Aristides Androulakis

Left Atrial Mechanical Function in the Healthy Elderly: New Insights From a Combined Assessment of Changes in Atrial Volume and Transmitral Flow Velocity

To assess left atrial mechanical function in the elderly, 35 old (age > 70 years) and 18 sex-matched young (age < 50 years) healthy subjects were studied. Transmitral flow velocities were recorded with pulsed Doppler echocardiography. Left atrial volumes were measured echocardiographically at mitral valve opening (maximal) and closure (minimal) and at onset of atrial systole (P wave of the electrocardiogram) according to the biplane area-length method. Left atrial passive emptying was assessed with the passive emptying volume (maximal-volume at onset of atrial systole) and fraction (passive emptying volume/maximal). Left atrial active emptying was assessed with the active emptying volume (volume at onset of atrial systole-minimal) and fraction (active emptying volume/volume at onset of atrial systole) and with left atrial ejection force = 0.5.blood density.volume at onset of atrial systole.active emptying fraction.(A velocity)2/A integral. Left atrial volumes were greater in old compared with young subjects (maximal: 31 +/- 10 cm3/m2 vs 24 +/- 8 cm3/m2, p = 0.02; at onset of atrial systole: 23 +/- 8 cm3/m2 vs 15 +/- 5 cm3/m2, p = 0.0002; minimal: 13 +/- 5 cm3/m2 vs 9 +/- 4 cm3/m2, p = 0.001). Passive emptying volume and fraction were lower (7.8 +/- 1.7 cm3/m2 vs 9.2 +/- 3.2 cm3/m2 [p = 0.04] and 26.4% +/- 9.8% vs 37.9% +/- 11.2% [p = 0.003], respectively), whereas atrial ejection force and active emptying volume were greater in old compared with young subjects (6.8 +/- 3.3 kdynes/m2 vs 4.2 +/- 2.8 kdynes/m2 [p = 0.007] and 9.2 +/- 4.1 cm3/m2 vs 5.7 +/- 2.9 cm3/m2 [p = 0.002], respectively). The active emptying fraction was similar in the two groups (39.7% +/- 11% vs 38.4% +/- 13%; difference not significant). Thus advanced age is associated with depressed left atrial passive emptying function and increased left atrial volume. Left atrial dilation contributes to an increase in atrial ejection force and the amount of blood ejected during left atrial systole and may represent an important compensatory mechanism in this age population.

Effects of Cardiac Versus Circulatory Angiotensin-Converting Enzyme Inhibition on Left Ventricular Diastolic Function and Coronary Blood Flow in Hypertrophic Obstructive Cardiomyopathy

BACKGROUND Left ventricular (LV) diastolic function and coronary flow are impaired in hypertrophic obstructive cardiomyopathy (HOCM). This study was designed to evaluate the impact of cardiac and circulatory ACE inhibition on such derangements. METHODS AND RESULTS Twenty patients with HOCM underwent cardiac ACE inhibition with intracoronary (IC) enalaprilat (0.05 mg/min infused into the left anterior descending coronary artery for 15 minutes) followed by circulatory ACE inhibition with 25 mg sublingual (SL) captopril. Contrast ventriculography, pressure, and coronary flow measurements were performed at baseline, after IC enalaprilat infusion, and 45 minutes after SL captopril. Heart rate was not affected by the respective interventions (75+/-11 versus 76+/-13 versus 75+/-10 bpm; P=NS), whereas mean aortic pressure dropped slightly after IC enalaprilat and significantly after SL captopril (90+/-8 versus 85+/-10 versus 74+/-9 mm Hg; P<.05). Compared with baseline, IC enalaprilat resulted in a decrease in LV end-diastolic pressure (17.6+/-5.9 versus 14.4+/-4.9 mm Hg; P<.05), time constant of isovolumic LV pressure relaxation (tauG) (69+/-9 versus 52+/-10 ms; P<.05), and outflow gradient (45.2+/-6.9 versus 24.4+/-3.7 mm Hg; P<.05) and in an increase in coronary blood flow (107+/-10 versus 127+/-12 mL/min; P<.05) and coronary flow reserve (2.2+/-0.4 versus 2.6+/-0.3; P<.05). After SL captopril, tauG was prolonged (60+/-13 ms; P<.05 versus IC enalaprilat), and LV outflow gradient, coronary blood flow, and coronary flow reserve values returned to baseline (45.5+/-5.3 mm Hg, 107+/-12 mL/min, and 2.2+/-0.5, respectively; P=NS versus baseline). CONCLUSIONS Activation of the cardiac renin-angiotensin system contributes to LV diastolic dysfunction as well as to the decreased coronary blood flow and coronary flow reserve in HOCM. Cardiac ACE inhibition restores and circulatory ACE inhibition aggravates the above derangements.

