A Marciniak

Dose-Related Effect of Statins on Atrial Fibrillation After Cardiac Surgery

BACKGROUND Atrial fibrillation (AF) is the most common heart rhythm abnormality after cardiac surgery. It increases morbidity and prolongs hospital stay. A role for statins in the prevention of AF has been suggested. We hypothesized that the incidence of postoperative AF due to statin therapy is dose-related. METHODS A retrospective study of 680 consecutive patients undergoing coronary bypass graft surgery and/or aortic valve replacement was done. Excluded were 57 patients (8.4%) with history of AF, permanent pacemakers, and those receiving antiarrhythmic medication. Preoperative statin treatment and occurrence of postoperative AF were examined using propensity score matching to adjust for differences in patient characteristics between the statin and no-statin groups. RESULTS The cohort comprised 623 patients. The statin group had a 27.1% incidence of postoperative AF vs 38.3% in the no-statin group (adjusted odds ratio [OR], 2.00; 95% confidence interval, 1.24 to 3.24; p = 0.004). Simvastatin (40 mg) and atorvastatin (40 mg) demonstrated the greatest effect on postoperative AF at 15.6% and 21.2%, respectively, vs no statins (respective adjusted ORs, 3.89 [p < 0.0001] and 2.76 [p = 0.012]). Intermediate-dose (20 mg) statins were also effective against AF, at 24.4% for simvastatin (adjusted OR, 2.32; p = 0.004) and 26.4% for atorvastatin (adjusted OR, 1.99, p = 0.047). Low-dose statins, simvastatin or atorvastatin (10 mg), did not influence postoperative AF. CONCLUSIONS Statin treatment may reduce the incidence of AF after cardiac surgery. Higher-dose statins have the greatest preventative effect, whereas low-dose statins do not influence postoperative AF.

Myocardial deformation abnormalities in patients with aortic regurgitation: a strain rate imaging study

AIMS Early left ventricular (LV) dysfunction in asymptomatic patients with severe aortic regurgitation (AR) may go undetected due to the lack of a sufficiently sensitive diagnostic tool. Ultrasonic strain/strain rate (S/SR) imaging should now provide such sensitivity in detecting early dysfunction in regional LV systolic deformation. The aim of this study was to understand and define the changes in LV regional systolic deformation based on S/SR imaging in patients with asymptomatic or minimally symptomatic AR. METHODS AND RESULTS Eighty-one individuals were studied: 59 asymptomatic patients with isolated non-ischaemic AR who were divided into three sub-groups such as mild, moderate, and severe AR and 22 age-matched healthy subjects. All patients underwent standard echocardiographic examinations including a tissue Doppler imaging study. For LV radial deformation, the posterior wall (LVPW) was examined. To assess LV longitudinal deformation, S and SR data were acquired from the LV lateral wall and septum. Radial as well as longitudinal peak systolic SRs were significantly decreased in patients with both moderate AR (LVPW, P=0.0009; septum, P=0.03; LV lateral wall, P=0.0009) and severe AR (P<0.0001) compared with healthy subjects. Changes in regional LV deformation correlated inversely both with LV end-diastolic volume and with end-systolic volume. CONCLUSIONS Strain rate imaging is a sensitive tool in detecting the spectrum of changes in radial and longitudinal deformation in asymptomatic or minimally symptomatic patients with AR. The index where volume was corrected by deformation should form the basis for predicting subclinical LV dysfunction in patients with increasing LV dilatation.

