Jan Krejčí

Prognostic Importance of the Right Ventricular Function Assessed by Doppler Tissue Imaging

AIMS We sought to assess whether the peak systolic and diastolic tricuspid annular velocities as indicators of the right ventricular systolic and diastolic function are of prognostic importance in patients with symptomatic heart failure. METHODS AND RESULTS The study included 139 consecutive patients with symptomatic heart failure. Their mean left ventricular ejection fraction was 24% (range, 10-39%); 107 patients (77%) were in functional class III according to the New York Heart Association. All patients underwent clinical and laboratory examination, standard echocardiography completed by the Doppler tissue imaging of the tricuspid annular motion, and the right-sided heart catheterization. They were followed up for cardiac-related death and non-fatal cardiac events including the need for implantation of a cardioverter-defibrillator and hospitalization for heart failure. The median follow-up was 11 months (range, 1-48 months). There were 17 cardiac-related deaths and 23 non-fatal cardiac events. The multivariate stepwise Cox regression modelling revealed three effective predictors for both survival and event-free survival: aetiology of heart failure, left ventricular end-diastolic diameter, and the peak systolic tricuspid annular velocity (Sa). Patients with Sa<10.8cms(-1) exhibited worse survival (P=0.048) and event-free survival (P<0.001) compared with those having Sa>/=10.8cms(-1). Risk values of Sa (<10.8cms(-1)) and the left ventricular end-diastolic diameter (>70mm) were found to be of additive simultaneous influence leading to a very poor prognosis, mainly if aetiology of heart failure was idiopathic dilated cardiomyopathy (P<0.001). CONCLUSION The Sa represents a significant independent predictor of survival and event-free survival in patients with symptomatic heart failure. Its combination with the left ventricular end-diastolic diameter provides a very powerful tool for patient risk stratification.

A Fast and Simple Echocardiographic Method of Determination of the Optimal Atrioventricular Delay in Patients After Biventricular Stimulation

The optimization of atrioventricular (AV) delay is known to signifcantly contribute to maximum cardiac performance. The aim of this study was to validate a new, fast, and simple echocardiographic method of identifying the AV delay that provides the maximum cardiac output (CO). Right heart catheterization and Doppler echocardiography of transmitral filling were performed simultaneously in 18 patients with heart failure and at least minimum functional mitral regurgitation treated with atrial synchronized biventricular pacing. CO derived from catheterization and Doppler filling parameters were measured at the predicted optimal AV delay (oAVD), the short AV delay (oAVD − 50 ms), and the long AV delay (oAVD + 28 ms on average/range, +10 ms to +50 ms) during a constant heart rate. The AV delay was regarded as optimal if the end of atrial contraction (represented by the end of A wave of transmitral filling) coincided with the beginning of ventricular contraction (heralded by the onset of the systolic component of mitral regurgitation). Prediction of the optimal AV delay included the following steps: (1) The maximum AV delay at which full ventricular capture is still preserved was found under electrocardiographic control. (2) This value, decreased by 5 to 10 ms, was designated as “the testing long AV delay,” and the time interval from the end of the A wave to the onset of the systolic component of mitral regurgitation (time t1) was measured at this setting. (3) oAVD was simply calculated as “the testing long AV delay”− time t1. The CO measured at the oAVD (4.5 ± 0.7 1 · min−1) significantly exceeded those at the short AV delay (4.3 ± 0.7 1 · min−1, P < 0.01) and the long AV delay (4.4 ± 0.8 1 · min−1, P < 0.01), respectively. The method correctly determined the maximum CO in 78% of the patients. In conclusion, Doppler echocardiography enables very rapid and accurate optimization of AV synchrony in patients after the implantation of a biventricular pacemaker. (PACE 2004; 27:58–64)

Left Ventricular Mechanics in Idiopathic Dilated Cardiomyopathy: Systolic-Diastolic Coupling and Torsion

