Tamer Sayin

Assessment of left ventricular diastolic function with Doppler tissue imaging: Effects of preload and place of measurements

Mitral inflow velocities are widely used for the evaluation of left ventricular (LV) diastolic function. However, they are closely affected by other factors such as preload. The purpose of this study was to evaluate the usefulness of tissue Doppler velocities obtained from the mitral annulus for the evaluation of ventricular relaxation in patients under different loading conditions. We also evaluated the effect of preload at different sides on the mitral annulus. The study population consisted of 62 consecutive patients (38 male, 24 female with a mean age of 42 ± 13 years) who have undergone hemodialysis. Both mitral inflow velocities (E wave, A wave, E wave deceleration time and isovolumetric relaxation time) and mitral annulus tissue Doppler velocities (E′, A′) from the septal, lateral, anterior, posterolateral and inferior sides of the mitral annulus were measured immediately before and after hemodialysis. Mitral inflow E and A wave velocities and E/A ratio decreased significantly (p < 0.001, p = 0.007, p < 0.001, respectively) after hemodialysis. Mitral annulus E′ wave velocities and E′/A′ ratios obtained from five different sides of the annulus also changed significantly (p < 0.001 for all); however, there was no change in the A′ wave velocity (p > 0.05 for all) after hemodialysis. The decrease in E wave and E/A ratio in mitral inflow measurements and E′ velocities and E′/A′ ratios in tissue Doppler measurements were correlated with the amount of fluid extracted (for mitral inflow E wave, r = 0.392, p = 0.002 and E/A ratio, r = 0.280 and p = 0.027; for lateral side E′, r = 0.329, p = 0.009 and E′/A′ ratio, r = 0.286, p = 0.04; for septal side E′, r = 0.376, p = 0.003 and E′/A′ ratio, r = 0.297, p = 0.019; for anterior side E′, r = 0.342, p = 0.007 and E′/A′ ratio, r = 0.268, p = 0.035; for posterolateral side E′, r = 0.423, p = 0.001 and E′/A′ ratio, r = 0.343, p = 0.007; and for inferior side E′, r = 0.326, p = 0.01 and E′/A′ ratio, r = 0.278, p = 0.029). We conclude that mitral annular velocities obtained by tissue Doppler are preload dependent parameters for the evaluation of LV diastolic function.

Exercise-induced myocardial ischemia in patients with coronary artery ectasia without obstructive coronary artery disease

BACKGROUND Aetiology, clinical significance and treatment options for coronary artery ectasia/aneurysm is not clear. OBJECTIVE We sought to determine whether exercise can induce coronary ischemia in patients with coronary artery ectasia/aneurysm without significant coronary stenosis. METHODS Coronary artery ectasia was defined as 1.5-2-fold, aneurysm as >2-fold luminal dilatation of the adjacent normal segment. The study patients could have irregularities with ectatic coronaries but they did not have stenotic lesions >50% with visual assessment of two blinded observers. Patients having coronary artery ectasia or aneurysm with prior myocardial infarction, dilated cardiomyopathy, valvular heart disease, bundle branch block, significant ST-T changes were excluded. The control group was formed from a well matched population of 32 patients with normal coronary arteries who have not performed a treadmill test before coronary angiography. The study group underwent a symptom limited treadmill test if they did not have one before coronary angiogram, all control patients underwent treadmill test. RESULTS Thirty-three patients with coronary artery ectasia/aneurysm (ranging from one to three vessels) but without significant stenosis were derived from 4470 cardiac catheterization procedures between January 1998 and July 2000. In the study group, 17 of the patients had positive treadmill tests with respect to five patients in the control group (P = 0.004). In subgroup analysis, diffuse ectasia/aneurysm (involving 2-3 vessels) was found to be strongly related with ischemia (P = 0.005) with respect to local disease. CONCLUSION Coronary artery ectasia/aneurysm may lead to exercise induced ischemia, especially in the diffuse form.

