Alexander N. Borg

β blocker treatment is associated with improvement in renal function and anaemia in patients with heart failure

Over the past three decades, there has been rapid progress in the diagnosis and management of patients with chronic congestive heart failure (CHF). However, the mortality from CHF remains high, partly due to comorbidity, the very existence of which may have excluded some patients from previous large-scale clinical trials. Hence, the full effect of modern treatment on non-trial “real life” patients with CHF in clinical practice remains uncertain. Chronic renal impairment (CRI) and anaemia are common comorbidities associated with CHF, and are both independent predictors of poor prognosis.1 It has previously been shown that treatment with either angiotensin-converting enzyme inhibitors (ACEI) or β blockers improves prognosis in patients with CHF with or without CRI.2,3 Among the most recent treatments of CHF, ACEIs are potentially nephrotoxic and may cause worsening of anaemia.3 Thus, the relationship between treatment and outcome in patients with CHF with CRI and anaemia needs further investigation. We aimed to assess the effect of β blocker treatment on renal function and anaemia in consecutive ambulatory patients with CHF in routine clinical practice. A retrospective case study of 134 consecutive patients (alive at the time of analysis) with stable CHF, attending our heart failure clinic between 2002 and 2004, was conducted. Serum creatinine and haemoglobin levels checked …

Left ventricular filling and diastolic myocardial deformation in chronic primary mitral regurgitation.

AIMS Chronic primary mitral regurgitation (MR) results in enhanced filling of the left ventricle (LV) during early diastole. Filling is impaired with the onset of LV systolic dysfunction, due to increased myocardial stiffness and reduced restoring forces. We investigated echocardiographic parameters of early diastolic function in relation to LV systolic function. METHODS AND RESULTS Early diastolic transmitral flow and tissue Doppler velocities, propagation velocity of early filling (V(p)), and early diastolic strain rates (SR-E) were measured in 30 patients with chronic degenerative MR and 30 age-matched controls. MR subjects were further subdivided into group 1 (14 subjects) if they had well compensated LV, and group 2 (16 subjects) if they had one or more of the following: functional limitation (> NYHA class I), LV end-systolic diameter >or=4.0 cm, and LV ejection fraction <or=60%. Group 1 had increased early diastolic transmitral flow and tissue velocities, V(p) and SR-E, compared with controls. V(p) and SR-E in group 2 (46.5 +/- 9.92 cm/s and 1.44 +/- 0.36 s(-1), respectively) decreased significantly compared with group 1 (74.4 +/- 19.9 cm/s and 1.96 +/- 0.53 s(-1), P <or= 0.002). Onset and peak of early long-axis expansion and myocardial lengthening were significantly delayed in MR, and this delay was directly correlated with preload parameters. CONCLUSION In chronic MR, novel echocardiographic measurements of early diastolic function exhibit a biphasic pattern depending on the state of LV systolic function, and may prove useful in the timing of surgery.

Localised myocardial scar related to left ventricular false tendons.

Left ventricular false tendons (LVFT) are fibromuscular strands connecting ventricular endocardial sites, frequently found on echocardiography (∼40%), with higher incidence on post-mortem studies (∼60%). Although considered normal variants, previous studies have linked LVFT to ventricular ectopics and tachycardia, and specialized conducting tissue is frequently reported within these structures. Repetitive stretching of septal Purkinje fibres at the …

Cardiovascular magnetic resonance validation of fractional changes in annulo-apical angles and tricuspid annular plane systolic excursion for rapid assessment of right ventricular systolic function.

To evaluate the use of right ventricular (RV) annulo‐apical angle (AA) changes acquired by magnetic resonance imaging (MRI), alongside tricuspid annular plane systolic excursion (TAPSE), for its association with RV systolic function.

Cardiovascular aspects in the diagnosis and management of Turner’s syndrome

Turner’s syndrome (TS) is a relatively common chromosomal abnormality frequently associated with cardiovascular abnormalities, such as a bicuspid aortic valve and coarctation of the aorta, as well as cardiovascular risk factors such as hypertension, hypothyroidism, and diabetes mellitus. Epidemiological studies have shown that these patients have increased cardiovascular morbidity and mortality. In addition, there is at least the theoretical potential that well-established treatments that are intended to address the short stature and hormonal deficiencies in these patients may negatively influence their cardiovascular risk profile. Further, the congenital structural abnormalities commonly found in TS, and long-term complications associated with them, warrant regular monitoring utilizing various cardiovascular imaging modalities to determine the need for timely surgical intervention. In this review, we summarize the main features of this syndrome, with emphasis on issues that impact the management, diagnostic work up, and monitoring of cardiovascular problems in adult patients with TS.

