Fotios Panou

Effects of darbepoetin-alpha on quality of life and emotional stress in anemic patients with chronic heart failure.

Objective Anemia is a frequent comorbidity in chronic heart failure (CHF) adversely affecting patients’ prognosis. Erythropoietin seems to improve exercise capacity in CHF patients. This study investigates the effects of recombinant human erythropoietin analog darbepoetin-α on quality of life and emotional stress, evaluated by relevant questionnaires in patients with CHF and anemia. Methods Forty-one CHF patients [New York Heart Association class: II-III; left ventricular (LV) ejection fraction (EF) ≤40%; hemoglobin < 12.5 g/dl; serum creatinine < 2.5 mg/dl] were randomized (1:1) to receive either 3-month darbepoietin-α at 1.5 μg/Kg every 20 days plus iron orally (n = 21) or placebo plus iron orally (n = 20). Echocardiographic LVEF, questionnaires addressing quality of life (Kansas City Cardiomyopathy Questionnaire, functional and overall, Dukes Activity Status Index) and emotional stress [Zung self-rating depression scale (SDS), Beck Depression Inventory], as well as plasma b-type natriuretic peptide and 6-min walking distance (6MWT as a marker of exercise capacity) were assessed at baseline and posttreatment. Results A significant improvement in LVEF (32 ± 6 from 26 ± 6%, P < 0.001), 6MWT (274 ± 97 from 201 ± 113m, P < 0.01), hemoglobin (12.8 ± 1.4 from 10.9 ± 1.0 g/dl, P < 0.001) and plasma b-type natriuretic peptide (517 ± 579 from 829 ± 858 pg/ml, P = 0.002) was observed posttreatment only in darbepoetin-treated group. Kansas City Cardiomyopathy Questionnaire functional (78 ± 14 from 57 ± 24%, P < 0.01) and overall (68 ± 20 from 47 ± 22, P < 0.001), Dukes Activity Status Index (19 ± 11 from 14 ± 9, P < 0.05), Zung SDS (38 ± 10 from 47 ± 11, P < 0.05) and Beck Depression Inventory (11 ± 9 from 16 ± 10, P < 0.05) scores also improved in darbepoetin-treated patients, whereas they remain unchanged in the placebo group except for the Zung SDS which worsened (P≤0.05). A significant correlation between drug-induced percent changes in 6MWT and Zung SDS (r = –0.627, P < 0.05) was also observed. Conclusions Darbepoetin-α improves quality of life and emotional stress in CHF patients with anemia, with a parallel increase in exercise capacity.

Prognostic Value of Tissue Doppler Right Ventricular Systolic and Diastolic Function Indexes Combined With Plasma B-Type Natriuretic Peptide in Patients With Advanced Heart Failure Secondary to Ischemic or Idiopathic Dilated Cardiomyopathy

Right ventricular (RV) dysfunction adversely affects prognosis in patients with chronic heart failure (CHF) due to left ventricular (LV) dysfunction. However, little evidence exists regarding the prognostic role of RV systolic and diastolic function indexes in combination with plasma B-type natriuretic peptide (BNP) in advanced CHF. Thus, 102 consecutive hospitalized patients with advanced CHF (New York Heart Association classes III to IV) due to LV systolic dysfunction (LV ejection fraction <35%) were studied by 2-dimensional conventional and tissue Doppler imaging (TDI) echocardiography of the left and right ventricles. Plasma BNP was also measured. Patients were followed for 6 months for major cardiovascular events (cardiovascular death and/or CHF-related hospitalization). During follow-up, 13 patients died and 63 patients reached the combined end point of cardiovascular death or CHF-related hospitalization. By univariate analysis, RV TDI systolic velocity, dilated cardiomyopathy, digoxin treatment (all p values <0.01), and female gender (p <0.05) were associated with increased cardiovascular death. Transmitral Doppler to mitral annular TDI early diastolic velocity ratio, RV TDI early diastolic velocity (p <0.05), and ratio of early to late RV diastolic TDI velocities (p <0.01) predicted the combined end point. In multivariate analysis, decreased RV systolic velocity, dilated cardiomyopathy, and female gender (all p values <0.05) were independent predictors of cardiovascular death, whereas increased ratio of early to late RV diastolic TDI velocities (p <0.01) and increased BNP (p <0.05) predicted the combined end point. In conclusion, RV TDI indexes combined with increased plasma BNP additively predict adverse cardiac outcomes in advanced CHF.

