G. Ducloux

Right ventricular ejection fraction is an independent predictor of survival in patients with moderate heart failure

OBJECTIVES We sought to study the relationship between survival and right ventricular ejection fraction (RVEF) in a subgroup of patients with moderate congestive heart failure (CHF). BACKGROUND It has been demonstrated that RVEF is an independent predictor of survival in patients with advanced CHF. METHODS Cardiopulmonary exercise testing and radionuclide angiography (to determine right and left ventricular ejection fraction) were prospectively performed in 205 consecutive patients with moderate CHF (140 patients in New York Heart Association [NYHA] class II, 65 in class III). RESULTS Left ventricular ejection fraction was 29.3%+/-10.1%, RVEF was 37.5%+/-14.6% and peak oxygen consumption (VO2) was 16.2+/-5.4 ml/min/kg (60.2%+/-19% of maximal predicted VO2). After a median follow-up period of 755 days, there were 44 cardiac-related deaths, 3 deaths from noncardiac causes and 15 transplantations of whom 2 were urgent; 1 patient was lost to follow-up. Multivariate analysis showed that three variables-NYHA classification, percent of maximal predicted VO2 and RVEF-were independent predictors of both survival and event-free cardiac survival. Left ventricular ejection fraction and peak VO2 normalized to body weight had no predictive value. The event-free survival rates from cardiovascular mortality and urgent transplantation at 1 year were 80%, 90% and 95% in patients with an RVEF <25%, with a RVEF > or =25% and <35% and with a RVEF > or =35%, respectively. At 2 years, survival rates were 59%, 77% and 93% in the same subgroups, respectively. CONCLUSIONS In addition to the NYHA classification and to the percent of maximal predicted VO2, RVEF is an independent predictor of survival in patients with moderate CHF.

Kinetics of oxygen consumption during and after exercise in patients with dilated cardiomyopathy. New markers of exercise intolerance with clinical implications.

OBJECTIVES This study analyzed the kinetics of oxygen consumption during and after a maximal cardiopulmonary exercise test in patients with dilated cardiomyopathy. The prognostic information derived from indexes of recovery was also studied. BACKGROUND Previous studies have examined the kinetics of oxygen consumption during a short recovery period in a limited number of patients. To our knowledge, no study has examined the prognostic information derived from indexes of recovery. METHODS We studied 153 patients and 55 control subjects. We calculated the ratio between total oxygen consumption during exercise and recovery, the half-recovery time of peak oxygen consumption, the time constant of recovery, the recovery time and the ratio between duration of exercise and recovery time. RESULTS Recovery of oxygen consumption was significantly delayed in patients, and this delay was related to the degree of exercise intolerance. After a median follow-up period of 439 days, for the total study group, percent of predicted peak oxygen consumption (p = 0.003) and ejection fraction (p = 0.03) were independent predictors of survival. In a subgroup of patients with moderate exercise intolerance (percent peak oxygen consumption > 40%), the ratio between total oxygen consumption during exercise and recovery (p = 0.013) and the ejection fraction (p = 0.013) were independent predictors of survival. CONCLUSIONS The kinetics of oxygen consumption during recovery was delayed in patients with dilated cardiomyopathy. Although indexes of recovery were not prognostic markers in the total study group, the ratio between total oxygen consumption during exercise and recovery was an independent prognostic marker in patients with moderate exercise intolerance.

Malignant pericardial effusions: Usefulness of pericardioscopy

In cases of malignant pericardial effusion, surgical subxiphoid biopsy sometimes fails to prove malignancy. To assess the usefulness of pericardioscopy, which allows an endoscopic investigation of the pericardial cavity, this technique was systematically performed during surgical drainage procedures that were performed on 40 patients who had pericardial effusions of suspected malignant origin. Twenty-six patients had a history of neoplasm, 10 had a history of hematologic malignancy, and four had recent tumors or lymphadenopathies that were suspected to be of malignant origin. Classical tests that are usually performed during a conventional surgical drainage procedure (fluid studies and subxiphoid biopsy) were combined with direct visualization of the pericardial surfaces and guided biopsies of suspicious areas. The follow-up period after pericardioscopy was at least 12 months. Two early deaths occurred after pericardioscopy, but no death was directly related to the endoscopy. According to all of the tests that were performed, diagnoses were malignant pericardial effusion in 15 of 40 patients (group I, 37%) and nonmalignant pericardial effusion in 25 of 40 patients (group II, 73%). In 3 of 13 patients (23%) in group I, the diagnosis was obtained only by pericardioscopy (results of cytologic studies and subxiphoid biopsy were negative). In two patients in group I, pericardioscopy could not be completed, but the diagnosis of malignant pericardial effusion was obtained by pericardiocentesis. In group II, effusion was considered to be postradiation pericarditis in five cases, infectious pericarditis in three cases (bacterial in one and tuberculous in two), hemopericardium induced by coagulation disturbances in three cases, and idiopathic pericarditis in 14 cases.(ABSTRACT TRUNCATED AT 250 WORDS)

