Mai Salama

Tissue Doppler and Strain Rate Imaging Detect Improvement of Myocardial Function in Iron Deficient Patients with Congestive Heart Failure after Iron Replacement Therapy

Background: Iron deficiency may contribute to diminished exercise tolerance in patients with congestive heart failure (CHF) even in absence of anemia. The aim of this study was to evaluate the effect of correction of iron deficiency on functional capacity and myocardial function in patients with CHF. Methods: We studied 40 patients with ejection fraction <40%, hemoglobin% >12 g/dL, serum ferritin <100 ug/L, and transferrin saturation <20%. Patients received 200 mg weekly doses of iron dextran complex until serum ferritin level was between 200 and 300 ug/L or transferrin saturation level was between 30% and 40%. Transthoracic echocardiogram, tissue Doppler imaging, peak systolic strain rate, and 6 minute walk test were performed before iron therapy and at 12‐week follow up. Peak early diastolic myocardial tissue velocity (E’), peak late diastolic myocardial tissue velocity (A’), and peak systolic myocardial tissue velocity (S’) were measured. Results: There was a significant improvement of New York Heart Association functional class (3.0 ± 0.4 vs. 2.1 ± 0.3, P < 0.05) and 6minutes walk distance (322 ± 104 vs. 377 ± 76, P < 0.01) from rest to follow up, respectively. Ejection fraction did not change significantly (32 ± 8% vs. 34 ± 9%, respectively). There was a significant improvement of S’‐wave (3.0 ± 0.8 cm/sec vs. 6.0 ± 1.2 cm/sec, P < 0.05), E/E’ ratio (22 ± 3 vs. 13 ± 3, P < 0.05), and peak systolic strain rate (−0.72 ± 0.11/s vs. −1.09 ± 0.37/s, P < 0.05) from baseline to follow‐up, respectively. Conclusion: Correction of iron deficiency improves functional class and walking distance in nonanemic iron deficient patients with systolic heart failure. Tissue Doppler and strain rate demonstrated a significant improvement of diastolic and systolic function after therapy despite lack of improvement of ejection fraction. (Echocardiography 2012;29:13‐18)

Evaluation of coronary flow reserve in hypertensive patients by Dipyridamole transesophageal doppler echocardiography

This study evaluates the coronary flow reserve (CFR) in hypertensive patients with and without left ventricular (LV) hypertrophy. CFR was assessed by transesophageal Doppler echocardiography in 15 normal subjects (group I), 21 hypertensive patients without LV hypertrophy (group II), and 27 hypertensive patients with LV hypertrophy (group III). All hypertensive patients were complaining of typical anginal pain and had normal coronary angiograms. The sample volume was placed at the bifurcation of the left main and left anterior descending coronary arteries. Coronary blood flow velocities were evaluated at rest, 2 minutes after dipyridamole infusion, and 2 minutes after intravenous aminophylline. The ratios of dipyridamole to rest peak diastolic and systolic velocities were considered as indexes of CFR. Peak diastolic velocity ratio was significantly lower in group III than in groups I and II (1.6 +/- 0.2, 2.7 +/- 0.4, and 2.1 +/- 0.2, respectively; p <0.05), and it was significantly lower in group II than I (p <0.05). The peak systolic velocity ratio was significantly lower in group III than in groups I and II (1.7 +/- 0.3, 2.8 +/- 0.3, and 2.1 +/- 0.2, respectively; p <0.05), and it was significantly lower in group II than I (p <0.05). The peak diastolic velocity ratio was inversely related to systolic blood pressure, diastolic blood pressure, and LV mass index (r = -0.48, -0. 51, and -0.37 respectively) in hypertensive patients. It is concluded that CFR is significantly impaired in hypertensive patients, especially those with LV hypertrophy, compared with healthy subjects. The degree of impairment of CFR is related to LV mass index.