Transthoracic echocardiography for the diagnosis of left ventricular thrombosis in the postoperative care unit

IntroductionTransthoracic echocardiography (TTE) is a reliable, noninvasive imaging method that is useful in the evaluation of cardiovascular thrombosis. We conducted a retrospective study of all the echocardiograms from patients in the postoperative care unit to assess the role of TTE in thrombus identification in the left ventricle.MethodsThis retrospective database evaluation included all echocardiograms during a 14-month period. The echocardiographic examination protocol included the subcostal four-chamber view, the apical four-chamber view, the apical two-chamber view and the parasternal view, along the long and short axes in both spontaneously and mechanically ventilated patients. All echocardiograms were obtained within the 48 hours immediately following surgery.ResultsIn total, 160 postoperative echocardiograms were obtained from 160 patients and resulted in the detection of five cases of left ventricular thrombosis. Subgroup analysis showed that 21 and 35 of the 160 patients examined had either dilated or ischemic cardiomyopathy, respectively. In these patients, preoperative echocardiograms had been obtained recently prior to surgery and were negative for left ventricular thrombus. In three of 35 patients with ischemic cardiomyopathy and two of 21 patients with dilated cardiomyopathy, thrombus was identified in the left ventricle. The thrombi were mobile, uncalcified and pedunculated and were located in the apex of the left ventricle. In addition, no clinical consequences of the left ventricular thrombi were recorded.ConclusionsLow-flow conditions in heart chambers due to ischemic or dilated cardiomyopathy in conjunction with the hypercoagulability caused by perioperative prothrombotic factors may lead to thrombotic events in the left ventricle.

Exercise-induced changes in E/E' ratio in patients with suspected coronary artery disease.

ObjectivesIschemia affects the left ventricular (LV) diastolic function earlier than the systolic function. The ratio of the early diastolic transmitral velocity to the early diastolic tissue velocity (E/E′) measured by tissue Doppler echocardiography allows a reliable assessment of the diastolic function. We investigated whether exercise-induced changes in E/E′ ratio may help in the detection of coronary artery disease (CAD). MethodsThe study population consisted of 114 patients undergoing coronary angiography. Patients with impaired LV ejection fraction, earlier myocardial infarction, arterial hypertension greater than stage I, or LV hypertrophy were excluded. Patients underwent a treadmill exercise test combined with an echocardiogram at baseline and within the first minute after exercise. ResultsCoronary angiography showed a stenosis more than 70% in 72 (63%) patients (CAD group), the remaining 42 formed the non-CAD group. The two groups did not differ regarding age, sex, LV dimensions, and function. At baseline, the E/E′ lateral and septal ratios and their average did not differ between the two groups. The exercise-induced changes of the E/E′ ratios were higher in the CAD group (change of E/E′ average: 1.9±3.3 vs. −1.1±2.3, P<0.001). In the CAD group, 78% showed an exercise-induced increase of E/E′ average compared with 24% in the non-CAD group (P<0.001). In multivariate analysis, the association between an increase of E/E′ average and the presence of obstructive CAD was independent of traditional risk factors, exercise test result or exercise-induced wall motion abnormalities (odds ratio=8.1, P<0.001). ConclusionExercise-induced changes in E/E′ ratio may offer significant assistance in the detection of CAD.

Diastolic stress echocardiography detects coronary artery disease in patients with asymptomatic type II diabetes.

