Lambros Anthopoulos

Leptin serum levels in cachectic heart failure patients: Relationship with tumor necrosis factor-α system

Cachexia is a strong predictor for mortality in patients with congestive heart failure. To investigate the role of leptin and regulators of apoptosis in cardiac cachexia we compared leptin concentrations and their relation to the TNF system, interleukin 1-beta (IL-1b), and soluble Fas in patients with heart failure with and without cachexia. Patients with cardiac cachexia have increased levels of interleukin-1b compared to non-cachectic heart failure patients [mean(S.E.)=1.11(0.62) vs. 0.02(0.02), P=0.01] and decreased concentrations of leptin [10.79(3.93) vs. 23.24 (8.35), P=0.1]. Leptin levels correlate with TNF-RI in cachectic heart failure patients (r=0.58, P=0.018). The TNF-RI levels were also correlated with Fas, both in all the patients taken together (r=0.5, P=0.006) and in those with cachexia (r=0.52, P=0.036). Our data indicate that more prospective studies are needed to clarify the role of leptin in the pathophysiology of heart failure cachexia.

Detection of Coronary Artery Disease in Patients with Severe Aortic Stenosis with Noninvasive Methods

Exercise stress ECG testing is not generally recommended in patients with severe aortic stenosis. Analysis of the utility of exercise testing, both with and without the use of myocardial thallium-201 scintigraphy for the diagnosis of coronary artery disease (CAD), yielded low specificity. A noninvasive, safe, and accurate diagnostic modality to ascertain the presence of CAD is not available to date for patients with severe aortic stenosis. The aim of this study was to assess the safety and diagnostic accuracy of adenosine stress echocardiography (A-Stress-Echo) and of adenosine stress myocardial perfusion scintig raphy (A-SPECT), for the detection of CAD in patients with severe aortic stenosis. The study included 50 patients with severe aortic stenosis (maximal instantaneous aortic valve gradient > 80 mmHg, range 81 to 144 mmHg, and aortic valve area < 0.75 cm2). All patients were submitted to A-Stress-Echo, after a 6-minute infusion of adenosine (140 μg/kg body weight/min), and then (>3 days later) A-SPECT with the same dosage of adenosine as above. Coronary angiography was performed in all patients. No major complications were observed. The unpleasant symptoms were brief and did not necessitate cessation of the test. Both modalities showed the same sensitivity (85% for A-SPECT and 85% for A-Stress-Echo) angiographically diagnosed CAD while A-Stress-Echo yielded much higher specificity (96.7% vs 76.7%). Concordance of the two methods was found in 40 cases and the specificity for those patients was 100%. A-Stress-Echo and A-SPECT, either separately or in combination, constitute excellent and safe noninvasive diagnostic methods in detecting CAD in patients with severe aortic stenosis.

Detection of Myocardial Viability in the Prediction of Improvement in Left Ventricular Function After Successful Coronary Revascularization by Using the Dobutamine Stress Echocardiography and Quantitative SPECT Rest-Redistribution-Reinjection 201TI Imaging After Dipyridamole Infusion

The aim of this study was to assess the feasibility, safety, and respective diagnostic accuracy of low-dose dobutamine infusion and rest-redistribution-reinjection thallium 201 single photon emission computed tomography (SPECT) after dipyridamole infusion (Th-DIP), in the prediction of functional improvement of asynergic infarcted zones, after successful revascularization in patients with chronic ischemic heart disease. Thirty-one patients with a previous myocardial infarction and left ventricular dysfunction (mean ejection fraction: 41 ±5.8%) were studied. The regional wall motion of the left ventricle was evaluated by basic echocardiography before and 14 ± 1.7 weeks after successful revascularization (19 by percutaneous transluminal coronary angioplasty and 12 by coronary artery bypass grafting). Dobutamine stress echocardiography (DSE) was performed in all patients with dobutamine infusion of 5 and 10 μg/kg/minute over five minutes. Within three days after DSE and prior to revascularization, all patients underwent Th-DIP for myocardial viability assessment. A 16-ventricular-segment model was used for basic, DSE, and Th-DIP images. Viability was assessed by applying the (continued on next page) standard criteria for each technique. In the 31 patients, 496 segments were analyzed. By basic echocardiography, 164 (33%) of them were classified as asynergic. The DSE detected viable tissue in 69/496 (14%) segments, whereas Th-DIP identified viability in 95/496 (19%) segments. When the postrevascularization basic echocardiographic study was used as the gold standard in identifying myocardial viability, the sensitivity and specificity for the DSE and Th-DIP were 86.5%, 94.4% and 90.5%, 69%, respectively. No major side effects were observed with both techniques. In conclusion, DSE seems to be an accurate method for identifying viable but asynergic myocardium in patients with chronic ischemic heart disease, whereas Th-DIP overestimates the postrevascularization recovery. Detection of hibernating myocardium can be obtained by these two noninvasive methods. However, DSE seems to be more useful in determining the prospective selection of patients who are going to benefit from revascularization.

Functional and prognostic significance of silent ischemia during dobutamine stress echocardiography in the elderly.

