Bent Østergaard Kristensen

Tissue Doppler imaging predicts improved systolic performance and reversed left ventricular remodeling during long-term cardiac resynchronization therapy.

OBJECTIVESnWe sought to evaluate the long-term impact of cardiac resynchronization therapy (CRT) on left ventricular (LV) performance and remodeling using three-dimensional echocardiography and tissue Doppler imaging (TDI).nnnBACKGROUNDnThree-dimensional echocardiography and TDI allow rapid and accurate evaluation of LV volumes and performance.nnnMETHODSnTwenty-five consecutive patients with severe heart failure and bundle branch block who underwent biventricular pacemaker implantation were included. Before and after implantation of the pacemaker, three-dimensional echocardiography and TDI were performed. These examinations were repeated at outpatient visits every six months.nnnRESULTSnFive patients (20%) died during one-year follow-up. In the remaining 20 patients, significant reductions in LV end-diastolic volume and LV end-systolic volume of 9.6 +/- 14% and 16.5 +/- 15%, respectively (p < 0.01), could be demonstrated during long-term follow-up. Accordingly, LV ejection fraction increased by 21.7 +/- 18% (p < 0.01). According to a newly developed TDI technique-tissue tracking-all regional myocardial segments improved their longitudinal systolic shortening (p < 0.01). The extent of the LV base displaying delayed longitudinal contraction, as detected by TDI before pacemaker implantation, predicted long-term efficacy of CRT. The QRS duration failed to predict resynchronization efficacy.nnnCONCLUSIONSnCardiac resynchronization significantly improved LV function and reversed LV remodeling during long-term follow-up. Patients likely to benefit from CRT can be identified by TDI before implantation of a biventricular pacemaker.

Sequential Versus Simultaneous Biventricular Resynchronization for Severe Heart Failure: Evaluation by Tissue Doppler Imaging

Background—Cardiac resynchronization therapy (CRT) by means of simultaneous biventricular pacing improves left ventricular systolic performance and synchrony in patients with heart failure and bundle-branch block. We used tissue tracking and 3D echocardiography to evaluate the impact of sequential CRT with individualized interventricular delay programming. Methods and Results—Twenty consecutive patients with severe heart failure and left bundle-branch block were included. Tissue tracking and 3D echocardiography were carried out before and on the day after pacemaker implantation. Eleven different interventricular delays were examined in each patient. Patients were reexamined after 3 months. Simultaneous CRT immediately reduced the extent of myocardium displaying delayed longitudinal contraction (DLC) from 48.6±16% to 23.2±13% (P <0.01) and increased left ventricular ejection fraction percentage (LVEF%) from 22.4±6% to 29.7±5% (P <0.01). However, optimum sequential CRT caused a further reduction in the extent of DLC from 23.2±13% to 11.1±7.2% (P <0.01), with a simultaneous increase in LVEF% (from 29.7±5% to 33.9±6%, P <0.01). Three months of optimum sequential CRT further improved LVEF% (from 33.6±6% to 38.6±7.2%, P <0.01). Tissue tracking detected the segments with DLC, and their location determined optimum interventricular delay programming. Compared with simultaneous CRT, sequential CRT increased diastolic filling time by 7±2.5%. Conclusions—Compared with simultaneous CRT, sequential CRT significantly improves left ventricular systolic and diastolic performance. Tissue tracking can be used to select optimum interventricular delay during CRT.

Clinical and epidemiological description of aortic dissection in Turner's syndrome.

