Fotis Panou

Evaluation of left atrial longitudinal function in patients with hypertrophic cardiomyopathy: a tissue Doppler imaging and two-dimensional strain study

Objective: We sought to quantify left atrial longitudinal function by tissue Doppler (TDI) and two-dimensional (2D) strain in patients with hypertrophic cardiomyopathy (HCM). Design: Case-control study. Setting: Tertiary university hospital. Patients: 43 consecutive patients with familial HCM, aged 49 (SD 18) years, along with 21 patients with non-HCM left ventricular hypertrophy (LVH, aged 52 (12) years) and 27 healthy volunteers (aged 42 (13) years). Interventions: Subjects were studied by both TDI and 2D left atrial strain during all three atrial phases (reservoir, conduit, contractile), as well as by left ventricular systolic strain; total atrial deformation (TAD) was defined as the sum of maximum positive and maximum negative strain during a cardiac cycle. Main outcome measures: Left atrial longitudinal function. Results: Both TDI and 2D atrial strain and TAD were significantly reduced in HCM, compared to the other two groups in all atrial phases (p<0.001 in most cases); left ventricular systolic strain was also significantly reduced in HCM (p<0.001). Adding 2D contractile atrial strain to a model of conventional echo measurements (including left atrial diameter and volume index, interventricular septal thickness and E/A ratio and E/e′ ratios) increased its prognostic value in differentiating HCM from non-HCM LVH (p value of the change <0.001), while addition of TDI atrial strain or left ventricular strain did not. A cut-off for 2D contractile strain of −10.82% discriminated HCM from non-HCM LVH with a sensitivity of 82% and a specificity of 81%. Intra-observer and inter-observer variabilities for atrial strain in HCM were 16% and 17.5% for TDI and 8% and 9.5% for 2D, respectively. Processing time per case in HCM was 12.5 (2.6) minutes for TDI versus 3.8 (1.2) minutes for 2D strain (p<0.001). Conclusion: Left atrial longitudinal function is reduced in HCM compared to non-HCM LVH and healthy controls. In addition, 2D atrial strain has an additive value in differentiating HCM from non-HCM LVH and it is more reproducible and less time consuming than TDI strain.

The predictive value of inflammatory and oxidative markers following the successful cardioversion of persistent lone atrial fibrillation

BACKGROUND Although there is evidence that inflammation and oxidative stress might contribute to the pathogenesis of atrial fibrillation (AF), the predictive value of inflammatory and oxidative stress markers in patients with AF has not been fully assessed. The aim of this study is to evaluate these markers as predictors of sinus rhythm (SR) maintenance, in patients with persistent lone AF. METHODS Among 268 patients with symptomatic AF, we studied 46 patients with a first episode of recently established persistent lone AF. We measured the circulating levels of hs-CRP, TNF-alpha, IL-6, IL-10, sICAM-1, sVCAM-1, malondialdehyde (MDA) and nitrotyrosine (NT) before, 1 h, 24 h, 1, 2, 4 and 6 weeks after cardioversion. During a 12-month follow-up period, AF recurrence was evaluated by Holter ECG recordings every month and when symptoms were reported. RESULTS Baseline levels of CRP, TNF-alpha, sICAM-1, MDA, and NT were elevated in patients with AF compared to controls, and higher in patients with than in those without persistent AF recurrence, while IL-6 levels were equally elevated in the two subgroups. SR maintenance was associated with lower baseline MDA values and faster decrease in IL-6, sICAM-1 and NT levels within the first 2 weeks following SR restoration. CONCLUSIONS Increased markers of inflammation and oxidative stress are found in patients with lone AF, implying that inflammation and oxidative stress may be associated with the presence of the arrhythmia. IL-6, sICAM-1, MDA and NT, assessed prior to and after the first cardioverted episode of persistent arrhythmia, appear to be reliable, early predictors of SR maintenance during the following year.

Long-term nonoutflow septal versus apical right ventricular pacing: relation to left ventricular dyssynchrony.

Background: Right ventricular (RV) apical pacing deteriorates left ventricular (LV) function. RV nonoutflow (low) septal pacing may better preserve ventricular performance, but this has not been systematically tested. Our aim was to assess (1) whether long‐term RV lower septal pacing is superior to RV apical pacing regarding LV volumes and ejection fraction (EF), and (2) if the changes in LV dyssynchrony imposed by pacing are related to the long‐term changes in LV volumes and EF.

Spironolactone improves endothelial and cardiac autonomic function in non heart failure hemodialysis patients.

Objectives: Hemodialysis patients have a cardiovascular mortality rate of 20–40 times that of the general population. Aldosterone inhibition by spironolactone has exerted beneficial, prognostically significant cardiovascular effects in patients with heart failure maintained on hemodialysis or peritoneal dialysis. Our aim was to investigate spironolactones effect in non heart failure hemodialysis patients. Methods: Fourteen stable chronic hemodialysis patients (nine men), 59.5 ± 3.1 years of age were evaluated in a sequential, fixed-dose, placebo-controlled study. Heart failure was diagnosed on the basis of signs and symptoms of heart failure or left ventricular ejection fraction less than 50%. Following an initial 4-month period of placebo administration after each dialysis, patients received spironolactone (25 mg thrice weekly after dialysis) for the next 4 months. Data were recorded at baseline, at the end of placebo administration, and at the end of spironolactone treatment and included endothelial function by forearm reactive hyperemia during venous occlusion plethysmography, cardiac autonomic status by heart rate variability in the time and frequency domain, blood pressure response, and echocardiographic and laboratory data. Results: Placebo induced no changes in the aforementioned parameters. Following spironolactone, salutary effects were observed in the extent and duration of reactive hyperemia (P < 0.05 for both), as well as in heart rate variability (P < 0.05) and blood pressure control (P < 0.05). No changes occurred in echocardiographically derived left ventricular dimensions or mass. Conclusion: Low-dose spironolactone therapy in clinically stable non heart failure hemodialysis patients is associated with favorable effects on cardiovascular parameters known to adversely affect survival, such as endothelial dysfunction and heart rate variability. Spironolactone treatment might benefit long-term cardiovascular outcome of such patients.

