Dirk Frechen

Association of echocardiographic atrial size and atrial fibrosis in a sequential model of congestive heart failure and atrial fibrillation

BACKGROUND Cardioversion (CV) success of atrial fibrillation (AF) inversely correlates to the size of the left atrium (LA). Atrial fibrillation and its most important risk factor, congestive heart failure (CHF), both induce atrial structural enlargement and fibrosis. To investigate the effect of AF and CHF on atrial dilatation and fibrosis, and to estimate whether echocardiographically determined atrial size may be used as a marker for atrial fibrosis. METHODS In six dogs, pacemakers were implanted followed by HIS bundle ablation. After 4 weeks of rapid ventricular stimulation (185 bpm) for CHF induction, additional rapid atrial stimulation (500 bpm) was maintained for 7 weeks to induce AF. Serial determinations of echocardiographic atrial size were performed. Seven dogs with sinus rhythm served as histological controls. Postmortem tissue was obtained to determine the degree and composition of atrial fibrosis. RESULTS While the ejection fraction of the AF/CHF dogs decreased significantly from 57+/-5% to 19+/-7% (P<.01), an increased degree of atrial fibrosis was found (right atrium [RA], 4.9+/-2.0% to 19.9+/-5.4%; LA, 4.4+/-1.6% to 22.2+/-3.2%; P<.01), accompanied by a significant increase of atrial volumes (LA: 21+/-4 to 44+/-4 mm3; P<.01; RA: 10+/-3 to 18+/-6 mm3; P<.05) and LA diameters (34+/-4 to 43+/-2 mm, P<.05). Atrial fibrosis and size significantly correlated. CONCLUSIONS Atrial fibrillation/CHF leads to a significant atrial fibrosis and dilation. The increased echocardiographic size correlates to the degree of atrial fibrosis and may be used as clinical marker for atrial fibrosis. The fibrosis accompanying atrial dilatation may also explain why LA size, as determined by echocardiography, is a strong predictor of CV success.

Integration of Automatic Intrathoracic Fluid Content Measurement into Clinical Decision Making in Patients with Congestive Heart Failure

Background: Hospitalizations due to decompensation are a frequent problem in treating patients with congestive heart failure (CHF). Continuous impedance measurement via implantable devices may detect pulmonary fluid accumulation due to worsening CHF. An acoustic alert might allow an earlier treatment of impending decompensation. An algorithm that implemented impedance measurement into clinical decision making in treating CHF patients was evaluated.

Dysnatremia, vasopressin, atrial natriuretic peptide and mortality in patients with community-acquired pneumonia: results from the german competence network CAPNETZ.

BACKGROUND Dysnatremia is a frequent finding in patients with community acquired pneumonia (CAP) and a predictor of mortality. We studied the relation between dysnatremia, comorbidities and CT-pro-AVP and MR-proANP. METHODS We enrolled 2138 patients (60 ± 18 years, 55% male) with CAP from the CAPNETZ database. Pro-atrial natriuretic peptide (proANP), pro-vasopressin (proAVP), serum sodium and CRB-65 score were determined on admission. Patients were followed up for 28 days. Sodium concentration on admission was examined as a function of mortality at 28 days. Hyponatremia (HypoN) was defined as admission serum sodium <136 mmol/L, hypernatremia (HyperN) as admission serum sodium >145 mmol/L. RESULTS HypoN was diagnosed in 680 (31.8%) patients, HyperN in 29 (1.4%) patients. Comorbidities were associated with sodium levels, and CT-pro-AVP and MR-proANP were inversely related to sodium levels. Patients with HypoN were older, had a higher CRB-65 score and higher values of CT-proAVP and MR-proANP (all p < 0.05). When examined as a function of sodium values, a U-shaped association was found between sodium levels and 28 day mortality. In multivariate Cox proportional hazards analysis, HypoN and HyperN were independent predictors of 28 day mortality. Sodium levels added to the predictive potential of proAVP and proANP. CONCLUSION HypoN is common at admission among CAP patients and is independently associated with mortality. HyperN is rare at admission among CAP patients but is also independently associated with mortality. The combination of sodium and CT-pro-AVP and MR-proANP levels achieved the highest prediction of mortality.

Pulmonary perfusion imaging: new insights into functional consequences of pulmonary embolism using a multicomponent cardiovascular magnetic resonance imaging protocol.