BackgroundThe functional and prognostic significance of silent ischemia relative to symptomatic ischemia during non‐invasive testing remains controversial. DesignThe aim of this prospective study was to assess whether the presence of dobutamine‐induced silent ischemia was associated with the amount of myocardial ischemic burden and to determine the prognostic significance of painless ischemia in elderly people with stable coronary artery disease. MethodsA cohort of 289 patients ≥70 years of age with positive dobutamine stress echocardiography result and significant coronary artery disease proven by coronary arteriography, were followed up during a 35 ± 13 month period for the development of cardiac events. ResultsThe prevalence of silent ischemia during dobutamine infusion was 63%. Patients with painful ischemia were more likely to have lower peak heart rate (P  < 0.01) and showed ST segment depression more frequently during the dobutamine stress test than did patients with painless ischemia (52 versus 31%, P  < 0.05). There was no significant difference between the patients with and without angina according to wall motion score index at rest (1.35 ± 0.29 versus 1.32 ± 0.37) and at peak stress (1.61 ± 0.35 versus 1.58 ± 0.44), stress–rest wall motion index difference (0.27 ± 0.09 versus 0.25 ± 0.08), the presence of dyskinesia at peak stress (36 versus 31%), the number of segments with regional ≥2 point change from rest to peak stress (38 versus 29%) and the decrease of left ventricular end systolic volume at peak stress (89 versus 86%). During the follow‐up period a total of 269 patients developed 153 (57%) cardiac events: 15 cardiac deaths, 19 non‐fatal myocardial infarctions, 119 episodes of unstable angina. No significant difference in cardiac mortality and in total cardiac event rate was observed between patients with or without angina (6 versus 5% and 60 versus 55%, respectively). ConclusionsOur data demonstrate that the magnitude of myocardial dysfunction assessed by dobutamine stress echocardiography is comparable in elderly patients with or without anginal chest pain. The presence of painful ischemia is not accompanied by an increased risk for subsequent cardiac events in this cohort of patients.

Stress Echocardiography Using Adenosine Combined with Nitroglycerin- Dobutamine in the Detection of Viable Myocardium in Patients with Previous Myocardial Infarction

The aim of this study was to assess the value of adenosine (A) and the combination of nitroglycerin (N) with dobutamine (D) stress echocardiography (SE) in the identification of viable myocardium. The clinical and electrocardiographic (ECG) effects of both tests were also evaluated. Fifty-two coronary artery disease patients, aged 56.4 ±8 years, with left ventricular dysfunction due to a previous myocardial infarction (mean ejection fraction: 49 ±8%) were included in the study. Cardiac catheterization was performed in all patients before A (140 μg/kg/minute for five minutes) and the combination of N with D (5-10 μg/kg/minute) stress echocardiography. On the echocardiogram, the left ventricle was divided into 16 segments and wall motion was graded semiquantitatively from 1 (normal) to 4 (dyskinesia). The echocardiographic index was also estimated. A segment was considered viable during A infusion when resting asynergy showed deterioration of one grade or more. In contrast, segmental viability was considered to be present during the combination of N with D infusion when resting asynergy showed improvement of one grade or more. A thallium 201 single photon emission computed tomography (SPECT) with reinjection was performed as reference standard for the identification of viable myocardium. Stress echocardiography during infusion of A was associated with short-duration angina attacks in 3 (5.8%) patients and transient complete atrioventricular (AV) block in 1 (1.9%), whereas during the combination of N with D infusion, 6 (11.5%) patients expe rienced ventricular bigeminy lasting for a short period. ST segment elevation greater than 1 mm was recorded in those leads having a Q wave, in 19 (36.5%) patients. In 10 of these 19 (52.6%), viable myocardium was present in SPECT, as it was in 33 patients (63.5%) having no ST segment elevation (P=NS). Of a total of 832 segments that were graded during A-SE, 276 exhibited resting asynergy and the remaining 556 had normal motion and thickening at rest. The echocardiographic index during A infusion increased from 1.52 ±0.22 to 1.71 ±0.24 (P < 0.001), whereas during D and N infusion it decreased from 1.53 ±0.31 to 1.30 ±0.42 (P < 0.001). With SPECT considered as the gold standard for the identification of viable myocardium, sensitivity, specificity, and positive and negative predictive values of A-SE in detecting viable myocardium were 54%, 86%, 65% and 80%, respectively. The respective values for the combination of nitroglycerin with D-SE were 91%, 89%, 78%, and 96%, respectively. Stress echocardiography during A, and the combination of N with D, constitute safe methods in the identification of viable myocardium. The detection of ST segment elevation in the ECG leads with a Q wave during the combined infusion of nitroglycerin and dobutamine is not related to the presence of viable myocardial tissue. The A-SE provide moderate diagnostic accuracy, while the combination of N with D during SE is much superior in detecting viable myocardium.

