Lilian J. Meijboom

Heart Function Analysis in Cardiac Patients with Focus on Sex-Specific Aspects

Cardiac function is best described by investigating the pressure-volume relationships. This information permits description in terms of the ventricular volume regulation graph (VRG), estimation of systolic elastance, evaluation of lusitropic properties, and assessment of ventriculo-arterial coupling. Current techniques yield noninvasive determination of cardiac compartmental volumes, along with systolic/diastolic arterial pressure, while ventricularxa0end-diastolic pressure can be inferred from an echocardiography-based surrogate measure. Ventricular volume is known to vary with age, as well as to be affected by intrinsic cardiac disease and abnormalities of the vascular system. Moreover, 35xa0years ago it has been shown in healthy adults that left ventricular volume is significantly smaller in women compared to men. This important observation has serious implications for several metrics which are routinely used in clinical practice, e.g., ejection fraction. The remarkable difference between ventricular size in men and women is also a powerful starting point for the study of aging and the investigation of interventions such as exercise. In this review we evaluate sex-specific characteristics of the VRG and the implications for various cardiac patient populations, during basal conditions and intervention such as exercise.

The Pythagorean theorem reveals the inherent companion of cardiac ejection fraction

BACKGROUNDnQuantification of ventricular performance requires a comprehensive metric which is manageable for patient care and clinical trials. Ejection fraction (EF) has been embraced as an attractive candidate. However, being a dimensionless ratio, EF has serious limitations.nnnMETHODSnWe aim to identify what information is not recognized when limiting the volume-related analysis by exclusively relying on EF. This investigation applies the volume domain concept, relating end-systolic volume (ESV) to end-diastolic volume (EDV). This approach allows graphical identification of the information not covered by EF. Implications for atria, left ventricle (LV) and right ventricle (RV) are investigated in healthy individuals, and cardiac patient groups using various imaging modalities.nnnRESULTSnThe Pythagorean theorem indicates that the hypotenuse which relates any {EDV, ESV} combination to EF corresponds with the information not covered by the single metric EF. The impact of the recovered EF companion (EFC) is illustrated in healthy adults (Nu202f=u202f410, LV 2D echocardiography), heart transplant patients (Nu202f=u202f101, LV CT), individuals with heart failure (Nu202f=u202f197, biplane angiocardiography), for the RV with corrected Fallot (Nu202f=u202f124, MRI), diameters for left atrium (Nu202f=u202f49, MRI) and area for right atrium (Nu202f=u202f51, MRI). For any limited EF range we find a spectrum of EFC values, showing that the two metrics contain (partly) independent information, and emphasizing that the sole use of EF only partially conveys the full information available.nnnCONCLUSIONSnThe EFC is a neglected companion, containing information which is additive to EF. Analysis based on ESV and EDV is preferred over the use of EF.

Sensitivity of a Simple Noninvasive Screening Algorithm for Chronic Thromboembolic Pulmonary Hypertension after Acute Pulmonary Embolism

Background u2003Recently, we constructed a noninvasive screening algorithm aiming at earlier chronic thromboembolic pulmonary hypertension (CTEPH) detection after acute pulmonary embolism (PE), consisting of a prediction score and combined electrocardiography (ECG)/N-terminal pro-brain natriuretic peptide (NT-proBNP) assessment. The aim of this study was to confirm the algorithms sensitivity for CTEPH detection and to evaluate the reproducibility of its individual items. Methods u2003Two independent researchers calculated the prediction score in 54 consecutive patients with a history of acute PE and proven CTEPH based on clinical characteristics at PE diagnosis, and evaluated the ECG and NT-proBNP level assessed at the moment of CTEPH diagnosis. Interobserver agreement for the assessment of the prediction score, right-to-left ventricle (RV/LV) ratio measurement on computed tomography pulmonary angiography, as well as ECG reading was evaluated by calculating Cohens kappa statistics. Results u2003Median time between PE diagnosis and presentation with CTEPH was 9 months (interquartile range: 5–15). The sensitivity of the algorithm was found to be 91% (95% confidence interval [CI]: 79–97%), indicating that 27 of 30 cases of CTEPH would have been detected when applying the screening algorithm to 1,000 random PE survivors with a 3% CTEPH incidence (projected negative predictive value: 99.7%; 95% CI: 99.1–99.9%). The interobserver agreement for calculating the prediction score, RV/LV ratio measurement, and ECG reading was excellent with a kappa of 0.96, 0.95, and 0.89, respectively. Conclusion u2003The algorithm had a high sensitivity of 91% and was highly reproducible. Prospective validation of the algorithm in consecutive PE patients is required before it can be used in clinical practice.