To the Editor: Multidetector computed tomography (MDCT) is frequently used as the first-line technique to directly visualize pulmonary embolism (PE) with a reported sensitivity and specificity of 83% to 100% and 89% to 97%, respectively ([1][1]). However, for rapid and profound clinical decision

Another brick in the wall: adrenomedullin and prognosis in community-acquired pneumonia

Community-acquired pneumonia (CAP) continues to be a major healthcare problem. The associated mortality of 14% in hospitalised patients is still high [1]. Established clinical scores, such as the Pneumonia Severity Index (PSI) and CRB-65 score (confusion, respiratory frequency ≥30 breaths·min−1, systolic blood pressure <90 mmHg or diastolic blood pressure ≤60 mmHg, and age ≥65 yrs) are used for the determination of mortality risk. Since CAP is an infectious disease, we traditionally use biomarkers of infection for diagnostic and prognostic purposes. Inflammatory markers such as white blood cell (WBC) count and C-reactive protein (CRP) are still widely used in the management of CAP, although it is well known that their value for the diagnosis of clinically relevant bacterial infection and prediction of death and complications in CAP is limited. With respect to better diagnosis and guidance of antibiotic therapy, procalcitonin (PCT) is much better, with a broad spectrum of interventional studies in the field of lower respiratory tract infections [2]. However, PCT is not the ideal biomarker for prognosis in CAP, where cardiovascular biomarkers show better predictive value [3–5]. In the current issue of the European Respiratory Journal , Bello et al. [6] adds another brick to the multifaceted wall of prognostic assessment in CAP. The authors performed a prospective study in immunocompetent CAP patients and evaluated whether the prognostic role of pro-adrenomedullin (proADM) depends on different aetiologies of CAP. They compared …

Prognosis of ventilator-associated pneumonia: what lies beneath

Ventilator-associated pneumonia (VAP) continues to be a major problem in the care of intensive care unit (ICU) patients. The incidence of VAP in mechanically ventilated patients is high, ranging from 10 to 30%. The clinical symptoms of VAP are ambiguous and there is no generally accepted gold standard for the diagnosis of VAP. The associated mortality is still high at 30–40% 1, 2. Established clinical scores and biomarkers are only of limited value in terms of diagnosis and prognosis. Since VAP is an infectious disease we traditionally use biomarkers of infection for diagnostic and prognostic purposes. Inflammatory markers such as leukocyte count and C-reactive protein (CRP) are still widely used in the diagnosis of VAP, although it is well known that sensitivity in the ICU setting is highly limited. Until recently, only procalcitonin as a more accurate marker of bacterial infection turned out to be of clinical value. Procalcitonin is useful for the guidance of antibiotic therapy in community-acquired pneumonia (CAP), which has been shown by several studies of the Basel group in recent years 3, 4. Nobre et al. 5 were the first to demonstrate a median reduction of antibiotic treatment of 4 days (six versus 10) following a procalcitonin-guided strategy as opposed to a clinical strategy in patients with VAP. The ProVAP trial demonstrated that procalcitonin guidance can reduce the duration of antibiotic therapy in patients with VAP. In the ProVAP trial Stolz et al. 6 performed a multicentre, randomised, controlled trial with 101 patients with VAP. Patients were either assigned to an antibiotic discontinuation strategy according to American Thoracic Society/Infectious Diseases Society of America guidelines (control group) or to a strategy using serial serum procalcitonin measurements (procalcitonin group). The number of antibiotic-free days patients were alive 28 days after VAP onset was significantly …

Cardiovascular Complications in Community-acquired Pneumonia

Cardiovascular complications and comorbidities in community-acquired pneumonia (CAP) are very frequent. Therefore clinicians must see CAP not as a simple infectious accident. They should look at CAP patients as high-risk cardiovascular patients and have to diagnose and treat them in an appropriate way. Cardiac complications in the acute phase of CAP are most often seen in the first days of disease. Therefore, better monitoring, diagnostics, and risk stratification in CAP with respect to cardiovascular diseases should be established. There is a long-term higher risk for cardiovascular events and mortality in CAP patients that has not been adequately recognized. Cardiovascular morbidity and mortality, especially in patients with known cardiovascular disease, might be reduced by influenza and pneumococcal vaccination.

[Uhl's disease--rare cause of chronic right heart failure].