BACKGROUNDnWomen with Turners syndrome have an increased risk of congenital cardiac malformations, ischaemic heart disease, hypertension and stroke. Aortic dissection seems to occur with increased frequency.nnnAIMnTo describe in more detail aortic dissection as encountered in Turners syndrome, giving attention to clinical, histological and epidemiological aspects.nnnMATERIALS AND METHODSnBased on a retrospective study, we describe the clinical, karyotypic, and epidemiological aspects of aortic dissection as encountered in cases of Turners syndrome seen in Denmark and Sweden.nnnRESULTSnThe median age at onset of aortic dissection in 18 women was 35 years, ranging from 18 to 61 years. Fourteen of 18 women had a 45,X karyotype, while 2 patients had 45,X/45,XY, and 2 had the 45,X/46,X+r(X) complement, respectively. Echocardiography was performed in 10 of 18 patients before their acute illness, and showed signs of congenital cardiac disease, with either bifoliate aortic valves, dilation of the aortic root, or previous aortic coarctation evident in most patients. In 5 patients evidence of a bifoliate aortic valve was conclusive. Hypertension was present in 5 of 18 patients, while 10 of the patients died from aortic dissection, of so-called type A in 6, type B in 3, while in the final case the origin of dissection could not be determined. Biochemical analysis showed altered ratio between type I and type III collagen. Histology showed cystic medial necrosis in 3 of 7 cases. We estimated an incidence of dissection of 36 per 100,000 Turners syndrome years, compared with an incidence of 6 per 100,000 in the general population, and a cumulated rate of incidence of 14, 73, 78, and 50 per 100,000 among 0-19, 20-29, 30-39, and 40+ year olds, respectively.nnnCONCLUSIONnAortic dissection is extremely common in the setting of Turners syndrome, and occurs early in life. Patients with Turners syndrome should be offered a protocol for clinical follow-up similar to that provided for patients with Marfan syndrome, and each clinic should embrace a programme for follow-up.

Short and long-term cardiovascular effects of growth hormone therapy in growth hormone deficient adults

OBJECTIVE Since GH substitution therapy is now available for adult GH deficient patients, information on the cardiovascular effects of GH substitution has assumed major clinical interest. We have therefore assessed cardiovascular effects of short and long‐term growth hormone substitution therapy in these patients.

Perivalvular cavities in endocarditis : abscesses versus pseudoaneurysms ? A transesophageal Doppler echocardiographic study in 118 patients with endocarditis

The appearance of perivalvular cavities (PCs) in patients with infectious endocarditis (IE) was studied by transesophageal echocardiography (TEE) color Doppler examinations to determine whether the color Doppler TEE presentation was in keeping with the current concept of PCs representing abscesses. Two heart centers participated in the study. Videotape recordings of TEE examinations in patients with IE were analyzed retrospectively for 18 months in both centers, and one center included patients prospectively for an additional 18 months. A total of 118 patients with a diagnosis of IE based on TEE and clinical and laboratory findings were seen during the study period. TEE showed PCs in 34 patients. In 3 patients who died, no autopsy was performed; the PCs were proved at autopsy or surgery in the remaining 31 patients, who constituted the study population. All PCs were echo free at TEE. Apart from one technically inadequate examination, all PCs contained color Doppler signals indicating intracavitary blood flow; the PCs communicated through a narrow channel with high-pressure regions (the left ventricle or the ascending aorta). At surgery or autopsy, only 2 of the 31 patients had pus accumulations besides the blood-filled PCs. At TEE the pus accumulations presented as echo-rich, shaggy tissue thickening. It is concluded that well-delineated, echo-free PCs with intracavitary color Doppler signals at TEE appear to be pseudoaneurysms, and therefore the term abscess should not be used in these cases. Although further studies are needed, our findings suggest that PCs more likely occur by infectious tissue weakening and subsequent dissection rather than as a result of primary abscess formation with secondary rupture.(ABSTRACT TRUNCATED AT 250 WORDS)

Three dimensional echocardiography documents haemodynamic improvement by biventricular pacing in patients with severe heart failure