BACKGROUND In idiopathic dilated cardiomyopathy (IDC), myocardial deformational parameters and their mutual relationships remain incompletely characterized. METHODS Thirty-seven patients with IDC underwent two-dimensional speckle-tracking echocardiography (2D-STE) to assess left ventricular rotation, torsion, and longitudinal, circumferential, and radial systolic and diastolic strains and strain rates. Additionally, 2D-STE was performed in 14 controls. RESULTS All deformational parameters on 2D-STE were significantly lower in patients with IDC compared with controls. Seven patients exhibited opposite basal (positive, counterclockwise) and 11 patients exhibited opposite apical (negative, clockwise) rotation at end-systole. Circumferential, radial, and longitudinal early diastolic strain rates were correlated most strongly with the corresponding spatial components of systolic deformation. CONCLUSION In patients IDC, all torsional, systolic, and diastolic deformational parameters were decreased. Corresponding three-dimensional components of systolic and diastolic deformations were closely coupled. Considerable variation in the direction of basal and apical rotation exists in a subset of patients with IDC.

Long-term clinical outcome after alcohol septal ablation for obstructive hypertrophic cardiomyopathy: results from the Euro-ASA registry

AIMS The first cases of alcohol septal ablation (ASA) for obstructive hypertrophic cardiomyopathy (HCM) were published two decades ago. Although the outcomes of single-centre and national ASA registries have been published, the long-term survival and clinical outcome of the procedure are still debated. METHODS AND RESULTS We report long-term outcomes from the as yet largest multinational ASA registry (the Euro-ASA registry). A total of 1275 (58 ± 14 years, median follow-up 5.7 years) highly symptomatic patients treated with ASA were included. The 30-day post-ASA mortality was 1%. Overall, 171 (13%) patients died during follow-up, corresponding to a post-ASA all-cause mortality rate of 2.42 deaths per 100 patient-years. Survival rates at 1, 5, and 10 years after ASA were 98% (95% CI 96-98%), 89% (95% CI 87-91%), and 77% (95% CI 73-80%), respectively. In multivariable analysis, independent predictors of all-cause mortality were age at ASA (P < 0.01), septum thickness before ASA (P < 0.01), NYHA class before ASA (P = 0.047), and the left ventricular (LV) outflow tract gradient at the last clinical check-up (P = 0.048). Alcohol septal ablation reduced the LV outflow tract gradient from 67 ± 36 to 16 ± 21 mmHg (P < 0.01) and NYHA class from 2.9 ± 0.5 to 1.6 ± 0.7 (P < 0.01). At the last check-up, 89% of patients reported dyspnoea of NYHA class ≤2, which was independently associated with LV outflow tract gradient (P < 0.01). CONCLUSIONS The Euro-ASA registry demonstrated low peri-procedural and long-term mortality after ASA. This intervention provided durable relief of symptoms and a reduction of LV outflow tract obstruction in selected and highly symptomatic patients with obstructive HCM. As the post-procedural obstruction seems to be associated with both worse functional status and prognosis, optimal therapy should be focused on the elimination of LV outflow tract gradient.

Long-term survival after alcohol septal ablation for hypertrophic obstructive cardiomyopathy: a comparison with general population

AIMS We decided to determine the long-term survival of patients after alcohol septal ablation (ASA) for hypertrophic obstructive cardiomyopathy (HOCM) and compare this with the general population. METHODS AND RESULTS A total of 178 highly symptomatic, consecutive patients (58 ± 12 years, 53% women) were treated by ASA between April 1998 and April 2013 and followed-up for 4.8 years (IQR 2.1-7.5). At baseline, 155 patients (87%) suffered from dyspnoea ≥3 class of NYHA; at the most recent examination, 87 patients (49%) and 23 patients (13%) reported dyspnoea of NYHA class 1 and ≥3, respectively. The left ventricular outflow gradient was significantly reduced (68 ± 42 vs. 20 ± 25 mmHg; P < 0.01). A total of 19 deaths (11%) occurred during 925 patient-years, which means an overall mortality rate of 2.1% per year. Survival free of all-cause mortality at 1, 5, and 10 years was 97% (95% CI, 93-99%), 92% (95% CI, 87-96%), and 82% (95% CI, 70-90%), respectively. This observed mortality was comparable to the expected survival for age- and sex-comparable general population (P = 0.34). According to multivariate analysis, the only independent predictor of all-cause mortality was age at ASA (hazard ratio 1.09, 95% CI 1.04-1.14; P < 0.01). CONCLUSIONS This study suggests that in patients with HOCM and important symptoms who underwent ASA, long-term survival after the procedure did not differ significantly from that of the general population.