ObjectivesDiabetes mellitus is considered as an equivalent of coronary artery disease (CAD). Aim of the study was to investigate whether in asymptomatic patients with type II diabetes, diastolic stress echocardiography may represent an alternative tool for the detection of CAD. MethodsThe study population consisted of 105 patients with diabetes mellitus (age 61±9 years, 26% female, duration of diabetes 37±14 months). We performed an exercise stress test, followed by an echo-study and a single-positron emission tomography. Coronary angiography was performed within 1 month. ResultsCoronary angiography revealed a coronary artery stenosis of at least 70% in 72 patients (69%, CAD group), while the remaining formed the non-CAD group. Exercise induced an increase of both E/E′ lateral and septal ratios as well as their average in the CAD group and on the contrary a decrease of these ratios in the non-CAD group. Receiver operating curve analysis for discrimination between patients with and without obstructive CAD showed an optimal cut-off value of −0.0708 for the exercise-induced change of E/E′ average (area under curve 0.892, P<0.001). Sensitivities of scintigraphy and of diastolic stress echocardiography for detection of CAD were 75.0 and 93.1%, respectively; specificity was 78.8% for both methods. In asymptomatic patients, sensitivities of scintigraphy and diastolic stress echocardiography were 76.9 and 92.3%; specificity of both was 80%. ConclusionIn patients with type II diabetes, diastolic stress echocardiography, by means of E/E′ ratio exercise-induced changes, can be used for the diagnosis and severity of CAD and for the detection of occult myocardial ischemia.

Ultrasound in cardiac trauma

&NA; In the perioperative period, the emergency department or the intensive care unit accurate assessment of variable chest pain requires meticulous knowledge, diagnostic skills, and suitable usage of various diagnostic modalities. In addition, in polytrauma patients, cardiac injury including aortic dissection, pulmonary embolism, acute myocardial infarction, and pericardial effusion should be immediately revealed and treated. In these patients, arrhythmias, mainly tachycardia, cardiac murmurs, or hypotension must alert physicians to suspect cardiovascular trauma, which would potentially be life threatening. Ultrasound of the heart using transthoracic and transesophageal echocardiography are valuable diagnostic tools that can be used interchangeably in conjunction with other modalities such as the electrocardiogram and computed tomography for the diagnosis of cardiovascular abnormalities in trauma patients. Although ultrasound of the heart is often underused in the setting of trauma, it does have the advantages of being easily accessible, noninvasive, and rapid bedside assessment tool. This review article aims to analyze the potential cardiac injuries in trauma patients, and to provide an elaborate description of the role of echocardiography for their accurate diagnosis.

Lung Ultrasound and Transthoracic Echocardiography in the Differentiation Between Pericardial and Left Pleural Effusion in a Cardiac Surgery Patient

Significant morbidity and mortality are associated with acute pulmonary embolus (PE) during the perioperative period.1 Patients with massive PE who are hemodynamically unstable may require surgical embolectomy. As established by Aklog et al,2 patients undergoing embolectomy for severe PE show a survival rate of 89%. Patient survival is related directly to early diagnosis and surgical intervention.2 We report a case in which intraoperative transesophageal echocardiography was used to detect an acute PE that occurred during an elective laparoscopic procedure. The transesophageal echocardiographic diagnosis allowed the patient to undergo emergent thrombectomy, which was lifesaving. A 71-year-old man with a malignant cecal mass underwent an elective laparoscopic hemicolectomy. Less than an hour into the procedure, the patient became acutely hemodynamically unstable. A transesophageal echocardiogram showed a severely underfilled left heart, right ventricular (RV) dilation, severe RV dysfunction, right-to-left atrial septal bowing, and a large right atrial (RA) thrombus (Fig 1 and Video 1 [supplementary video is available online]). Estimated pulmonary artery systolic pressure, derived from the tricuspid regurgitant jet, was 69 mmHg. Despite resuscitation efforts, the patient continued to decompensate. The patient was emergently placed on cardiopulmonary bypass, and an embolectomy was performed. A large RA thrombus and bilateral pulmonary emboli were removed. Echocardiographic-guided anesthesia management was used continually throughout the procedure to guide therapies. The cecal mass also was removed. The patient was extubated 48 hours after surgery and discharged 2 weeks later. Echocardiography performed by trained physicians can rapidly detect and direct resuscitation of patients with hemodynamic instability from acute PE.3 The midesophageal RV inow-outflow and midesophageal 4-chamber views are the most