Prevalence and clinical significance of antiphospholipid antibodies in heart valve disease: A case-control study

The purposes of this study were (1) to assess the prevalence of antiphospholipid (aPL) antibodies in patients with non-specific heart valve disease referred for valve replacement and (2) to determine whether the presence of aPL antibodies carries a risk for thrombotic events during a postoperative follow-up in a prospective cohort. The sera of 89 consecutive patients and 80 matched control subjects were tested for antibodies to cardiolipin (immunoglobulin G and immunoglobulin M) and for lupus anticoagulant. The prevalence of aPL antibodies was significantly higher in patients (19 [21%] of 89) than in control subjects (7 [9%] of 80) (p < 0.05). Patients were divided into two subgroups according to the presence (subgroup A) or the absence (subgroup B) of aPL antibodies. No significant difference in age or sex ratio was observed between the two subgroups. A history of arterial thrombosis was more frequent in subgroup A (8 [42%] of 19) than in subgroup B (8 [11%] of 70) (p < 0.01). No significant difference with respect to the occurrence of thrombotic events was observed during a median follow-up period of 8.7 months. Thus a high prevalence of aPL antibodies was found in patients referred for heart valve replacement compared with matched control subjects. No increased risk has been demonstrated in the patients with aPL antibodies.

Association between anticardiolipin antibodies and mortality in patients with peripheral arterial disease

PURPOSE Anticardiolipin antibodies may be associated with recurrent thromboembolic events in patients with myocardial infarction or stroke. We sought to determine the prevalence of anticardiolipin antibodies in patients with peripheral arterial disease and their association with subsequent thromboembolic events and mortality. METHODS We ascertained anticardiolipin antibodies using a standardized enzyme-linked immunosorbent assay (immunoglobulin G [IgG] anticardiolipin > or =15 GPL units or IgM anticardiolipin > or =15 MPL units) in 232 patients with peripheral arterial disease and 100 control subjects. Patients were observed to determine overall and cardiovascular mortality, and incident thromboembolic events. RESULTS IgG anticardiolipin antibodies were significantly more common in the patients with peripheral arterial disease (36 of 232 [16%]) than in the controls (7 of 100 [7%], P = 0.03). During a median follow-up of 3.5 years, 3 of the 232 patients were lost to follow-up and 56 (24%) died. Overall mortality was significantly greater in the IgG anticardiolipin-positive patients (16 of 35 [46%]) compared with those who were IgG anticardiolipin-negative (40 of 194 [21%], P = 0.0003), largely due to an increase in cardiovascular mortality among the IgG anticardiolipin-positive patients. In a multivariate proportional hazards analysis, IgG anticardiolipin antibodies were an independent risk factor for overall mortality (hazard ratio [HR] = 2.1, 95% confidence interval [CI]: 1.2 to 4.0) and cardiovascular mortality (HR = 4.4, 95% CI: 1.6 to 12). CONCLUSIONS IgG anticardiolipin antibodies are common in patients with peripheral arterial disease and are associated with an increased risk of overall and cardiovascular mortality.

Comparative Diagnostic Value of Ankle-to-Brachial Index and Transcutaneous Oxygen Tension at Rest and After Exercise in Patients with Intermittent Claudication

Background: Few studies have compared sensitivities of ankle-to-brachial index (ABI) and transcutaneous oxygen tension (TcPO2) in a large group of patients with Leriche stage II intermittent claudication. Method and Results: 111 patients (138 limbs) with a stable chronic (> three months) intermittent claudication and significant peripheral vascular disease (PVD) proved by angiography were studied. They performed a treadmill test (10%, 3 km/hr) limited by limb pain. ABI and TcPO2 were measured before, just after exercise, and after three and ten minutes of recovery in supine position. Sensitivities per patient for ABI and TcPO2 were respectively at rest: 82.9% and 28.8%, and after exercise: 88.3% and 62.2%. Sensitivities per leg (n=138) for ABI and TcPO2 were respectively at rest: 73.9% and 26.8%, and after exercise: 82.6% and 34%. The sensitivity of TcPO2 increased to 56.5% after three minutes of recovery but was always less than that of ABI, which was maximal just after exercise (82.6%). The sensi tivity of the regional perfusion index was similar to that of TcPO2. The sensitivity of TcPO2 increased with respect to the Leriche stage and the number of lesions but was always lower than that of ABI. There was a weak correlation between TcPO2 and ABI after exercise, but no correlation was noted between maximal walking distance, ABI, and TcPO2. Conclusion: TcPO 2 is not required in patients with Leriche stage II intermittent clau dication but might be useful either in severely affected patients (Leriche stage III or IV) or in selected patients.