Non-invasive evaluation of coronary reserve Assessment of coronary reserve in patients with coronary artery disease by transesophageal-Doppler echocardiography

We assessed coronary flow reserve using transesophageal Doppler echocardiography in patients with coronary artery disease. The study included 33 coronary artery disease patients who were undergoing coronary arteriography. The blood flow velocities of the left anterior descending artery before and after intravenous infusion (0.56 mg/min for 4 min) of dipyridamole were recorded using transesophageal Doppler echocardiography. Fourteen normal healthy individuals, matched for age, served as a control group. The index of coronary flow reserve, i.e. the ratio of dipyridamole to baseline maximum diastolic velocity, was calculated. Maximal coronary flow reserve in coronary artery disease patients was significantly lower than in the control group (1.4+/-0.2 vs. 2.8+/-0.3, P<0.001). The coronary artery disease patients were classified into three groups: Group A included 10 patients with <50% left anterior descending artery stenosis; Group B included seven patients with 50-69% left anterior descending artery stenosis; 16 patients with >70% left anterior descending artery stenosis constituted Group C. The maximum coronary flow reserve was significantly different for A vs. B and A vs. C. (A, 1.77+/-0.18; B, 1.51+/-0.1; C, 1.28+/-0.24). A strong and significant correlation was found between the maximum coronary flow reserve and the degree of proximal left anterior descending artery stenosis (r=0.78, P<0.001). Coronary artery disease patients without left anterior descending artery stenosis on the arteriogram exhibited lower maximum coronary flow reserve compared to the control subjects (1.78+/-0.19 vs. 2.8+/-0.3, P=0.000).

Atrioventricular plane displacement during low dose dobutamine infusion predicts recovery of left ventricular dyssynergies

Sir,—We read with interest the study by Willenheimer et al regarding the prognostic significance of left atrioventricular plane displacement (AVPD) in patients with heart failure.1 This study showed that mortality in patients with heart failure is strongly related to systolic left atrioventricular plane motion. The movement of the left atrioventricular plane is a result of the longitudinal shortening of left ventricular fibres. During systole, the contraction of the longitudinal fibres of the left ventricle leads to a descent of the atrioventricular plane towards the relatively immobile cardiac apex. It should not be forgotten that assessment of left ventricular systolic function by cross sectional echocardiography is sometimes difficult because endocardium is inadequately visualised, especially in the elderly. In contrast, the mitral ring is distinctly outlined and easily studied by m mode recording,2-4 and, as it was related to mortality in cardiac failure patients,m mode echocardiography was recommended for general use.1 Willenheimer et al proposed further studies of the effects of different drugs on systolic AVPD. We recently assessed the value of left AVPD during low dose dobutamine infusion to predict functional improvement of asynergic infarcted myocardial …

Transesophageal Echocardiographic Doppler Study of Coronary Flow in a Patient with Myocardial Bridging A Case Report

A case report of myocardial bridging of the left anterior descending artery is described. Coronary flow proximal to the myocardial bridge was studied with transesophageal echo Doppler. The patient, a 62-year-old farmer who sustained an anterior myocardial infarc tion, underwent thrombolysis and was admitted. He subsequently underwent coronary angiography and left ventriculography, which showed a severe myocardial bridge of the midshaft of the left anterior descending artery. The ejection fraction improved from 25 to 48% after thrombolysis, as measured by using echocardiography. Transesophageal Doppler study proximal to the myocardial bridge revealed a relative increase of the diastolic coronary flow velocity (increased acceleration), which reached its peak value in early diastole. Despite the presence of severe myocardial bridging, coronary flow reserve increased substantially two minutes after the infusion of dipyridamole (0.56 mg/kg iv for 4 minutes). Transesophageal Doppler study of coronary blood flow proximal to the myocardial bridge in the left anterior descending artery showed a characteristic waveform that may prove to be indicative of this condition.

Epidemiology of Coronary Artery Disease Among Hansen's Patients

The prevalence of coronary heart disease (CHD) and its risk factors were studied in 475 Hansens patients (HPs) by a special questionnaire, physical examination, electrocardiogram at rest and after exercise, and biochemical and hematologic investigations. It was found that the prevalence of CHD (Minnesota codes 1-1 to 1-3 and 4-1) was 10.92%, which is higher than that found in epidemiologic studies of nonHansens populations. The only CHD risk factors detected were age, obesity, and hypertension. There was no statistically significant difference in the prevalence of CHD between HPs living confined in the institution and those living in their homes. Factors enhancing the development of CHD in this group may include hypertension and obesity as well as psychological factors, which particularly common in these patients, and of course old age.

Arteriovenous Fistula and Multiple Saccular Arterial Aneurysms of a Finger, Following Childhood Human Bite:

or acquired, is an uncommon clinical entity. In view of the constant exposure of the hand to trauma, including human bite, and the many arteries superficially placed in the hand, one might expect that arteriovenous fistula of the hands and fingers would be quite common. We have not found reports of arteriovenous fistula of the hand secondary to human bite. The purpose of this paper is to present a case of an arteriovenous fistula of the fifth finger. The lesion, we believe, was a, complication of a human bite which, some years later, was evidenced by spontaneous, periodic, subungual spurting of arterial blood. Hemodynamic, arteriographic and clinical data, including surgical therapy, are presented.