Cardiovascular ultrasonography detection of embolic sources in trauma

Venous thromboembolism (deep vein thrombosis and pulmonary embolism) and bone cement implantation syndrome are major sources of embolic events in trauma patients. In these patients, embolic events due to venous thromboembolism and bone cement implantation syndrome have been detected with cardiac and vascular ultrasonography in the emergency setting, during the perioperative period, and in the intensive care unit. This article discusses the ultrasonography modalities and imaging findings of embolic events related to venous thromboembolism and bone cement implantation syndrome. The aim is to present a short review with exceptional illustrations that can enable physicians to identify sources of emboli in trauma patients with cardiovascular ultrasonography.

Reply: Long term impact of CPAP on myocardial function in OSA. Always measurable cardiac index?

We appreciate the interest of A.M. Esquinas and R. PerezRojo regarding our manuscript [1] relevant to the impact of continuous positive airway pressure (CPAP) treatment on myocardial performance, in patients with obstructive sleep apnea (OSA). We agree that beyond OSA, various factors and associated comorbidities may affect leftand right-sided myocardial performance [2]. Nevertheless, in our study, we selected a cohort of patients with a little comorbidity as possible in order to focus on the net effect of CPAP treatment on OSA patients and to exclude possible confounders. We would also like to emphasize that our study was designed to give clues on how CPAP treatment affects cardiac function in patients with either moderate or severe OSA, since according to the guidelines, the latter subgroup of patients is eligible for CPAP treatment [3]. Moreover, we applied a regression model for the association between the change in apnea-hypopnea index and the change in the estimated pulmonary artery systolic pressure. Therefore, we can indirectly draw conclusions on the impact of OSA severity and weight, body mass index, and neck circumference on the outcome of CPAP treatment. Furthermore, we agree that a study specifically designed to examine the relative impact of shortversus longer-term application of CPAP would be of interest, since in our study, there was no improvement of pulmonary artery systolic pressure according to the percentage of days on CPAP use. Finally, we would like to assert that the dropout of 13 patients from the study did not affect our final results since we applied a paired analysis in which values before CPAP and after completion of the study period were compared for every patient as a match. The same analysis also ensured that the impact of medications was not a significant determinant of the outcome, since there were no changes of treatment during the study period. In conclusion, as OSA is associated with numerous comorbidities and the patients’ compliance is not assured, it is difficult to predict response to treatment in such a population [4]. Nevertheless, as awareness of the clinical significance of OSA steadily increases, specifically designed studies are required to address in detail the net impact of CPAP treatment on myocardial performance.

Transesophageal Echocardiographic Examination in the Diagnosis of Bowel Ischemia Due to Thoracic Aorta Thrombosis

1. Sidebotham D, McGeorge A, McGuinness S, et al: Extracorpoeal membrane oxygenation for treating severe cardiac and respiratory ailure in adults: Part 2-technical considerations. J Cardiothorac Vasc nesth 24:164-172, 2010 2. Combes A, Leprince P, Luyt CE, et al: Outcomes and long-term uality-of-life of patients supported by extracorporeal membrane oxygention for refractory cardiogenic shock. Crit Care Med 36:1404-1411, 2008 3. Marasco SF, Lukas G, McDonald M, et al: Review of ECMO extra corporeal membrane oxygenation) support in critically ill adult atients. Heart Lung Circ 17:S41-S47, 2008 (suppl 4) 4. Muehrcke DD, McCarthy PM, Stewart RW, et al: Complications of xtracorporeal life support systems using heparin-bound surfaces. The risk f intracardiac clot formation. J Thorac Cardiovasc Surg 110:843-851, 995