No late effects of growth hormone exposure on ventricular mass and function in patients with Turner's syndrome

Background Patients with Turner’s syndrome have increased cardiovascular (CV) morbidity and mortality, potentially over and above that explained by the higher rate of both congenital heart disease and associated endocrine disorders and hypertension. GH administration to maximise adult height is a well-established treatment form but may affect cardiovascular status, ventricular mechanics and myocardial function. Furthermore, given the adverse CV effects of supra-physiological GH levels associated with acromegaly and in the field of sports doping, concern has been voiced about potential risks associated with this form of treatment. CMR based strain derivatives offer advanced analysis of myocardial deformation and function. Such technologies are thought to increase sensitivity and may allow detection of “pre-clinical” disease not apparent by assessment of conventional parameters such as ventricular volumes and ejection fraction (EF). Methods 52 patients with Turner syndrome underwent a comprehensive CV CMR study. Patients with structural heart disease such as aortic coarctation, haemodynamically important valve disease, previous myocardial infarction or cardiac surgery were excluded. Of the remaining 35 adult patients 14 had a history of previous exposure to GH (GH +ve), 21 had no history of GH treatment (GH -ve).

CMR validation of fractional changes in annulo-apical angles and TAPSE for rapid assessment of right ventricular systolic function

Background Volumetric assessment of the right ventricle (RV) by Cardiac Magnetic Resonance (CMR), albeit time-consuming, provides accurate and reproducible measurement of RV ejection fraction (RVEF). Tricuspid annulus peak systolic excursion (TAPSE) is a predominantly Echo-validated rapidly-derived surrogate of RV function. Correlations between RVEF and systolic changes in annulo-apical angles (AAAs) have not previously been evaluated.

Comparison of local sine wave modelling with harmonic phase analysis for the assessment of circumferential myocardial strain from tagged cardiovascular magnetic resonance images

Background Assessment of regional ventricular deformation is more sensitive than ejection fraction (EF) for detecting myocardial dysfunction. We sought to compare a local sinewave modelling (SinMod) method with the more established harmonic phase analysis (HARP) technique, for assessment of Lagrangian left ventricular (LV) peak systolic circumferential strain (ecc) from tagged cardiovascular magnetic resonance images, in patients with cardiomyopathies and healthy volunteers. The variability and rapidity of each technique, and the effect of contrast, were also assessed. Methods Sixty participants (15 each with hypertrophic, dilated or ischaemic cardiomyopathy and 15 healthy controls) with a wide range of LV ejection fraction (14-78%) underwent spatial modulation of magnetization tagging of a mid-ventricular short-axis slice at 1.5 Tesla. Global and segmental peak transmural ecc were measured using HARP and SinMod. Repeated measurements were performed on 15 randomly selected scans (25%) in order to assess observer variability. Tagged images were acquired pre- and post-contrast in 10 additional patients in order to assess the effect of contrast. Results

083 Annulo-apical angles and tapse to rapidly assess right ventricular systolic function: a cardiac magnetic resonance study