OBJECTIVES To quantify the short term haemodynamic effects of biventricular pacing in patients with heart failure and left bundle branch block by using three dimensional echocardiography. DESIGN Three dimensional echocardiography was performed in 15 consecutive heart failure patients (New York Heart Association functional class III or IV) with an implanted biventricular pacing system. Six minute walk tests were performed to investigate the effect of biventricular pacing on exercise capacity. Data were acquired at sinus rhythm and after short term (2–7 days) biventricular pacing. RESULTS Compared with baseline values, biventricular pacing significantly reduced left ventricular end diastolic volume (EDV) by mean (SD) 4.0 (5.1)% (pu2009<u20090.01) and end systolic volume (ESV) by 5.6 (6.4)% (pu2009<u20090.02). Mitral regurgitant fraction was significantly reduced by 11 (12.1)% (pu2009<u20090.003) and forward stroke volume (FSV) increased by 13.9 (18.6)% (pu2009<u20090.02). Exercise capacity was significantly improved with biventricular pacing by 48.4 (43.3)% (pu2009<u20090.00001). Regression analyses showed that the percentage increase in FSV independently predicted percentage improvement in walking distance (r 2u2009=u20090.73, pu2009<u20090.0002). Both basal QRS duration and QRS narrowing predicted pacing efficacy, showing a significant correlation with %ΔEDV, %ΔESV, and %ΔFSV. CONCLUSIONS In five of 15 consecutive patients with heart failure and left bundle branch block, biventricular pacing induced a more than 15% increase in FSV, which predicted a more than 25% increase in walking distance and was accompanied by an immediate reduction in left ventricular chamber size and mitral regurgitation.

Elevated endothelin concentrations are associated with reduced coronary vasomotor responses in patients with chest pain and normal coronary arteriograms

OBJECTIVESnThe purpose of this study was to investigate the relationship between arterial and coronary sinus endothelin (ET) concentrations and coronary vasomotor responses during rapid atrial pacing in patients with chest pain and normal coronary arteriograms (CPNA).nnnBACKGROUNDnPlasma ET concentrations are significantly higher in CPNA patients than in healthy control subjects.nnnMETHODSnWe investigated 19 carefully characterized CPNA patients (14 women; mean age 53 +/- 9 years) of whom 10 had positive electrocardiographic responses to exercise. The percentage fall in coronary vascular resistance (%d.CVR) after 10 min of rapid atrial pacing was determined using a thermodilution pacing catheter. Plasma ET concentrations were measured by radioimmunoassay on simultaneously drawn arterial and coronary sinus samples.nnnRESULTSnNo significant differences in ET concentrations were observed between men and women, but a strong statistical trend suggested that %d.CVR was lower in women than men (27[23 to 31]% vs. 34[29 to 45]%--median[interquartile range]; p = 0.07). Simple regression analysis including only the women (n = 14) suggested a significant relationship between baseline arterial ET concentrations and %d.CVR (R2 = 0.34; p = 0.06). Furthermore, stepwise multivariate regression analysis of the group as a whole indicated that both gender (p = 0.03) and baseline arterial ET concentration (p = 0.02) were independently predictive of %d.CVR (R2 = 0.44; overall p = 0.02); this relationship predicts that women with high ET levels would have the lowest %d.CVR during pacing.nnnCONCLUSIONSnThese data support the hypothesis that elevated ET activity may be associated with reduced coronary flow responses during rapid atrial pacing in CPNA patients.

Pulmonary endarterectomy for chronic thromboembolic pulmonary hypertension. Ten years experience in Denmark.

Objectives. To evaluate survival and functional outcome in patients treated by pulmonary endarterectomy (PEA) for chronic thromboembolic pulmonary hypertension in Denmark. Design. Follow-up of the first 50 patients operated at Aarhus University Hospital, Denmark. Results. Fifty patients underwent PEA in the period from 1994 to mid 2004. Prior to surgery all patients were in World Health Organization (WHO) function class III (nu200a=u200a33) or IV (nu200a=u200a17). The mean pulmonary artery pressure was 50 mmHg (range 25–76), cardiac index 1.8 l min−1u2009m−2 (range 0.8–2.8) and pulmonary vascular resistance 819 dynu2009su2009cm−5 (range 241–3 067). In-hospital mortality was 12/50 (24%). Surgical mortality was highest in the early period. Since year 2000 in-hospital deaths occurred in only 2 among 23 patients (9%). Leading causes of death were persistent pulmonary hypertension and bleeding. Three patients died during long-term follow-up with a median observation time of 3 years. The overall 5 year survival rate was 74%. At 3 months follow-up 90% of the patients (34/38) had improved one or more WHO functional classes and the systolic pulmonary artery pressure estimated by Doppler echocardiography had decreased from 80 mmHg (range 49–115) to 43 mmHg (range 14–95). Conclusion. Pulmonary endarterectomy has been successfully implemented in Denmark. The perioperative mortality was reduced over time to 9% during the past 5 years. Functional outcome and long-term survival were excellent stressing the importance of surgical treatment for chronic thromboembolic pulmonary hypertension.