Prediction of postoperative left ventricular systolic function in patients with chronic mitral regurgitation undergoing valve surgery — the role of deformation imaging

OBJECTIVE Preoperative left ventricular systolic function is an important prognostic factor in patients undergoing mitral valve surgery. Preoperative myocardial deformation may be impaired without reduction in conventional indices such as ejection fraction (EF). Strain rate (SR) imaging is very sensitive in detecting regional systolic abnormalities and might allow diagnosis of subclinical changes in systolic left ventricular (LV) function before surgery. We aimed to investigate the value of preoperative regional myocardial peak systolic SR as a predictor of postoperative LV systolic function in patients with severe mitral regurgitation (MR) undergoing surgery. METHODS A total of 62 patients (age 52±12) with chronic severe MR, who underwent mitral valve repair, were studied. A standard echo examination, extended with tissue Doppler, was performed before and at 12 months after surgery. For the evaluation of longitudinal function, mid-ventricular segment shortening was analysed for the septum, LV lateral wall and anterior and inferior walls. RESULTS Patients were divided into two groups based on postoperative EF: group 1 with EF(post-op)>50% and group 2 with EF(post-op)<50%. Group 1 had a significantly (p=0.004) higher preoperative SR (LV lateral wall: -1.97±0.26s(-1); septum: -1.74±0.31s(-1); anterior wall: -1.94±0.30s(-1), inferior wall: -1.93±0.29s(-1)) compared to group 2 (LV lateral wall: -0.98±0.23s(-1); septum: -0.98±0.26s(-1); anterior wall: -0.94±0.30s(-1), inferior wall: -1.00±0.24s(-1)). When SR was corrected for size, the SR/EDV index (EDV is end diastolic volume) also showed significant changes (p=0.0007) at baseline between the groups. For detecting subclinical changes in deformation of the LV lateral wall, a cut-off value of the SR/EDV index<0.006 had 89% sensitivity and 93% specificity; for the anterior wall, SR/EDV index<0.005 had 88% sensitivity and 94% specificity. CONCLUSIONS SR imaging (corrected for geometry) can detect abnormalities in LV function at subclinical levels in patients with severe mitral regurgitation.

Usefulness of Changes in Left Ventricular Wall Thickness to Predict Full or Partial Pressure Reperfusion in ST-Elevation Acute Myocardial Infarction

Experimental studies have shown that if an acute transmural myocardial infarction is reperfused at full pressure there is an immediate and persisting increase in end-diastolic wall thickness (EDWT) due to massive intramural edema, with the amount of edema inversely related to the residual stenosis in the infarct-related artery. This study investigated if these findings are paralleled in the clinical setting and whether the resultant myocardial substrate differs after percutaneous coronary intervention (PCI) versus thrombolysis (the latter having a higher incidence of residual flow limiting stenosis in the culprit vessel). Eighty-eight consecutive patients with ST-elevation myocardial infarction were enrolled. Twenty-seven patients underwent primary PCI, 23 had rescue PCI, and 38 had thrombolysis. Standard M-mode and 2-dimensional echocardiographies were performed within 12 hours. Regional EDWT was measured in 904 infarct-related segments after the different reperfusion strategies and compared with 504 remote noninfarcted segments. EDWT of infarct-related segments after primary PCI was significantly increased compared with normal segments. At follow-up, after 6 months, EDWT of these segments was significantly decreased, indicating transmural infarction. EDWT of infarct-related segments after thrombolysis did not differ from that of normal segments. After rescue PCI, EDWT of infarct-related segments was significantly decreased compared with that of normal segments. In conclusion, full-pressure restoration of epicardial blood flow after transmural myocardial infarction causes an immediate increase in EDWT, easily detected by echocardiography. In contrast, pressure-limiting reperfusion (typical for thrombolysis) resultsin normal EDWT. This confirms experimental data that PCI and thrombolysis can differ in their resultant myocardial substrate.