Balloon pulmonary angioplasty in sarcoid-related pulmonary hypertension

A 43-year-old, never-smoking, African-American female was referred to our outpatient clinic for progressive dyspnoea. She had a medical history of sarcoidosis with lymph-node, pulmonary, skin and ocular involvement. Diagnosis was based on a previously conducted chest high-resolution computed tomography (CT) that showed bilateral hilar and mediastinal lymphadenopathy containing calcifications and multiple small lung nodules with peri-lymphatic distribution along the pleura and fissures A histological analysis of biopsy specimens from a lymph node located in the left side of the neck revealed large granulomas with multinucleated foreign body giant cells without necrosis. Microbiological cultures were negative. Extrapulmonary manifestations consisted of anterior uveitis and several cutaneous lesions and the reason for initiating corticosteroid therapy, which ameliorated the sarcoidosis. After discontinuation of corticosteroid therapy, the patients condition deteriorated and she developed progressive dyspnoea (New York Heart Association (NYHA) functional class 3). Thoracic CT showed bilateral pleural and pericardial effusion. There were no signs of pulmonary fibrosis or cardial signs of pulmonary hypertension (PH). Analysis of the pleural fluid showed exudation with lymphocytosis. An infectious cause was excluded. Balloon pulmonary angioplasty can be a successful treatment option in pulmonary hypertension due to sarcoidosis http://ow.ly/ul4w30h4GVW

Rationale and design of a cohort study on primary ovarian insufficiency in female survivors of Hodgkin’s lymphoma: influence on long-term adverse effects (SOPHIA)

Introduction Hodgkin’s lymphoma (HL) has become the prototype of a curable disease. However, many young survivors suffer from late adverse effects of treatment. Both chemotherapy (CT) and radiotherapy (RT) may induce primary ovarian insufficiency (POI), which has been associated with reduced bone mineral density (BMD), neurocognitive dysfunction and possibly cardiovascular disease (CVD). While the general assumption is that POI increases CVD risk, other hypotheses postulate reverse causality, suggesting that cardiovascular risk factors determine menopausal age or that biological ageing underlies both POI and CVD risk. None of these hypotheses are supported by convincing evidence. Furthermore, most studies on POI-associated conditions have been conducted in women with early natural or surgery-induced menopause with short follow-up times. In this study, we will examine the long-term effects of CT-induced and/or RT-induced POI on BMD, cardiovascular status, neurocognitive function and quality of life in female HL survivors. Methods and analysis This study will be performed within an existing Dutch cohort of HL survivors. Eligible women were treated for HL at ages 15–39 years in three large hospitals since 1965 and survived for ≥8 years after their diagnosis. Women visiting a survivorship care outpatient clinic will be invited for a neurocognitive, cardiovascular and BMD assessment, and asked to complete several questionnaires and to provide a blood sample. Using multivariable regression analyses, we will compare the outcomes of HL survivors who developed POI with those who did not. Cardiovascular status will also be compared with women with natural POI. Ethics and dissemination This study has been approved by the Institutional Review Board of the Netherlands Cancer Institute and has been registered at ‘Toetsingonline’ from the Dutch Central Committee on Research involving Human Subjects (file no. NL44714.031.13). Results will be disseminated through peer-reviewed publications and will be incorporated in follow-up guidelines for HL survivors.