Five-year follow-up after percutaneous balloon mitral valvuloplasty in children and adolescents

Balloon mitral valvuloplasty (BMV) is an effective intervention in patients with symptomatic mitral stenosis. However, the late results of BMV in children and adolescents have not been well studied. The aim of this study was to assess the late functional and morphologic results after BMV in children and adolescents. BMV was performed in 46 children and adolescents (mean age 15.5 +/- 3.2 years, range 7 to 19; 19 males) with rheumatic mitral stenosis. Serial clinical and echocardiographic evaluation was conducted to assess the long-term results of the procedure during a follow-up period of 66 +/- 6 months. The mitral valve score was 6 +/- 2/16. BMV was successful in 45 patients (98%). There was a significant increase of the mean mitral valve area index (MVAI) (0.65 +/- 0.14 vs 1.54 +/- 0.23 cm2/m2, p <0.001) and a significant reduction of the mean transmitral pressure gradient (16.1 +/- 2.9 vs 5.1 +/- 3.1 mm Hg, p <0.001) from pre- to post-BMV, respectively. There was no significant change of MVAI or the pressure gradient during the follow-up compared with immediately after BMV (1.51 +/- 0.31 cm2/m2 and 4.9 +/- 2.5 mm Hg, respectively). No deaths or mitral valve replacement occurred during the follow-up period. Restenosis (loss of >50% of the achieved increase in MVAI) occurred in 3 patients (6.5%). All other patients showed persistent improvement in their New York Heart Association class (< or = II). Thus, the event-free survival with good functional results was encountered in 42 patients (91%) at the end of the follow-up period. The left atrial diameter decreased from 4.6 +/- 0.9 before BMV to 3.7 +/- 0.6 cm at follow-up (p <0.05). It is concluded that BMV has excellent intermediate-term results in children and adolescents with a relatively low mitral valve score.

Immediate effect of balloon valvuloplasty on hemostatic changes in mitral stenosis

This study was conducted to assess right and left atrial hemostatic function in patients with mitral stenosis (MS) and to investigate the immediate effect of balloon mitral valvuloplasty (BMV) on hemostatic function. BMV was performed in 28 patients with MS (age 29 +/- 8 years) who had sinus rhythm and no left atrial (LA) thrombus. Right and left atrial biochemical markers of platelet activity (platelet factor 4 [PF4] and B thromboglobulin [BTG]), coagulation (thrombin-antithrombin III complex [TAT]), and fibrinolytic activity (D-dimer) were measured before and 30 minutes after BMV. Right atrial levels of these markers were also measured in 20 control subjects. Compared with control subjects, patients with MS had higher right atrial levels of PF4 (30 +/- 15 vs 5 +/- 2 IU/ml), BTG (231 +/- 53 vs 30 +/- 8 IU/ml), TAT (7 +/- 4 vs 2 +/- 0.3 microg/L), and D-dimer (380 +/- 145 vs 160 +/- 35 ng/ml, p < 0.0001 in all). TAT levels were higher in the left atrium than in the right atrium of patients before BMV (8 +/- 4 vs 7 +/- 4 microg/L, p < 0.0001). BMV was successful (final mitral valve area > or = 1.5 cm2 and > or = 50% increase of the initial valve area) in all patients. There was a significant reduction of LA levels of PF4 (35 +/- 8 to 26 +/- 9 IU/ml, p < 0.0001), BTG (225 +/- 41 to 196 +/- 28 IU/ml, p < 0.001), and TAT (10 +/- 5 to 7 +/- 1 microg/L, p < 0.05) in the 16 patients with LA pressure < 10 mm Hg after BMV, whereas these markers were not reduced in the 12 patients with left atrial pressure > or = 10 mm Hg after BMV. These data indicate that platelet function, coagulation status, and fibrinolytic activity are increased regionally in the left atrium and in the systemic circulation in patients with MS and sinus rhythm in the absence of LA thrombus. Successful BMV induces a significant reduction of prethrombotic status in patients with low LA pressure after the procedure. Patients with high LA pressure after BMV maintain a high prethrombotic state and may be considered at an increased risk of thromboembolism after the procedure.

Clinical and biochemical predictors of increased carotid intima-media thickness in overweight and obese adolescents with type 2 diabetes.