Right ventricular dysfunction in chronic heart failure patients

To evaluate any differences in haemodynamic and echocardiographic parameters in patients with both left (LV) and right ventricular (RV) systolic dysfunction and in patients with isolated LV systolic dysfunction.

Detection of pesticides in the environment using biosensors based on cholinesterases

Abstract Amperometric biosensors based on acetylcholinesterase or butyrylcholinesterase were used for the kinetic determination of organophosphate and carbamate pesticides. The current of the biosensor Iss was measured continuously with substrate; the addition of samples with pesticides resulted in the time decrease of the current dl/dt. The relative inhibition RI=(dl/dt)Iss was used as the signal for evaluations. For several pesticides, different calibration curves (dependencies of RI on concentration c) were obtained depending on the affinity of the individual pesticide to the cholinesterase used. This affinity was described using the bimolecular inhibition constant ki. The single calibration curve independent on the type of pesticide was obtained as the dependence of RI on the product kic, thus indicating the effects of both concentration and inhibiting properties on the response of the biosensor. The relative inhibition was used to characterise anticholinesterase toxicity of the sediments collected fr...

Estimation of left ventricular filling pressures by speckle tracking echocardiography in patients with idiopathic dilated cardiomyopathy

AIMS the ratio of early diastolic transmitral flow velocity (E) to early diastolic mitral annular velocity (E(a)) is frequently used to predict an increase in left ventricular filling pressure (LVFP). However, this approach has several limitations. The aim of this study was to test whether additional information is gained by new echocardiographic indexes utilizing strain and strain rate (SR) derived from 2-dimensional speckle tracking echocardiography (2D-STE) for the estimation of LVFP. METHODS AND RESULTS fifty-one patients with idiopathic dilated cardiomyopathy (IDC) underwent pulsed-wave tissue Doppler echocardiography and 2D-STE performed simultaneously with right heart catheterization. Receiver operating characteristic analysis showed that circumferential strain and the SR during late diastolic LV filling (0.956 and 0.951, both P = 0.001), E/circumferential SR at early diastolic LV filling (0.949, P = 0.001), and E/circumferential strain at the time of peak E-wave (0.948, P = 0.001) had greater area under the curve than the E/E(a) ratio (0.911, P = 0.001) for the prediction of pulmonary capillary wedge pressure > 12 mmHg. CONCLUSION when compared with the E/E(a) ratio, several 2D-STE-derived parameters better estimated the increase in LVFP in patients with IDC.

Outcome of patients after alcohol septal ablation with permanent pacemaker implanted for periprocedural complete heart block

Highly symptomatic patients with hypertrophic obstructive cardiomyopathy (HOCM) irresponsive to medical therapy are treated with surgical myectomy, dual-chamber pacing or alcohol septal ablation(ASA). Based on single-center studies or national registries it seems that both short- and long-term outcomes of ASA are acceptable. The most frequent major complication associated with ASA is the mostly self-terminating complete heart block (CHB) that occurs in 20–50% of patients and requires permanent pacemaker implantation in 9–20% of all ASA patients [2,3]. Accordingly, this retrospective study was undertaken to evaluate the long-term outcome of patients who underwent early permanent pacemaker implantation due to post-ASA CHB.

Prognosis of patients with chronic coronary artery disease and severe left ventricular dysfunction. The importance of myocardial viability

The choice of optimal treatment strategy in patients with coronary artery disease (CAD) and severe left ventricular (LV) dysfunction is often difficult. The aim of this study was to compare long‐term results of patients with chronic CAD, severe heart failure and a defined scope of myocardial viability treated with coronary revascularization, heart transplantation, or kept on medical therapy.