Miklós Csanády

Prognostic Significance of the Dobutamine Echocardiography Test in Idiopathic Dilated Cardiomyopathy

Dobutamine stress echo provides potentially useful information on idiopathic dilated cardiomyopathy (IDC). From February 1, 1997, to October 1, 1999, 186 patients (131 men and 55 women, mean age 56 +/- 12 years) with IDC, ejection fraction <35%, and angiographically normal coronary arteries were studied by high-dose (up to 40 micro/kg/min) dobutamine echo in 6 centers, all quality controlled for stress echo reading. In all patients, wall motion score index (WMSI) (from 1 = normal to 4 = dyskinetic in a 16- segment model of the left ventricle) was evaluated by echo at baseline and peak dobutamine. One hundred eighty-four patients were followed up (mean 15 +/- 13 months) and only cardiac death was considered as an end point. There were 29 cardiac deaths. Significant parameters for survival prediction at univariate analysis are: DeltaWMSI (chi-square 20.1; p <0.0000), New York Heart Association (NYHA) class (chi-square 17.57; p <0.0000), rest ejection fraction (chi-square 10.41; p = 0.0013), angiotensin-converting enzyme inhibitors (chi-square 8.23; p = 0.0041), and hypertension (chi-square 8.08, p = 0.0045). In the multivariate stepwise analysis only DeltaWMSI and NYHA were independent predictors of outcome (DeltaWMSI = hazard ratio 0.02, p < 0.0000; NYHA class = hazard ratio 3.83, p < 0.0000). Kaplan-Meier survival estimates showed a better outcome for patients with a large inotropic response (DeltaWMSI > or =0.44, a cutoff identified by receiver-operating characteristic curves analysis) than for those with a small or no myocardial inotropic response to dobutamine (93.6% vs 69.4%, p = 0.00033). Thus, in patients with IDC, an extensive contractile reserve identified by high-dose dobutamine stress echocardiography is associated with a better survival.

Cardiac manifestations in primary Sjögren's syndrome.

OBJECTIVE: To determine cardiac manifestations in primary Sjögrens syndrome (SS). METHODS: Echocardiographic examination was undertaken in 64 patients (62 women, two men) with primary SS (54 definite (DSS) and 10 probable (PSS)) who had systemic symptoms. Twenty one healthy women volunteers of similar age acted as controls. RESULTS: Acute exudative pericarditis occurred in only one patient. An echogenic pericardium was demonstrated in 21 patients (19 DSS, two PSS) (33%) who had a previous symptom free pericarditis, but in none of the controls. Pulmonary pressure was significantly greater in the patients than in the controls (31 (SD 8) mm Hg compared with 24 (7) mm Hg), but there was no significant difference between the DSS and PSS groups. Left ventricular (LV) systolic function was similar in patients and controls. Twenty two patients (20 DSS, two PSS) and one control subject were excluded from LV diastolic function evaluation because of conditions likely to influence the parameters. Of the remaining 42 patients with SS (34 DSS, eight PSS), 21 (17 DSS, four PSS) had impaired diastolic function, confirmed by several diastolic parameters. LV diastolic dysfunction and echogenic pericardium occurred independently of each other, and there was no correlation between the occurrence of these silent cardiac abnormalities and the clinical and laboratory findings. CONCLUSIONS: Obvious cardiac involvement is rare in primary SS, but clinically silent manifestations (symptom free pericarditis and LV diastolic dysfunction) are common. The clinical and prognostic significance of these changes cannot yet be defined.

The heart in acromegaly: an echocardiographic study

We used echocardiography to study anatomic and functional changes of the heart in 25 patients with acromegaly. Asymmetric septal hypertrophy was found in 10 patients, in the range of 12 to 30 mm, with an average of 16 mm. The degree of septum-thickness was severe in 1 case, marked in 5 cases and mild in 4 cases. Concentric left ventricular hypertrophy was present in 1 patient. In 8 patients the left ventricle was normal and left ventricular dilatation of more than 60 mm was present in 6 cases. Except in one patient, the ejection fraction was decreased in the dilated group, indicating diminished myocardial contractility. The growth hormone level was higher in patients with left ventricular hypertrophy as compared to those patients with normal or dilated left ventricles. In acromegaly primary myocardial hypertrophy may be related to the growth hormone level.

