Jarosław Drożdż

Myocardial Viability and Survival in Ischemic Left Ventricular Dysfunction

BACKGROUND The assessment of myocardial viability has been used to identify patients with coronary artery disease and left ventricular dysfunction in whom coronary-artery bypass grafting (CABG) will provide a survival benefit. However, the efficacy of this approach is uncertain. METHODS In a substudy of patients with coronary artery disease and left ventricular dysfunction who were enrolled in a randomized trial of medical therapy with or without CABG, we used single-photon-emission computed tomography (SPECT), dobutamine echocardiography, or both to assess myocardial viability on the basis of prespecified thresholds. RESULTS Among the 1212 patients enrolled in the randomized trial, 601 underwent assessment of myocardial viability. Of these patients, we randomly assigned 298 to receive medical therapy plus CABG and 303 to receive medical therapy alone. A total of 178 of 487 patients with viable myocardium (37%) and 58 of 114 patients without viable myocardium (51%) died (hazard ratio for death among patients with viable myocardium, 0.64; 95% confidence interval [CI], 0.48 to 0.86; P=0.003). However, after adjustment for other baseline variables, this association with mortality was not significant (P=0.21). There was no significant interaction between viability status and treatment assignment with respect to mortality (P=0.53). CONCLUSIONS The presence of viable myocardium was associated with a greater likelihood of survival in patients with coronary artery disease and left ventricular dysfunction, but this relationship was not significant after adjustment for other baseline variables. The assessment of myocardial viability did not identify patients with a differential survival benefit from CABG, as compared with medical therapy alone. (Funded by the National Heart, Lung, and Blood Institute; STICH ClinicalTrials.gov number, NCT00023595.).

EURObservational Research Programme: regional differences and 1‐year follow‐up results of the Heart Failure Pilot Survey (ESC‐HF Pilot)

The ESC‐HF Pilot survey was aimed to describe clinical epidemiology and 1‐year outcomes of outpatients and inpatients with heart failure (HF). The pilot phase was also specifically aimed at validating structure, performance, and quality of the data set for continuing the survey into a permanent Registry.

EURObservational Research Programme: The Heart Failure Pilot Survey (ESC-HF Pilot)

The primary objective of the new ESC‐HF Pilot Survey was to describe the clinical epidemiology of outpatients and inpatients with heart failure (HF) and the diagnostic/therapeutic processes applied across 12 participating European countries. This pilot study was specifically aimed at validating the structure, performance, and quality of the data set, for continuing the survey into a permanent registry.

European Society of Cardiology Heart Failure Long-Term Registry (ESC-HF-LT): 1-year follow-up outcomes and differences across regions

The European Society of Cardiology Heart Failure Long‐Term Registry (ESC‐HF‐LT‐R) was set up with the aim of describing the clinical epidemiology and the 1‐year outcomes of patients with heart failure (HF) with the added intention of comparing differences between participating countries.

Myocardial ischemia and autonomic activity in dippers and non-dippers with coronary artery disease: assessment of normotensive and hypertensive patients.

OBJECTIVES The aim of this study was to assess the relations between the circadian variations of blood pressure (BP) and the pattern of ischemia and autonomic activity in normotensive and hypertensive patients with coronary artery disease (CAD). PATIENTS AND METHODS On the basis of the results of ambulatory BP monitoring, 115 patients with stable CAD were divided into Group 1 (with arterial hypertension) and Group 2 (normotensives). Groups were subdivided into dippers and non-dippers. Holter monitoring was performed to assess the occurrence and circadian pattern of ischemic episodes. Time domain and frequency domain HRV analyses were performed to evaluate the autonomic activity. RESULTS The total number of ischemic episodes was similar in dippers and non-dippers. Non-dippers had a greater number of silent episodes and a different circadian pattern of ischemia with more night episodes. Among the time-domain HRV parameters, only SDNN was similar in dippers and non-dippers. Non-dippers had lower pNN50 and rMSSD-the parameters expressing parasympathetic activity. Differences between diurnal and nocturnal results of spectral HRV analysis were observed in dipper patients only. They presented an elevation of HF power and a decline of LF power at night. All differences between dippers and non-dippers were of similar significance in both hypertensives and normotensives. CONCLUSIONS A lack of a nocturnal fall in BP is present in normotensive and hypertensive patients with CAD. Non-dippers with CAD had silent and nighttime ischemia more often. They also had an abnormal pattern of autonomic activity with higher sympathetic and lower parasympathetic modulation.

In-hospital and 1-year mortality associated with diabetes in patients with acute heart failure: results from the ESC-HFA Heart Failure Long-Term Registry

The aim of this study was to evaluate the in‐hospital and 1‐year prognostic impact of diabetes and elevated blood glucose levels at hospital admission in patients with acute heart failure (HF).