ZusammenfassungHintergrund:Der Morbus Uhl ist eine seltene Erkrankung, die durch eine Aplasie des rechtsventrikulären Myokards charakterisiert ist. Die massive Funktionseinschränkung des rechten Ventrikels mit seiner pergamentartig dünnen Wand führt zu einer massiven Rechtsherzdilatation und bei Ausprägung des Vollbildes zum progredienten Rechtsherzversagen.Fallbeschreibung:Ein 70-jähriger Patient mit progredienter Dyspnoe und massiven peripheren Ödemen stellte sich mit dem Bild einer chronischen Rechtsherzinsuffizienz mit akuter Dekompensation vor. In einer auswärtigen Klinik waren bei Rechtsherzinsuffizienz die Verdachtsdiagnose einer pulmonalarteriellen Hypertonie gestellt und eine Therapie mit Sildenafil eingeleitet worden. In der Echokardiographie und der Kardio-MRT (Magnetresonanztomographie) fanden sich eine ausgeprägte Hypoplasie der freien Wand des rechten Ventrikels sowie eine ausgeprägte Rechtsherzdilatation ohne Nachweis einer pulmonalen Hypertonie. Anhand des typischen Kardio-MRTs wurde die Diagnose eines Morbus Uhl gestellt. Unter medikamentöser Herzinsuffizienztherapie konnte eine langsame kardiale Rekompensation erzielt werden. Der Patient war im weiteren Verlauf medikamentös über 9 Monate kardial stabil ohne erneute akute Dekompensation.Schlussfolgerung:Bei Patienten mit einer massiven Rechtsherzdilatation ohne Nachweis einer pulmonalen Hypertonie sollte auch im Erwachsenenalter an einen Morbus Uhl gedacht werden. Wichtigster diagnostischer Hinweis ist hierfür die Hypoplasie der freien Wand des rechten Ventrikels, die in der Echokardiographie und Kardio-MRT nachweisbar ist. Kausale Therapieoptionen bestehen nicht. Neben einer medikamentösen Herzinsuffizienztherapie ist evtl. eine rechtsventrikuläre Kardiomyoplastie oder als Ultima Ratio eine Herztransplantation erfolgversprechend.AbstractBackground:Uhl’s disease is a rare disorder characterized by aplasia of the right ventricular myocardium leading to its parchment-like appearance. The loss of right ventricular function causes massive dilation of the right heart with progressive right heart failure in severe cases.Case Report:A 70-year-old patient with progressive dyspnea and massive peripheral edema presented with an acute decompensation of chronic right heart failure. Previously, pulmonary arterial hypertension was suspected and therapy with sildenafil was initiated. Echocardiography and cardiac MRI (magnetic resonance imaging) showed marked hypoplasia of the right ventricular free wall and marked dilation of the right heart without pulmonary arterial hypertension. The diagnosis of Uhl’s disease was confirmed by typical MRI morphology. A slow cardiac recompensation was achieved by medicinal treatment of heart insufficiency. Hence the patient remained stable for 9 months with medicinal therapy without signs of further decompensation.Conclusion:Uhl’s disease should be suspected in patients with massive right heart dilation without pulmonary hypertension even in the adult. The major diagnostic clue is hypoplasia of the right ventricular free wall, which can be demonstrated by echocardiography and cardiac MRI. There is no causal therapy for the disease. Besides medicinal therapy for heart failure, right ventricular cardiomyoplasty and, ultimately, transplantation might be undertaken successfully.BACKGROUND Uhls disease is a rare disorder characterized by aplasia of the right ventricular myocardium leading to its parchment-like appearance. The loss of right ventricular function causes massive dilation of the right heart with progressive right heart failure in severe cases. CASE REPORT A 70-year-old patient with progressive dyspnea and massive peripheral edema presented with an acute decompensation of chronic right heart failure. Previously, pulmonary arterial hypertension was suspected and therapy with sildenafil was initiated. Echocardiography and cardiac MRI (magnetic resonance imaging) showed marked hypoplasia of the right ventricular free wall and marked dilation of the right heart without pulmonary arterial hypertension. The diagnosis of Uhls disease was confirmed by typical MRI morphology. A slow cardiac recompensation was achieved by medicinal treatment of heart insufficiency. Hence the patient remained stable for 9 months with medicinal therapy without signs of further decompensation. CONCLUSION Uhls disease should be suspected in patients with massive right heart dilation without pulmonary hypertension even in the adult. The major diagnostic clue is hypoplasia of the right ventricular free wall, which can be demonstrated by echocardiography and cardiac MRI. There is no causal therapy for the disease. Besides medicinal therapy for heart failure, right ventricular cardiomyoplasty and, ultimately, transplantation might be undertaken successfully.