Objective: To identify the clinical parameters associated with increased carotid intima-media thickness (CIMT) in overweight and obese adolescents with type 2 diabetes. Methods: We studied 27 patients (11 males) with type 2 diabetes. Criteria for selection were age (12–19 years), body mass index above the 95th percentile for age and gender, a positive family history of diabetes, normal or high C-peptide, and negative studies for islet cell antibodies. Age- and gender-matched healthy subjects were selected as the control group. Measurements of CIMT, lipid profile, hypersensitive C-reactive protein, hemoglobin A1C (HbA1C), and insulin resistance by homeostasis model of assessment (HOMA) were obtained for all participants. Results: CIMT was higher in diabetic patients than in healthy subjects (0.68 ± 0.16 vs. 0.58 ± 0.1, p < 0.01). The range of HbA1C in the 15 patients with uncontrolled diabetes was 7.6–10.4 (mean: 8.9 ± 0.9). CIMT, HbA1C, systolic blood pressure, triglycerides, HOMA, and C-reactive protein were significantly higher in patients with uncontrolled than with controlled diabetes. In diabetic patients, CIMT correlated positively with body mass index (p < 0.001), duration of diabetes (p < 0.001), systolic (p < 0.001) and diastolic blood pressure (p < 0.01), HbA1C (p < 0.001), HOMA (p < 0.01), and C-reactive protein (p < 0.01). Conclusions: CIMT is increased in adolescents with type 2 diabetes. Poor glycemic control, HOMA, increased C-reactive protein, body mass index, duration of diabetes, and elevated blood pressure are associated with early atherosclerosis in these patients.

Serum Soluble Fas in Patients with Schistosomal Cor pulmonale

Background: Schistosomal cor pulmonale is considered an important pathological condition in endemic areas. Few recent studies have reported the role of apoptosis in pulmonary hypertension. Objectives: The aim of this study was to assess serum levels of soluble Fas (sFas), an inhibitor of apoptosis, in patients with schistosomal cor pulmonale as compared to patients with cor pulmonale due to chronic obstructive pulmonary disease (COPD) and normal subjects. Methods: Serum sFas was assessed in 15 men with schistosomal cor pulmonale (age 32 ± 10 years), 15 men with chronic cor pulmonale secondary to COPD and 20 healthy men, matched for age. Results: Serum levels of sFas were significantly higher in patients with schistosomal cor pulmonale (74 ± 80 U/ml) than in patients with cor pulmonale due to COPD (15 ± 10 U/ml) and normal subjects (19 ± 11 U/ml, p < 0.001 in both). In patients with schistosomal cor pulmonale, sFas was significantly higher in patients with mean pulmonary artery pressure >30 mm Hg as compared to patients with pressure ≤30 mm Hg (109 ± 97 vs. 34 ± 20 U/ml, p = 0.01). There was a significant correlation between serum sFas and the mean pulmonary artery pressure in patients with bilharzial cor pulmonale (r = 0.4, p < 0.01), but not in patients with COPD (r = 0.1, p = NS). Conclusions: Serum sFas levels are elevated in patients with schistosomal cor pulmonale and they are related to the severity of pulmonary hypertension. These findings suggest a role of apoptosis in schistosomal cor pulmonale.

Comparison of Contrast Enhanced Magnetic Resonance Angiography with Invasive Cardiac Catheterization for Evaluation of Children with Pulmonary Atresia

Complete assessment of the source of pulmonary blood supply and delineation of the anatomy of pulmonary arteries are essential for the management and prognostic evaluation of pulmonary atresia (PA) patients. Invasive cardiac catheterization is considered the gold standard imaging modality to achieve this. We investigated the role of contrast enhanced magnetic resonance angiography (MRA) to evaluate the pulmonary blood supply and the anatomy of the pulmonary arteries and compared this with cardiac catheterization in children with PA. We studied 20 children with PA. Median age was 2.5 years (range 6 months–13 years). All patients were examined with cardiac catheterization and contrast enhanced MRA, and the results of both modalities were compared. There was a complete agreement between both modalities in the detection of the main pulmonary artery morphology and determination of the confluence state of the central pulmonary arteries. There was an 88% agreement for patency of the ductus arteriosus and 66% for patency of the surgically placed shunt. There was a complete agreement between both techniques on determining the presence of collaterals more than 2.5 mm. Twenty-eight collaterals of less than 2.5 mm were detected only by contrast enhanced MRA. There was a strong correlation between both modalities in measuring the pulmonary arteries and collaterals diameter (P<0.001). Contrast enhanced MRA is a safe and accurate non-invasive technique to evaluate the pulmonary artery morphology and the sources of pulmonary blood supply in children with PA.