Enlarged Left Atrium Is a Simple and Strong Predictor of Poor Prognosis in Patients after Myocardial Infarction

Background and Aim: Patients after myocardial infarction (MI) differ according to the extend of myocardial damage and prognosis. Diastolic function impairment may have great impact on development of heart failure and outcomes. We evaluated the prognostic value of various echocardiographic measurements in 18‐month and 3‐year observation after MI. Methods: 60 patients after MI (44 male, mean age 60 ± 11) were examined by transthoracic echocardiography with the assessment of wide spectrum of parameters. Mortality and combined end points (cardiac deaths and heart failure exacerbation) were assessed after 18‐month and 3‐year observation and groups with and without end points were compared. Optimal cutoff values were estimated by receiver operating characteristic (ROC) analysis and resulting Kaplan–Meier curves were compared. Results and Conclusions: After 18 months, 11 deaths occurred and 20 subjects experienced hospitalization caused by heart failure exacerbation. Although the group with cardiac events showed a greater enlargement of the left ventricle and lower ejection fraction, the highest relative risk of poor outcome (RR = 5.0) was related to the left atrial enlargement above 44 mm. Although restrictive or pseudonormal inflows were connected with 2.1 relative risk of combined end point, all patients with E deceleration time ≤130 ms experienced heart failure exacerbation or death. Despite tissue Doppler and propagation parameters describing elevated end‐diastolic pressure differed between groups with various outcomes in multivariate analysis, only enlarged left atrium was an independent predictor for both combined end point and cardiac death. Further 3‐year follow‐up solely confirmed the role of above described predictors.

Endothelium‐dependent and ‐independent vasodilation is more attenuated in ischaemic than in non‐ischaemic heart failure

Endothelial dysfunction in chronic heart failure (CHF) contributes to vasoconstriction. Underlying atherosclerosis may increase vascular abnormalities in ischaemic CHF. We aimed to compare flow‐mediated dilation (FMD) and nitroglycerin‐mediated dilation (NMD) of the brachial artery between patients with ischaemic and non‐ischaemic CHF.

Mechanisms of Functional Mitral Regurgitation in Ischemic Cardiomyopathy Determined by Transesophageal Echocardiography (from the Surgical Treatment for Ischemic Heart Failure Trial)

The mechanisms underlying functional mitral regurgitation (MR) and the relation between mechanism and severity of MR have not been evaluated in a large, multicenter, randomized controlled trial. Transesophageal echocardiography (TEE) was performed in 215 patients at 17 centers in the Surgical Treatment for Ischemic Heart Failure (STICH) trial. Both 2-dimensional (n = 215) and 3-dimensional (n = 81) TEEs were used to assess multiple quantitative measurements of the mechanism and severity of MR. By 2-dimensional TEE, leaflet tenting area, anterior and posterior leaflet angles, mitral annulus diameter, left ventricular (LV) end-systolic volume index, LV ejection fraction (LVEF), and sphericity index (p <0.05 for all) were significantly different across MR grades. By 3-dimensional TEE, mitral annulus area, leaflet tenting area, LV end-systolic volume index, LVEF, and sphericity index (p <0.05 for all) were significantly different across MR grades. A multivariate analysis showed a trend for annulus area (p = 0.069) and LV end-systolic volume index (p = 0.071) to predict effective regurgitant orifice area and for annulus area (p = 0.018) and LV end-systolic volume index (p = 0.073) to predict vena contracta area. In the STICH trial, multiple quantitative parameters of the mechanism of functional MR are related to MR severity. The mechanism of functional MR in ischemic cardiomyopathy is heterogeneous, but no single variable stands out as a strong predictor of quantitative severity of MR.

Left atrial appendage systolic forward flow

T he advent of transesophageal echocardiography (TEE) has greatly improved the ability to detect cardiac sources of embolism. 1 This technique allows an easy and accurate evaluation of anatomic structure and function of the left atria1 appendage (LAA).2-4 Although it is well established that there is an association of LAA thrombi and left atria1 spontaneous echo contrast with a history of peripheral embolism,2 only recently has a study focused on LAA Doppler flow signals.3 Kortz et al3 reported a quadriphasic pattern of LAA flow in normal subjects without overlapptig of tachycardia-related waves: a diastolic forward flow just after mitral valve opening is followed by a diastolic backward flow due to LAA recoil; subsequently, a forward and a backward flow wave respectivCly due to LAA contraction and relaxation can be detected. . . . We report our observations on a new LAA flow pattern characterized by the presence of an additional systolic forward flow wave after LAA relaxation. After the first occasional observation of a systolic LAA flow wave, a study was undertaken to characterize this new tiding. TEE was prospectively performed in 62 consecutive patients with sinus rhythm. Reasons for the examinations were determination of source of embolism (62%), assessment of suspected endocarditis (lo%), detection of aortic and mitral valve disease (18%), and evaluation of valve prosthesis (10%). Ten patients were excluded from the sttidy because of inadequate representation of the LAA. The study group consisted of 12 patients (mean age 51 f 16 years) in whom the presence of LAA systolic forward flow was observed. Anesthesia of the hypopharynx was p&formed with 10% lidocaine spray. For sedation, patients were given a mean intravenous dose of 2 mg of midazolam. TEE was performed using a Sonos 1500 (Hewlett-Packard, Andover, Massachusetts), a Sonolayer SSH 140-A (Toshiba, Tokyo, Japan), or a Domier (Deutsche Aerospace, Munich, Germany) ultrasound system equipped with 5 MHz multiplane phased-array transducers. The LAA was mainly visualized in the longitudinal view and the probe adjusted to maximize its dimensions. Flow velocities were obtained by positioning the sample volume inside the left atria1 appendage at the point that offered the best alignment with its flow and avoided the noise signal due to wall motion. Furthermore, color Mand B-mode of the left atrial appendage flow were recorded. The presence of systolic forward flow after LAA relaxation was assumed when there were concomitant pulsed Doppler signal and color Band M-mode findings. Pulmonary venous velocity recordings were obtained with