Reduced aortic distensibility and coronary flow velocity reserve in diabetes mellitus patients with a negative coronary angiogram

BACKGROUND Structural and functional abnormalities of the aortic wall and disturbances of the coronary circulation with presumed microvascular complications have been reported in patients with diabetes mellitus. OBJECTIVES To simultaneously establish the coronary flow velocity reserve (CFVR) and aortic distensibility indexes in type 2 diabetes mellitus patients who have normal epicardial coronary arteries by stress transesophageal echocardiography (STEE). METHODS The elastic properties of the descending aorta and the CFVR were evaluated simultaneously in 18 type 2 diabetes mellitus patients who had negative coronary angiograms. These results were compared with those of 21 nondiabetic subjects with normal epicardial coronary arteries and 24 patients with left anterior descending coronary artery (LAD) stenosis. STEE was used for the evaluation of elastic moduli of the descending aorta. The CFVR was calculated as the ratio of the average peak diastolic flow velocity during hyperemia to that at rest. RESULTS The CFVR of diabetic patients with normal epicardial coronary arteries and those with LAD stenosis was similarly decreased compared with the controls (2.10+/-0.63 and 1.78+/-0.47 versus 2.76+/-1.25, P<0.05 and P<0.001, respectively). The elastic modulus (in 103 mmHg) was similarly increased in patients with diabetes mellitus and normal epicardial coronary arteries, and in those with LAD stenosis, compared with the control subjects (0.94+/-0.82 and 0.91+/-0.59 versus 0.49+/-0.19, P<0.05 and P<0.05, respectively). CONCLUSIONS It may be stated that reduced aortic distensibility (increased elastic modulus) and the CFVR were demonstrated simultaneously during STEE in diabetic patients compared with nondiabetic subjects with negative coronary angiograms.

ALA (5-aminolevulinic acid)-induced protoporphyrin IX fluorescence in the endoscopic diagnostic and control of pharyngo-laryngeal cancer.

Photodynamic diagnosis is a modern method for the fluorescence imaging of superficial pharyngeal and laryngeal tumours. 5-aminolevulinic acid (ALA)-induced protoporphyrin IX fluorescence benefits the tumour selective accumulation of protoporphyrin; therefore, tumours can be differentiated from healthy tissue. ALA-induced fluorescence of laryngo-pharyngeal tumours and precancerous and benign lesions were evaluated by endoscopy. At the Department of Otorhinolaryngology, Head and Neck Surgery, Szeged, Hungary, 31 patients underwent ALA-induced protoporphyrin fluorescence imaging. After topical application of ALA, mesopharyngeal tumours were visualised by direct fluorescence endoscopy. Laryngeal and hypopharyngeal tumours were examined with a laryngomicroscope with the patients under general anaesthesia after inhalation of an ALA solution. Intensity of PPIX fluorescence was classified and compared with pathological findings. The examination of all 13 laryngeal and 12 pharyngeal tumours resulted in a middle or strong intensity of red fluorescence, but for one cancer, four praecancerous and two benign lesions. Healthy tissues showed green autofluorescence. Margins of mesopharyngeal and vocal cord tumours were clearly outlined under fluorescent vision, giving a helpful contribution to diagnosis and therapy even in clinically non-visible tumours. Laryngomicroscopy combined with laser surgery also indicated PPIX fluorescence examination visualising margins of the tumour intermediately with the endoscope. The ALA-induced PPIX fluorescence imaging method revealed a sensitivity of 96%. This method is applicable for detecting early superficial tumours, margins of tumours and follow-up after surgery/radiation therapy in the laryngo-pharynx.