Background Volumetric assessment of the right ventricle (RV) by Cardiac Magnetic Resonance (CMR), albeit time-consuming, provides accurate and reproducible measurement of RV ejection fraction (RVEF). Tricuspid annulus peak systolic excursion (TAPSE) is a predominantly Echo-validated rapidly—derived surrogate of RV function. Correlations between RVEF and systolic changes in annulo-apical angles (AAAs) have not previously been evaluated. Objective To assess the use of changes in AAAs and TAPSE as rapidly-derived surrogate markers of RV systolic function using CMR. Methods We measured RV volumes from short-axis bSSFP stacks in patients undergoing clinically indicated CMR scans. RVEF was calculated from volumes derived by semi-automated endocardial contouring (QMass®MR 7.2). AAAs (α, β, θ angles—see Abstract 083 figure 1), subtended by a triangle connecting the medial and lateral extent of the tricuspid valve annulus and RV apex, and fractional changes in AAAs (ΔAAA/EDAAA×100, whereby ΔAAA=EDAAA−ESAAA) were measured from end-diastolic (ED) and end-systolic (ES) 4chamber SSFP cine still frames. TAPSE was measured as the change in length of a line connecting the lateral tricuspid valve annulus with the RV apex from ED to ES. Parameters were compared with RVEF using Spearman rank correlations; ROC curves constructed to assess accuracy of the parameters in predicting an RVEF<50%.Abstract 083 Figure 1 Top: AAAs in ED on a 4 chamber view. Bottom: ROC curve analysis. Results 40 subjects were included: 10 normals, 10 mildly-impaired, 10 moderately-impaired, and 10 with severely-impaired RV systolic function. Median (25th–75th percentile) RVEF for each subgroup was 53.5% (51.4%–55.7%), 41.5% (38.1%–47.2%), 30.0% (21.7%–33.5%), and 15.8% (9.6%–21.2%), respectively. Correlations with RVEF: TAPSE (0.74, p<0.001), fractional changes of α angle (0.64, p<0.001), β angle (–0.39, p<0.05), and θ angle, which had the highest correlation (–0.77, p<0.001). Smaller increases or a decrease in magnitude of the θ angle from ED to ES are associated with lower RVEFs, whereby a fractional θ angle change of ≥ –25.5% predicts RVEF<50% [97% sensitivity, 91% specificity, AUC=0.98]. The cut-off for TAPSE is ≤1.87 cm [100% sensitivity, 82% specificity, AUC=0.98]. Intra- and inter-observer reproducibility is excellent as shown by intra-class correlation coefficients for TAPSE (0.98 and 0.87, respectively) and fractional θ angle change (0.96 and 0.94, respectively). Conclusion Both fractional θ angle change and TAPSE strongly correlate with RVEF, and are accurate predictors of RVEF<50%. These measurements provide an excellent alternative to the more time-consuming derivation of RVEF obtained volumetrically by endocardial chamber tracing.Abstract 083 Figure 2 Scatter graphs for fractional θ angle change and TAPSE, both plotted against RVEF. Dotted vertical lines represent the ROC cut-offs of RVEF<50%. Dashed horizontal lines represent cut-offs of ≥ –25.5% and ≤1.87 cm for fractional θ angle change and TAPSE, respectively.

121 Incidental extra-cardiac findings on clinical cmr; a comparison of 3 haste techniques

Introduction Cardiac magnetic resonance (CMR) is an increasingly important imaging modality, which by necessity incorporates a large field of view. Both “localiser” and multiple slice half-fourier spin echo (eg, HASTE) sequences provide coverage of the thorax and upper abdomen. Such imaging may reveal hitherto unexpected incidental extra-cardiac findings (IEF). First we sought to assess the frequency of IEF found on clinically indicated CMR scans. Second we compared the 3 clinically used HASTE acquisition protocols in this context. Lastly we determined the impact of the 3 different protocols on acquisition time and image quality. Methods Three subsequent groups of 238 patients (714 patients in total), all referred for clinically indicated CMR, were scanned with either breath-hold (BH) HASTE (Group 1), free breathing (FB) HASTE (Group 2) or diaphragmatic navigated (NAV) HASTE (Group 3). Additionally “localiser” sequences performed in 3 orthogonal planes were analysed. All 714 clinical reports were reviewed regarding the presence of IEF. These were categorised as either minor, or major if recommendations for further investigation, follow-up, and/or clinical correlation were made. Finally, to determine the impact of each HASTE protocol on acquisition time and image quality, an additional cohort of 15 patients underwent 3 protocols back to back in a random fashion. The length of each acquisition was timed and image quality was reviewed and scored externally. Results A total of 180 IEF were found in 162 (22.7%) out of 714 patients. There was no significant difference in frequency of IEF between the 3 HASTE groups. Out of 180 IEF, 88 were considered minor and 92 major findings. Of the latter, 8 (1.1%) were considered highly significant. These included one bronchoalveolar carcinoma stage 1B requiring lobectomy, 2 cases of florid sarcoidosis in patients presenting with VT and “structurally normal hearts” on echocardiography, one case of pulmonary aspergillosis, 2 cases of advanced pulmonary fibrosis, one ascending thoracic aortic aneurysm and a case of iatrogenic liver haemorrhage following placement of a pericardial drain. FB HASTE acquisition (69±2.5 s) was significantly faster than BH (105±3.8 s) and NAV (121±2.7 s), p<0.001, but also produced the lowest image quality on a 5 point scale; 3.5 (FB) vs 3.9 (BH) vs 3.8 (NAV), p=0.08. Conclusion Overall, IEF are common and lead to follow on investigations in a substantial minority of cases. However, the overall incidence of highly significant findings in the current study was low (∼1%). There was no difference in the frequency of incidental extra-cardiac findings between the 3 HASTE protocols. While the free breathing HASTE technique is statistically significantly faster than breath hold and navigated HASTE, the absolute time saving is small and probably out-weighted by lesser image quality.