to be reliable for estimating MVA in most patients with MS, even in the presence of MR. However, the presence of significant MR reduces the reliability of PHT-derived MVA, with underestimation of MVA in a significant number of subjects. The severity of MR has a direct impact on PHT-derived MVA.     

Effective regurgitant orifice area: A noninvasive Doppler development of an old hemodynamic concept

Objectives. The purpose of this study was to determine the feasibility, relation to other methods and significance of the effective regurgitant orifice area measurement.Background. Assessment of the severity of valvular regurgitation (effective regurgitant orifice area) has not been implemented in clinical practice but can be made by Doppler echocardiography.Methods. Effective regurgitant orifice area was calculated by Doppler echocardiography as the ratio of regurgitant volume/ regurgitant jet time-velocity integral and compared with color flow Doppler mapping, angiography, surgical classification, regurgitant fraction and variables of volume overload.Results. In 210 consecutive patients examined prospectively, feasibility improved from the early to the late experience (65% to 95%). Effective regurgitant orifice area was 28 ± 23 mm²(mean ± SD) for aortic regurgitation (32 patients), 22 ± 13 mm²for ischemic/functional mitral regurgitation (50 patients) and 41 ± 32 mm²for organic mitral regurgitation (82 patients). Significant correlations were found between effective regurgitant orifice and mitral jet area by color flow Doppler mapping (r = 0.68 and r = 0.63, p < 0.0001, respectively) and angiographic grade (r = 0.77, p = 0.0004). Effective regurgitant orifice area in surgically determined moderate and severe lesions was markedly different in mitral regurgitation (35 ± 12 and 75 ± 33 mm², respectively, p = 0.009) and in aortic regurgitation (21 ± 8 and 38 ± 5 mm², respectively, p = 0.08). Strong correlations were found between effective regurgitant orifice area and variables reflecting volume overload. A logarithmic regression was found between effective regurgitant orifice area and regurgitant fraction, underlining the complementarity of these indexes.Conclusions. Calculation of effective regurgitant orifice area is a noninvasive Doppler development of an old hemodynamic concept, allowing assessment of the lesion severity of valvular regurgitation. Feasibility is excellent with experience. Effective regurgitant orifice area is an important and clinically significant index of regurgitation severity. It brings additive information to other quantitative indexes and its measurement should be implemented in the comprehensive assessment of valvular regurgitation.     

Effect of atrial flutter on exercise tolerance in patients with grown-up congenital heart (GUCH)

Objectives To assess the effect of atrial flutter (AFL) on exercise tolerance in patients with grown-up congenital heart (GUCH), exercise tests with modified Bruce protocol were performed in 20 patients aged 21 to 62 years with GUCH (11 females, 9 males) during symptomatic AFL and again 24 to 48 hours after DC conversion to sinus rhythm (SR). At the same time, cardiac function was assessed by means of transthoracic Doppler echocardiography. Results Mean exercise duration was significantly less during AFL (6.4 ± 4.1 min) versus SR (10.9 ± 3.7 min) (P < .001). Heart rate was faster at rest and peak exercise while in AFL (106 ± 21 beats/min vs 77 ± 14 beats/min, P < .001, and 157 ± 31 beats/min vs 129 ± 24 beats/min, P < .01, respectively). Systolic blood pressure was lower at peak exercise with AFL (112 ± 25 mm Hg vs 137 ± 24 mm Hg, P < .001), as was mean blood pressure increase (5.3 ± 24.3 mm Hg vs 22.6 ± 15.8 mm Hg) compared with SR (P < .01). Four of the 6 patients after Fontan surgery had a decrease of 16 mm Hg in systolic blood pressure at peak exercise when in AFL. The reasons for exercise termination during AFL were mainly breathlessness, chest pain, or presyncope, whereas in SR it was caused by fatigue. Echocardiography during AFL showed shorter isovolumic relaxation time (40 ± 20 ms) compared with SR (50 ± 20 ms) (P < .05). Ventricular long-axis excursion was reduced (left 1.0 ± 0.3 cm vs 1.2 ± 0.4 cm, septal 0.5 ± 0.2 cm vs 0.7 ± 0.3 cm, and right 0.7 ± 0.2 cm vs 0.9 ± 0.4 cm respectively, P < .001 for all), as were peak pulmonary and aortic flow velocities (85 ± 30 cm/s vs 105 ± 50 cm/s, P < .001, and 137 ± 118 cm/s vs 143 ± 114 cm/s, P < .02) compared with sinus rhythm. There was a close correlation between exercise duration and blood pressure increase (r = 0.6), left-sided long-axis excursion and blood pressure increase (r = 0.57), and between aortic flow velocity and right-sided long-axis excursion (r = 0.71). Conclusions Atrial flutter causes dramatic reduction in exercise tolerance in patients with GUCH, and the combination of fast heart rate and hypotension may contribute to the development of presyncope, particularly in those with Fontan surgery. Marked improvement in effort tolerance and cardiac dynamics occurs after regaining SR. Thus, improving the quality of life in patients with GUCH requires maintaining SR. (Am Heart J 2002;144:173-9.)