Comparison of cardiac and peripheral arterial stiffening and ventriculovascular uncoupling in patients with uncomplicated hypertension versus patients with hypertension after heart transplantation

Despite normal ejection fractions, patients who undergo heart transplantation (HT) have low peak aerobic capacity and reduced arterial compliance, suggesting "ventriculovascular uncoupling." To what extent this is related to post-transplantation hypertension versus the unique characteristics of the donor-recipient relation remains poorly understood. Echocardiograms were retrospectively reviewed from 126 normal subjects, 309 patients with uncomplicated hypertension (UH), and 58 consecutive patients with HT >1 year after the procedure who were stable without evidence of rejection. Left ventricular (LV) end-systolic elastance (Ees), a measure of LV systolic performance; effective arterial elastance (Ea), a measure of vascular stiffness; and Ea/Ees, a parameter describing ventriculovascular coupling, were obtained. Compared with normal subjects, tandem increases in Ea (+24% and +85%, all p values <0.0001) and Ees (+23% and +33%, all p values <0.0001) were observed in patients with UH and HT, respectively, with patients with HT having significantly higher values than those with UH (both p values <0.05). Although the Ea/Ees ratio remained similar between normal subjects and patients with UH, patients with HT exhibited increases in the Ea/Ees ratio (all p values <0.01) and reduced stroke volume indexes (-20% and -22%, respectively, all p values <0.05). These changes were associated with a doubling of LV concentric remodeling in patients with HT compared with those with UH (67% vs 34%, p <0.0001). In conclusion, HT is associated with increases in Ees, Ea, and the Ea/Ees ratio, suggesting ventriculovascular uncoupling and maximal LV stroke work. These aberrations, which determine cardiovascular performance in the setting of HT, are not simply explained by vascular age or post-transplantation hypertension but may adversely affect functional capacity.     

Left ventricular geometry and survival in patients with normal left ventricular ejection fraction

In hypertensive populations, left ventricular (LV) geometry, which is characterized by hypertrophy, predicts cardiovascular outcome. The left ventricle can also alter its shape by concentric remodeling (CR) in the absence of LV hypertrophy, a feature that is detected by echocardiography. This study assessed the prevalence and prognostic significance of various forms of LV geometry and changes in LV geometry over time in patients with normal LV systolic function. Retrospective analysis of a large clinical population (n = 35,602) that was referred for echocardiography was done, with all-cause mortality as the primary outcome. Abnormal LV geometry was identified in 46% of patients, with CR present in 35% (n = 12,362) and LV hypertrophy in 11% (n = 3,958). Patients with abnormal LV geometry were older and more obese compared with subjects with normal LV geometry. There was a strong relation between abnormal LV geometry and mortality, and patients with CR and LV hypertrophy exhibited considerably higher relative risk for all-cause mortality compared with subjects with normal LV geometry (relative risk [RR] 1.99, 95% confidence interval [CI] 1.88 to 2.18, p <0.0001; RR 2.13, 95% CI 1.89 to 2.40, p <0.0001, respectively). Subjects with CR who reverted to a normal geometric pattern had improved survival (RR 0.64, 95% CI 0.42 to 0.97, p = 0.03) compared with those who progressed to LV hypertrophy (RR 1.54, 95% CI 1.01 to 2.47, p = 0.05). In conclusion, CR, a form of cardiac adaptation, is frequently noted in patients with normal LV ejection fractions and confers a risk of death similar to that of LV hypertrophy. Normalization of CR is associated with better survival, whereas transition to LV hypertrophy increases mortality.     

Formation of a facial hematoma during endodontic therapy

BACKGROUND: Sodium hypochlorite, or NaOCl, is one of the most commonly used irrigating solutions in endodontic practice. Its clinically proven antibacterial, solvent and lubricating properties make it a very appealing choice as an intracanal medicament. CASE DESCRIPTION: The authors present a case of facial hematoma formation after an inadvertent injection of NaOCl into the periapical tissues. The NaOCl solution caused extensive tissue destruction. Management of the condition required the hospitalization, intravenous antibiotic therapy and multiple intraoral surgical incisions to facilitate drainage. CLINICAL IMPLICATIONS: Use of NaOCl must be confined to the root canal system. This report reviews this intracanal medicament's potential toxicity and emphasizes the need for clinicians to remain cognizant of possible problems while using the solution.     