Plasma levels of endothelin-1 at rest and after exercise in patients with moderate congestive heart failure

Plasma levels of endothelin-1 are increased in patients with severe congestive heart failure related to various etiologies. However, conflicting data have been published in patients with moderate congestive heart failure. Moreover, the effect of exercise on plasma levels of endothelin-1 is not precisely known. We determined the plasma levels of endothelin-1 in a homogenous group of patients with idiopathic dilated cardiomyopathy in stage II of the New York Heart Association functional classification at rest and at peak exercise. In this group of patients, plasma levels of endothelin-1 were increased compared to a control group (2.9 +/- 0.27 vs. 1.96 +/- 0.24 pmol/l, P < 0.01, mean +/- S.E.M.), as were plasma levels of atrial natriuretic peptide (26.3 +/- 6.3 vs. 2.95 +/- 0.7 pmol/l, P < 0.001), plasma renin activity (12.6 +/- 2.98 vs. 1.75 +/- 0.23 ng/ml per h, P < 0.001) and plasma levels of aldosterone (217 +/- 29.3 vs. 154 +/- 18.8 pg/ml, P < 0.05). In contrast to the other hormones, exercise did not increase plasma levels of endothelin-1. There was no correlation between plasma levels of endothelin-1 and plasma levels of atrial natriuretic peptide, and no correlation between left ventricular ejection fraction, peak oxygen consumption and hormonal values. In conclusion, plasma levels of endothelin-1 are increased in a homogeneous group of patients with idiopathic dilated cardiomyopathy and moderate congestive heart failure. Endothelin-1 could participate in the progression of heart failure. Exercise did not increase the plasma levels of endothelin-1 in contrast to the other hormones.

Response of atrial natriuretic factor to surgical pericardial drainage in patients with chronic pericardial effusion

Previous studies have demonstrated the importance of atrial transmural pressure in the secretion of atrial natriuretic peptide. These studies have been performed in patients with pericardial effusion and hemodynamic compromise. The response of atrial natriuretic peptide to the drainage of chronic pericardial effusion without clinical evidence of tamponade is unknown. We studied 13 patients with chronic abundant pericardial effusion but without hemodynamic compromise. Blood samples for hormonal determinations were drawn before and after surgical pericardiocentesis. Right atrial pressure was measured during the procedure. Drainage induced a significant increase of atrial natriuretic peptide (from 12 +/- 3.9 to 105 +/- 22.8 pmol/l, P < 0.001, mean +/- S.E.M.), correlated with the fall in right atrial pressure (from 7.65 +/- 1.18 to 4.31 +/- 1.46 mmHg, P < 0.05, r = 0.68, P = 0.01). This increase was inversely correlated with the rise of mean blood pressure after surgery (from 84 +/- 2.37 to 100 +/- 5.3 mmHg, P < 0.05, r = 0.65, P < 0.02). Plasma renin activity decreased after drainage (from 8.12 +/- 2.57 to 3.27 +/- 0.65 ng/ml/h, P < 0.05). Surgery induced an increase of plasma levels of aldosterone (from 811 +/- 241 to 1199 +/- 249 pmol/l, P < 0.05), which were reduced after pericardiocentesis (371 +/- 102 pmol/l, P < 0.02). In patients with chronic abundant pericardial effusion, surgical pericardiocentesis induced a significant increase of atrial natriuretic peptide, correlated with a fall in right atrial pressure. The increase of atrial natriuretic peptide was similar than in patients with tamponade, despite a moderate fall in right atrial pressure.(ABSTRACT TRUNCATED AT 250 WORDS)

Usefulness of diltiazem in the acute management of supraventricular tachyarrhythmias in the elderly

SummaryAcute management of supraventricular tachyarrhythmias is often difficult in elderly patients. Diltiazem was given intravenously (loading dose of 0.25 mg/kg over 2 minutes followed by a 4 mg/kg/24 hr infusion) in 37 elderly patients (mean age 70 years, range 60–91). Fifteen out of the 37 patients (41%) had left ventricular cardiac disease, 12 (32%) had cor pulmonale, and 10 (27%) had no obvious cardiac disease. Hemodynamic tolerance of the supraventricular tachyarrhythmia was poor in 12 patients. A good result was defined as a return to sinus rhythm after bolus or infusion, or as a slowing of the ventricular rate (VR) to less than 100 beats/min. Of the 23 patients in atrial fibrillation, about half reverted to sinus rhythm after diltiazem, and in most of the others the ventricular rate decreased to less than 100 beats/min. Side effects occurred in 10 patients (bradycardia in 6, cutaneous rash in 2, hypotension in 2). They rapidly reversed after cessation of diltiazem. They were responsible for 2 out of the 5 poor results. Thus, diltiazem appeared effective and safe when used carefully in elderly patients with supraventricular tachyarrhythmia.

A dynamic and asymmetric phantom for left ventricular regional wall motion assessment

The authors have designed a phantom consisting of 2 independent latex balloon chambers to investigate regional left ventricular contractibility. The wall motion of each chamber has different, amplitudes thus simulating a regional dysfunction. This phantom is applicable to different imaging techniques (contrast angiography, 2-D echography, nuclear angiography and nuclear magnetic resonance). The preliminary results show satisfactory reliability and imaging quality as well as low variability of measurements.