A Fibrillating Left Atrial Appendage During Sinus Rhythm

A 57-year-old woman presented with intermittent atrial tachycardia having had extensive ablation for persistent atrial fibrillation 2 years and 7 years earlier. On the first procedure, isolation of the pulmonary veins, a roof line and a mitral line were undertaken. On the second, the pulmonary veins

Echocardiography in Diagnosis and Management of Patients with Marfan Syndrome

The cardiovascular complications of Marfan syndrome require lifelong monitoring, even after surgical intervention. Echocardiography plays a crucial role in the diagnosis and evaluation of cardiovascular features, follow up and further decision regarding management in patients with Marfan syndrome. Echocardiography is used worldwide, the most widely available and cost effective non invasive technique for evaluating cardiac structures and the proximal aorta. The technique uses ultrasound and is therefore completely safe. A full study takes 30 min. Moreover, machines are now available the size of a smart phone, making this technique attractive for scanning patients repeatedly.

Superior vena cava syndrome after radiofrequency sinus node modification treated with thrombolysis and stent implantation

A 30-year-old woman was admitted with symptomatic bradycardia 2 weeks after undergoing a third ablation procedure for inappropriate sinus tachycardia (IST) in another centre. A permanent pacemaker was implanted. She re-presented 3 days later with swelling of both arms, neck and head consistent …

Postpartum Lactobacillus jensenii endocarditis in patient with bicuspid aortic valve

Lactobacillus is a rare cause of endocarditis and has been linked to structural heart disease, invasive procedures, prosthetic valves, and dental infections. We report for the first time a case of Lactobacillus endocarditis that occurred in a 31-year-old woman without a medical history 1 month after her first pregnancy and vaginal delivery involving not only the native aortic valve but also the posterior part of ascending aorta, the roof of the left atrium, and the intra-atrial septum, requiring a complex surgical procedure.

915 The second regional systolic shortening found in LV lateral wall motion is due to ventricular interaction and should not be used to infer late contraction in this wall when studying LV dysynchrony

Variations in regional systolic velocity profiles (SVP) have been widely used to assess cardiac dyssynchrony. However, regional longitudinal SVP have a non-uniform pattern. SVP in the septum (SEP) and inferior wall are similar being mono-phasic with an early systolic peak. In contrast, SVP in the anterior (ANT) and lateral (LAT) walls differ, being bi-phasic with two systolic peaks. Thus when assessing the timing of delayed contraction in the ANT and LAT walls it is important to know what each peak represents. Ventricular interaction could be responsible for the early deceleration of the first peak in ANT and LAT wall motion and could explain the bi-phasic systolic pattern. We postulated that early cessation of the first systolic motion and appearance of a second shortening motion in the LAT wall may be due either to a combination of cardiac twisting around the long axis of the heart and interaction with right ventricle (RV) contractility rather than local myocardial shortening. As regional strain rates (SR) but not velocities (VEL) reflect myocardial contractile function we investigated the relationship between regional peak systolic SR and SVP in the RV free wall, SEP and LAT wall. Methods: In 23 normals (age 45.5±2) long axis regional SVP and SR were obtained from the basal segments of RV, SEP and LAT. Time to max deceleration of the first peak was measured in the LAT and its relationship to RV peak SVP determined. In addition the time to peak VEL and SR in all walls was calculated. Results: The timing of peak SVP in the RV corresponded to the end of deceleration of the first peak in the LAT SVP (0.199±0.03 vs 0.197±0.03 s. p=NS). There was a consistent and significant difference between the time to peak systolic VEL in LAT vs RV (0.130±0.02 vs 0.199±0.03 s, p<0.001) with the SEP peak systolic VEL in an intermediate position at 0.154±0.03 s (p=NS vs RV and LAT). Systolic SR in all walls had a single peak which occurred in early systole with no significant difference between cardiac walls (0.100±0.02; 0.103±0.02; and 0.105±0.02 s in SEP, LAT and RV respectively). The second systolic peak in the LAT wall was not associated with any measurable deformation on the SR curve. Conclusions: This study showed that the early cessation of the first peak systolic VEL and second VEL peak in the LW wall is due to motion induced by RV contraction and does not represent LV contractile function. Furthermore, first rather second peak in LAT corresponds to peak systolic SR, which reflects true myocardial contraction. Therefore measurement of cardiac synchronization should not be based on SVP but rather on SR profiles.