Difficult cases in heart failure. Novel diagnostic markers in heart failure: an emerging paradigm shift?

The differential diagnosis of dyspnea can be overwhelming in the presence of competing diseases. The recent advent of the peptide marker brain natriuretic peptide has ushered in an era of refined diagnostic capability in heart failure. We present a clinical scenario to illustrate the usefulness of this new biomarker assay in directing appropriate therapy for heart failure. (c)2001 CHF, Inc.     

Difficult cases in heart failure: Expanding the therapeutic armamentarium in decompensated heart failure: using intravenous fenoldopam

The authors report the clinical use of fenoldopam, a dopamine agonist, in a patient with decompensated heart failure and severe pulmonary hypertension. In addition, they explore the potential mechanisms by which fenoldopam exerts its beneficial effects and review the literature regarding the use of this agent in systolic heart failure. (c)2001 by CHF, Inc.     

Multicenter intravascular ultrasound validation study among heart transplant recipients: outcomes after five years

OBJECTIVES: We sought to assess the validity of first-year intravascular ultrasound (IVUS) data as a surrogate marker for long-term outcome after heart transplantation. BACKGROUND: Cardiac allograft vasculopathy (CAV) is a major impediment to long-term graft survival. Intravascular ultrasound is more sensitive than coronary angiography and detects intimal thickening (early CAV) in the coronary arteries of the donor heart. Single-center studies have suggested first-year IVUS results might be a surrogate marker for long-term outcome. METHODS: First-year IVUS results and subsequent five-year clinical follow-up data were reviewed in 125 heart transplant recipients from five institutions. The IVUS tapes (at baseline and one year) were re-analyzed at a core IVUS laboratory. The change in maximal intimal thickness (MIT) from baseline to one year was recorded for several matched sites in the same coronary artery. Patients were classified into two groups: those with >/=0.5 mm in the MIT in any matched site (group 1) and those with MIT <0.5 mm (group 2). RESULTS: Group 1 patients compared with group 2 patients had a higher incidence of death or graft loss (D/GL, 20.8% vs. 5.9%; p = 0.007), had more nonfatal major adverse cardiac events and/or D/GL (45.8% vs. 16.8%; p = 0.003), and had more findings of newly occurring angiographic luminal irregularities (65.2% vs. 32.6%, p = 0.004). CONCLUSIONS: This multicenter study suggests that progression of intimal thickening >/=0.5 mm in the first year after transplantation appears to be a reliable surrogate marker for subsequent mortality, nonfatal major adverse cardiac events, and development of angiographic CAV through five years after heart transplantation.     

Understanding B-type natriuretic peptide and its role in diagnosing and monitoring congestive heart failure

Congestive heart failure (CHF) is a complex clinical syndrome characterized by dysfunction of the left, right, or both ventricles, which results in the impairment of the heart's ability to circulate blood at a rate sufficient to maintain the metabolic needs of peripheral tissues and various organs. Owing to the drastic increase in cardiovascular risk factors such as obesity, diabetes, and improved survival rate after acute myocardial infarction and subsequent development of CHF in the last quarter of a century, CHF has become a major and increasing cause of death and disability in the United States. Unfortunately, the signs and symptoms are nonspecific for CHF Also, routine laboratory values, electrocardiograms, and X-rays are not always accurate enough to make the appropriate diagnosis. Recently, the US Food and Drug Administration approved a new biomarker, B-type natriuretic peptide (BNP), for the purpose of diagnosing and assessing severity of CHE BNP is synthesized, stored, and released primarily by the ventricular myocardium in response to volume expansion and pressure overload. The use of SNP, along with other diagnostic tools, can enable care providers to facilitate and optimize care of heart failure patients in a variety of clinical settings. Emerging clinical data will help further refine biomarker-guided therapeutic and monitoring strategies involving BNP.