Changes in Phasic Coronary Blood Flow Velocity Profile and Relative Coronary Flow Reserve in Patients With Hypertrophic Obstructive Cardiomyopathy

BACKGROUND In this study, we both investigated coronary flow velocity in hypertrophic obstructive cardiomyopathy (HOCM) and tested the hypothesis of differing coronary flow reserve (CFR) of coronary arteries perfusing left ventricular regions with nonuniform myocardial hypertrophy by measuring the relative CFR. METHODS AND RESULTS Coronary flow velocity was assessed in left anterior descending coronary (LAD) and left circumflex (LCX) arteries in 18 patients with HOCM and marked hypertrophy only in the ventricular septum, in 13 patients without obstruction (HCM), and in 9 age- and sex-matched normal subjects at rest, during rapid atrial pacing, and after dobutamine infusion (5 to 30 microg/kg per minute). Relative CFR was estimated as the ratio between absolute CFR of the LAD and absolute CFR of the LCX (LAD/LCX(CF)). At the peak of rapid atrial pacing and during dobutamine stress, LAD/LCX(CF) was reversed in HOCM patients (from 1.25+/-0.11 to 0.82+/-0.07 and 0.79+/-0.06, respectively), whereas it remained unchanged in control subjects (from 1.0+/-0.1 to 1.0+/-0.05 and 1.0+/-0.05, respectively; P<.001). In HCM patients, LAD/LCX(CF) at rest was 1.10+/-0.11, whereas during rapid atrial pacing and dobutamine stress, it was 0.92+/-0.08 and 0.90+/-0.09, respectively. Relative CFR was 0.62+/-0.05 in HOCM patients and 1.05+/-0.05 (P<.001) in normal subjects. There was an inverse correlation between relative CFR and peak systolic outflow tract gradient (r2=.74, P<.001). CONCLUSIONS Regional distribution of hypertrophy in some patients with HOCM resulted in regional impairment of coronary flow. Relative CFR can be used to estimate regional disturbances of coronary flow and may help in patient selection for new interventional therapeutic techniques.

In-vivo imaging of carotid plaque neoangiogenesis with contrast-enhanced harmonic ultrasound.

We describe a case where a mild carotid atherosclerotic plaque was assessed by contrast enhanced harmonic ultrasonography and image analysis. Quantitative indices of plaque echogenicity were determined prior and after the injection of microbubbles. Changes in plaque echogenicity were detected possibly due to the flow of microbubbles through vasa vasorum within the plaque and at the plaque base at the adventitial level. Future histological studies remain to be done to link the presence and the extent of plaque and adventitial neovascularization with the visual and quantitative findings derived by contrast enhanced harmonic ultrasound and image analysis.

Coronary Artery Ectasia, Aneurysm of the Basilar Artery and Varicose Veins: Common Presentation or Generalized Defect of the Vessel Wall?: A Case Report

A young man who suffered from an acute myocardial infarction is presented. He presented coronary artery ectasia along with coronary artery disease. Further evaluation revealed the presence of both a saccular aneurysm of the basilar artery as well as varicose veins of the lower limbs. A common pathogenic mechanism is discussed since all these findings are characterized by similar histologic substrate with the most profound defect being destruction of the myoelastic elements of the media.