Morbus Uhl – seltene Ursache einer chronischen Rechtsherzinsuffizienz@@@Uhl’s Disease – Rare Cause of Chronic Right Heart Failure

ZusammenfassungHintergrund:Der Morbus Uhl ist eine seltene Erkrankung, die durch eine Aplasie des rechtsventrikulären Myokards charakterisiert ist. Die massive Funktionseinschränkung des rechten Ventrikels mit seiner pergamentartig dünnen Wand führt zu einer massiven Rechtsherzdilatation und bei Ausprägung des Vollbildes zum progredienten Rechtsherzversagen.Fallbeschreibung:Ein 70-jähriger Patient mit progredienter Dyspnoe und massiven peripheren Ödemen stellte sich mit dem Bild einer chronischen Rechtsherzinsuffizienz mit akuter Dekompensation vor. In einer auswärtigen Klinik waren bei Rechtsherzinsuffizienz die Verdachtsdiagnose einer pulmonalarteriellen Hypertonie gestellt und eine Therapie mit Sildenafil eingeleitet worden. In der Echokardiographie und der Kardio-MRT (Magnetresonanztomographie) fanden sich eine ausgeprägte Hypoplasie der freien Wand des rechten Ventrikels sowie eine ausgeprägte Rechtsherzdilatation ohne Nachweis einer pulmonalen Hypertonie. Anhand des typischen Kardio-MRTs wurde die Diagnose eines Morbus Uhl gestellt. Unter medikamentöser Herzinsuffizienztherapie konnte eine langsame kardiale Rekompensation erzielt werden. Der Patient war im weiteren Verlauf medikamentös über 9 Monate kardial stabil ohne erneute akute Dekompensation.Schlussfolgerung:Bei Patienten mit einer massiven Rechtsherzdilatation ohne Nachweis einer pulmonalen Hypertonie sollte auch im Erwachsenenalter an einen Morbus Uhl gedacht werden. Wichtigster diagnostischer Hinweis ist hierfür die Hypoplasie der freien Wand des rechten Ventrikels, die in der Echokardiographie und Kardio-MRT nachweisbar ist. Kausale Therapieoptionen bestehen nicht. Neben einer medikamentösen Herzinsuffizienztherapie ist evtl. eine rechtsventrikuläre Kardiomyoplastie oder als Ultima Ratio eine Herztransplantation erfolgversprechend.AbstractBackground:Uhl’s disease is a rare disorder characterized by aplasia of the right ventricular myocardium leading to its parchment-like appearance. The loss of right ventricular function causes massive dilation of the right heart with progressive right heart failure in severe cases.Case Report:A 70-year-old patient with progressive dyspnea and massive peripheral edema presented with an acute decompensation of chronic right heart failure. Previously, pulmonary arterial hypertension was suspected and therapy with sildenafil was initiated. Echocardiography and cardiac MRI (magnetic resonance imaging) showed marked hypoplasia of the right ventricular free wall and marked dilation of the right heart without pulmonary arterial hypertension. The diagnosis of Uhl’s disease was confirmed by typical MRI morphology. A slow cardiac recompensation was achieved by medicinal treatment of heart insufficiency. Hence the patient remained stable for 9 months with medicinal therapy without signs of further decompensation.Conclusion:Uhl’s disease should be suspected in patients with massive right heart dilation without pulmonary hypertension even in the adult. The major diagnostic clue is hypoplasia of the right ventricular free wall, which can be demonstrated by echocardiography and cardiac MRI. There is no causal therapy for the disease. Besides medicinal therapy for heart failure, right ventricular cardiomyoplasty and, ultimately, transplantation might be undertaken successfully.BACKGROUND Uhls disease is a rare disorder characterized by aplasia of the right ventricular myocardium leading to its parchment-like appearance. The loss of right ventricular function causes massive dilation of the right heart with progressive right heart failure in severe cases. CASE REPORT A 70-year-old patient with progressive dyspnea and massive peripheral edema presented with an acute decompensation of chronic right heart failure. Previously, pulmonary arterial hypertension was suspected and therapy with sildenafil was initiated. Echocardiography and cardiac MRI (magnetic resonance imaging) showed marked hypoplasia of the right ventricular free wall and marked dilation of the right heart without pulmonary arterial hypertension. The diagnosis of Uhls disease was confirmed by typical MRI morphology. A slow cardiac recompensation was achieved by medicinal treatment of heart insufficiency. Hence the patient remained stable for 9 months with medicinal therapy without signs of further decompensation. CONCLUSION Uhls disease should be suspected in patients with massive right heart dilation without pulmonary hypertension even in the adult. The major diagnostic clue is hypoplasia of the right ventricular free wall, which can be demonstrated by echocardiography and cardiac MRI. There is no causal therapy for the disease. Besides medicinal therapy for heart failure, right ventricular cardiomyoplasty and, ultimately, transplantation might be undertaken successfully.