How Can Coronary Flow Reserve Be Altered by Severe Aortic Stenosis

The coronary flow reserve, a well‐known characteristic of the distensibility of the coronary arteries, can be measured by means of dipyridamole stress transesophageal echocardiography. This study compared the coronary flow reserve in patients with normal coronary arteries with aortic stenosis (Group 1), in patients with normal coronary arteries without aortic stenosis (Group 2), and in patients with significant left anterior descending coronary artery disease (Group 3). Patients and Methods: Groups 1 and 2 were comprised of 21 patients each, while Group 3 was comprised of 37 patients. Transesophageal stress echocardiography was carried out according to a standard protocol, with a vasodilator stimulus of dipyridamole in a dose of 0.56 mg/kg over 4 minutes. The coronary flow reserve was calculated as the ratio of posthyperemic to basal peak (CFR) and mean (mean CFR) diastolic flow velocities. Results: The left ventricular mass and left ventricular mass index were significantly higher in Group 1 than in Groups 2 and 3. The coronary flow reserve and the posthyperemic mean diastolic flow velocities were significantly lower, while the resting mean diastolic flow velocities were significantly higher in Groups 1 and 3 than in Group 2. Conclusions: In patients with aortic stenosis and a normal coronary angiogram, the coronary flow reserve is significantly lower, similarly as in the case of significant left anterior descending coronary artery disease. In severe aortic stenosis with left ventricular hypertrophy, stress transesophageal echocardiography is unable to distinguish between the drop in coronary flow reserve caused by a vascular or a myocardial component, and therefore, not suitable for the selection of patients with significant coronary artery disease, even in cases of left anterior descending coronary artery disease.

Relevance of anaesthesia for dofetilide-induced torsades de pointes in α1-adrenoceptor-stimulated rabbits

No information is available concerning the effects of anaesthetics in the most frequently used in vivo pro‐arrhythmia model. Accordingly, in this study we examined the effect of pentobarbital, propofol or α‐chloralose anaesthesia on the pro‐arrhythmic activity of the class III anti‐arrhythmic dofetilide in α1‐adrenoceptor‐stimulated rabbits.

Prognostic value of coronary flow reserve and aortic distensibility indices in patients with suspected coronary artery disease

In recent studies it has been demonstrated that a reduced coronary flow reserve (CFR) is independently associated with a less benign long-term outcome. Aortic stiffness is one of the most important cardiovascular risk factors predicting cardiovascular morbidity and mortality. Vasodilator stress transesophageal echocardiography (TEE) is a suitable method to evaluate simultaneously CFR and elastic properties of the descending thoracic aorta. The aim of the present study was to assess the relative prognostic value of simultaneously measured CFR and aortic elastic properties by pulsed-wave Doppler TEE in patients with suspected or known coronary artery disease (CAD). The study comprised 157 in-hospital patients with chest pain. In all patients, stress TEE was used for the simultaneous evaluation of CFR and aortic distensibility indices [elastic modulus E(p) and Young’s circumferential static elastic modulus E(s)]. During a mean follow-up of 48 ± 8 months, 13 patients suffered cardiovascular death. By univariate analysis older age, diabetes mellitus, increased left ventricular (LV) end-diastolic diameter, increased LV mass index, lower LV ejection fraction, and lower CFR were significant predictors of cardiovascular survival. Multivariate regression analysis showed that only CFR (hazard ratio [HR] 10.31, P = 0.04), age (HR 1.20, P = 0.001), and increased left ventricular (LV) end-diastolic diameter (HR 1.14, P = 0.02) were independent predictors of cardiovascular survival. Only in the small number of patients without CAD and abnormal CFR aortic distensibility seemed to provide complementary prognostic information over CFR. In the majority of patients aortic distensibility did not offer complementary prognostic information to CFR during vasodilator stress TEE testing.

Na+/Ca2+ exchanger inhibition exerts a positive inotropic effect in the rat heart, but fails to influence the contractility of the rabbit heart

Background and purpose: The Na+/Ca2+ exchanger (NCX) may play a key role in myocardial contractility. The operation of the NCX is affected by the action potential (AP) configuration and the intracellular Na+ concentration. This study examined the effect of selective NCX inhibition by 0.1, 0.3 and 1.0 μM SEA0400 on the myocardial contractility in the setting of different AP configurations and different intracellular Na+ concentrations in rabbit and rat hearts.

The role of the Na+/Ca2+ exchanger, INa and ICaL in the genesis of dofetilide-induced torsades de pointes in isolated, AV-blocked rabbit hearts

Background and purpose:  The Na+/Ca2+ exchanger (NCX) may contribute to triggered activity and transmural dispersion of repolarization, which are substrates of torsades de pointes (TdP) type arrhythmias. This study examined the effects of selective inhibition of the NCX by SEA0400 on the occurrence of dofetilide‐induced TdP.