Aortic distensibility associates with increased ascending thoracic aorta diameter and left ventricular diastolic dysfunction in patients with coronary artery ectasia.

Coronary artery ectasia is usually linked to coronary atherosclerosis. Its primary defect is a destruction of vascular media, which leads to coronary dilatation. The aim of the present study is to evaluate whether ascending aorta present anatomical and functional wall changes in patients with coronary ectasia compared with patients without ectasia. Forty patients with known coronary ectasia (group A) underwent echocardiography in order to study aortic lumen diameter and wall properties (distensibility and stiffness index). Twenty-five patients with coronary artery disease (group B) and 40 individuals with normal coronary arteries (group C) served as control groups. Both ascending aorta diameter and ascending aorta index were significantly increased in group A compared with groups B and C (P < 0.05 and P < 0.001, respectively). Furthermore, in patients with ectatic coronary arteries ascending aorta index, systolic blood pressure and diastolic dysfunction independently associate with aortic distensibility. In patients with coronary artery ectasia, ascending aortic diameter could be enlarged while aortic stiffness is related to diastolic dysfunction. We suggest that coronary ectasia is not an isolated lesion but a reflection of a generalized vascular media defect, and should not be recognized as a benign entity.

Pulse pressure determines left atrial enlargement in non-dipper patients with never-treated essential hypertension

Pulse pressure determines left atrial enlargement in non-dipper patients with never-treated essential hypertension

Effects of a Preload Increase on Ventricular Filling in Coronary Artery Disease

This study was conducted to investigate the effects of a preload increase on ventricular filling dynamics in 50 coronary artery disease patients both before and immediately after leg elevation. Mitral and tricuspid peak E and A velocities and the mitral E/A velocity ratio increased after leg elevation whereas isovolumic relaxation time and mitral deceleration time decreased. The increase in tricuspid peak A velocity after leg elevation was related to the positivity of the exercise stress test (p = 0.01). The increase in mitral peak A velocity was related to the history of old myocardial infarction (p = 0.006).

Tissue Doppler echocardiography reveals insufficient contractile reserve recruitment during effort in subjects with mitral valve prolapse and those with thick mitral valve.

Objective: To assess by tissue Doppler echocardiography (TDE), the tissue velocities, both at rest and after exercise stress testing, in subjects with mitral valve prolapse (MVP) and those with thick mitral valve (TMV). Methods: Twenty individuals with typical MVP, 30 with TMV, and 30 healthy controls were enrolled. TDE was performed at the basal‐inferior wall and the parameters evaluated were the S, Em, and Am velocities, as well as the Em/Am ratio. Results: The mean S‐wave at rest was higher in subjects with MVP compared to that of the TMV (P < 0.01) and the control groups (P = 0.00005), whereas after exercise it was higher in the control group compared to either MVP (P = 0.013) or TMV group (P = 0.00002). The mean Em wave at rest was higher in the control individuals both at rest (P = 0.007 compared with MVP group and P = 0.013 compared with TMV group), and after exercise (P = 0.0002 and 0.0009, respectively). The Am wave in the MVP group was higher compared with TMV and control subjects at rest (P = 0.022 and 0.00001, respectively) but it was not after exercise (P = ns for both comparisons). The Em/Am ratio of the control group at rest was higher than that of the MVP (P = 0.0000) and TMV (P = 0.00028) groups. However, after exercise, it was higher only when compared with the MVP group (P = 0.016). Conclusions: Subjects with MVP and those with TMV exhibit a less effective contractile response to exercise compared to healthy individuals. Some degree of diastolic dysfunction, particularly after exercise, was also detected in the individuals with MVP. (ECHOCARDIOGRAPHY, Volume 23, February 2006)

Emergency Bedside Echocardiography as a Tool for Early Detection and Clinical Decision Making in Cases of Suspected Pulmonary Embolism A Case Report

Massive pulmonary embolism (PE) constitutes the most unexpected cause of death in necropsy. Consequently, prompt diagnosis and treatment is considered imperative. This article reports the case of a 37-year-old man who presented with cardiogenic shock due to PE as detected with bedside echocardiography in the emergency department. The authors wish to emphasize the usefulness of emergency bedside echo-Doppler for a prompt diagnosis and treatment of this life threatening condition.

Left atrial function and atrial natriuretic factor/cyclic guanosine monophosphate changes in DDD and VVI pacing modes

Left atrial systolic function and the plasma of atrial natriuretic factor (ANF) and cyclic guanosine monophosphate (cGMP) were investigated as possible markers for the development of pacemaker syndrome during VVI pacing. Patients who developed pacemaker syndrome during VVI pacing had a significant decrease in left atrial emptying fraction and a substantial increase in ANF and cGMP plasma levels.