Sex differences in the anatomy of coronary artery disease

In a prospective study, the extent and severity of coronary artery disease (CAD) as well as the location of coronary stenoses were studied comparatively, in relation to age and sex, in 192 consecutive women vs 543 selected men, who all underwent coronary angiography during the same time period, and who were found to have significant CAD. Overall, the age of women (59 +/- 8 years) was higher than that of men (55 +/- 8 years), p < 0.001. Also, the prevalence of smoking was higher in men (81% vs 31%, p = 0.0000) and that of diabetes mellitus in women (29% vs 12%, p = 4 x 10(-6)). In addition, women over 50 years old had a higher incidence of hypertension (51% vs 32%, p = 6 x 10(-5)). Although in both sexes the prevalence of multivessel CAD increased with age, the prevalence of one-vessel CAD was significantly more and that of three-vessel CAD significantly less common in women than in men, both overall (35% vs 16%, p = 4 x 10(-8) and 36% vs 54%, p = 2 x 10(-5), respectively) and in all age subgroups. However, the location of coronary stenoses did not show important differences between men and women with the left anterior descending being the most frequently involved artery. Furthermore, the calculated Gensini index, which reflects cumulatively the extent, severity and location of coronary stenoses, was significantly higher in men (59.2 +/- 34.6 vs 52.2 +/- 36.2, p = 0.03), implying more severe and extensive CAD.(ABSTRACT TRUNCATED AT 250 WORDS)

Effects of ischemia on QT dispersion during spontaneous anginal episodes

Myocardial ischemia induced by pacing, angioplasty, or stress results in a significant increase in QT dispersion (QTd = QT maximum - QT minimum). This study investigated the effects of ischemia on QTd and the rate-corrected QTd (QT(c)d) during spontaneous anginal episodes in patients with coronary artery disease (CAD). Ninety-five patients with CAD and typical angina pectoris and 15 control subjects complaining of anginalike symptoms were studied. QTd and QT(c)d were calculated from 12-lead surface electrocardiograms recorded during and after the relief of pain. QTd and QT(c)d were significantly higher during the anginal episode (84+/-31 ms and 98+/-51 ms) compared to the painless conditions (69+/-24 ms and 71+/-24 ms) (P = .003 and P = .001 for QTd and QT(c)d, respectively) only in the 57 CAD patients who had a history of an old previous myocardial infarction. QTd and QT(c)d are significantly increased during spontaneous angina in patients with documented CAD and history of previous myocardial infarction.

Lack of a Thrombotic Tendency in Patients with Acute Myocardial Infarction and Angiographically Normal Coronary Arteries

The hematological profile of 12 patients with acute myocardial infarction and normal coronary arteriographic findings was compared to that of 8 patients with acute myocardial infarction associated with obstructive coronary artery disease, and of 12 patients with no evidence of myocardial infarction and normal coronary arteriographic and left ventriculographic findings who served as control. There were no significant differences in the hematological profile among the 3 groups, suggesting lack of a thrombotic tendency in patients with acute myocardial infarction and normal coronary arteriographic findings.

Response of left atrial systolic function to handgrip in normal subjects

BASELINE The normal cardiovascular response to isometric exercise includes increases in cardiac output, heart rate, and systolic and diastolic blood pressures, with little or no change in stroke volume and systemic vascular resistance.1 Previous studies of echocardiographic imaging and Doppler display have demonstrated alterations in left ventricular volumes and function during handgrip associated with increased active left atrial contribution to left ventricular filling.2, 3 The present study was undertaken to delineate the changes in left atrial mechanical function leading to increased active left atrial contribution during isometric muscular contraction in normal subjects. Methods. The study population consisted of 10 healthy volunteers (Table I). All were considered normal on the basis of their medical history, physical examination, electrocardiogram, chest radiograph, and M-mode and two-dimensional echocardiogram. Subjects with less than technically optimal baseline echocardiograms and subjects re-

A Rare Case of Primary Cardiac Lymphoma Presented as Superior Vena Cava Syndrome

![Figure][1] [![Graphic][3] ][3] A 45-year-old man was admitted to the hospital with dyspnea. Electrocardiogram and chest X-ray were normal; transthoracic echocardiography was not elucidative. The patient developed hemodynamic instability, with a typical brawny edema at the face and