Heart function in patients with chronic glomerulonephritis and mildly to moderately impaired renal function. An echocardiographic study.

UNLABELLEDnLeft ventricular hypertrophy and diastolic heart dysfunction have been reported in essential hypertension and in patients with chronic renal failure, treated with haemodialysis, but a close association with blood pressure (BP) level has not been uniformly documented. Thus, other factors could be involved in the pathogenesis of cardiac dysfunction. The aims of the present echocardiographic study were to investigate cardiac morphology and function in patients with chronic glomerulonephritis with mildly to moderately impaired renal function, and to study the relation between echocardiographic findings and glomerular filtration rate (GFR), BP and age. Twenty patients with chronic glomerulonephritis and 14 healthy controls, of the same age- and sex-distribution, were examined by 2D-, M-mode and pulsed-wave Doppler echocardiography. In patients, GFR was determined as plasma clearance of Cr-EDTA. The patients had significantly thicker left ventricular (LV) posterior walls in end diastole (8.7 vs 8.1 mm, p < 0.05), and a higher LV mass index (106.5 vs 93.8 g/m2, p < 0.05). Systolic functional indices, i.e. LV fractional shortening and LV ejection fraction, were statistically significantly lower in patients than in controls (p < 0.05). LV diastolic function in patients was characterized by a statistically significantly lower early peak flow velocity (E-Vmax) (0.66 compared with 0.8 m/s) and early to late peak flow velocity ratio (E/A ratio) (1.07 vs 1.41), as well as E/A ratio of time velocity indices (VTI-E/A) (1.45 vs 1.99) (p < 0.05). The right ventricular filling indices showed a tendency towards a lower E-Vmax in patients (0.55 compared with 0.62 m/s, p = 0.1). In patients, statistically significant negative correlations were found between age and mitral E/A ratio (r = -0.76, p < 0.0001), as well as LV VTI-E/A(r = -0.81, p < 0.0001). The same trend was seen for the tricuspid E/A ratio. No statistically significant correlations were found in patients between mitral or tricuspid E/A ratio and GFR, BP, LV mass or heart rate.nnnIN CONCLUSIONnin a group of patients with chronic glomerulonephritis and mildly to moderately impaired renal function, it was found by means of echocardiography that there was a higher LV mass index and decreased systolic function, when compared with healthy controls. In addition, the patients had diastolic dysfunction of primarily the left ventricle. The echocardiographic findings were not correlated to BP level or renal function. This suggests that factors other than GFR or BP per se might be involved in the pathogenesis of cardiac dysfunction, at an early stage.

Importance of abstention from alcohol in alcoholic heart disease

A case of alcohol-associated heart disease, presenting with congestive heart failure, was followed for 36 months. After abstinence from alcohol, fractional shortening rose from 13 to 60%. After 1 1/2 years of abstinence and normal physical capacity, the alcoholic abuse was resumed. Eleven months later, the patient was again in overt heart failure. Withdrawal of alcohol was again associated with significant clinical improvement, but despite being in functional NYHA class I, fractional shortening only increased from 14 to 29%. Endomyocardial morphology was unrelated to the severity of the disease. Alcoholic heart disease is partially reversible, but total abstinence is necessary to preserve cardiac function.