Association between the severity of heart failure and the susceptibility of myocytes to apoptosis in patients with idiopathic dilated cardiomyopathy

BACKGROUND Bcl-2 proto-oncogene, an inhibitor of apoptosis and Bax proto-oncogene, an inducer of apoptosis play critical roles in the molecular circuit controlling apoptosis in cardiac muscle. The ratio of Bax to Bcl-2 proto-oncogene determines survival or death after an apoptotic stimulus. We speculated that susceptibility of myocytes to apoptosis determined as the Bax/Bcl-2 ratio might vary with the severity of heart failure. METHODS AND RESULTS We studied immunohistochemically 108 endomyocardial biopsy specimens from 30 patients with idiopathic dilated cardiomyopathy (mild heart failure, n=14; moderate or severe heart failure, n=16) with the use of Bcl-2 and Bax monoclonal antibodies. The expression of each protein was determined semiquantitatively as the fraction of myocytes labeled with specific monoclonal antibodies using a digital morphometric analysis system. Patients with mild heart failure showed significantly increased Bax/Bcl-2 ratio than the patients with advanced heart failure (1.59+/-1.26 vs. 0.34+/-0.43, P=0.002). The expression of Bcl-2 was found to be independent of the severity of heart failure whereas the expression of Bax was significantly higher in patients with mild heart failure compared to the patients with moderate or severe heart failure (52.1+/-29.3 vs. 21.6+/-22.4%, P=0.005). Additionally, Bax/Bac-2 ratio was inversely correlated with the mitral E-interventricular septum distance, left ventricular end-systolic and end-diastolic diameter. CONCLUSION The susceptibility of myocytes to apoptosis is significantly increased in the early phase of heart failure but it decreases with worsening of the disease due to depressed expression of Bax onco-protein. Increased myocyte susceptibility to apoptosis may have a role in the transition from mild heart failure to severe in patients with idiopathic dilated cardiomyopathy.

Heart rate variability in hypertrophic obstructive cardiomyopathy: association with functional classification and left ventricular outflow gradients.

BACKGROUND The aim of this study was to investigate cardiac autonomic control in patients with hypertrophic obstructive cardiomyopathy (HOCM) and to assess the indexes of heart rate variability (HRV) in relation to the clinical and echocardiographic features. METHODS AND RESULTS Twenty-three patients (17 male, six female: mean age 43+/-11) with HOCM and 18 healthy volunteers were included. M-mode and two-dimensional echocardiography, pulsed and continuous-wave Doppler studies were obtained. All patients and volunteers underwent continuous 24-h ambulatory ECG monitoring. Time domain variables considered in this study were standard deviation of mean R-R intervals (SDNN), root mean-squared successive difference (RMSSD) and percentage of cycles differing from the preceding one by more than 50 ms (PNN 50%). Patients were compared to detect associations between indices of heart rate variability, left ventricular outflow tract obstruction and clinical status. Heart rate variability parameters were also correlated with the echocardiographic and clinical characteristics of the patients. Both New York Heart Association (NYHA) functional class I-II patients (group I) and NYHA III-IV patients (group II) had lower values of SDNN, RMSSD and PNN 50% when compared with the control group (P<0.001, P<0.05 and P<0.01, respectively, for group I and P<0.001, P<0.001 and P<0.001, respectively, for group II). Time domain heart rate variability parameters were found to be significantly correlated with the subaortic dynamic obstruction. CONCLUSION Heart rate variability is reduced in HOCM and well correlated with the degree of subaortic obstruction. Heart rate variability indices are also sensitive markers of the functional status.

Apical hypertrophic cardiomyopathy mimics acute coronary syndrome

We present a case who was initially thought to have an acute coronary syndrome but who was later diagnosed to have an apical hypertrophic cardiomyopathy. Interestingly, the diagnosis could be established with left heart catheterization, not echocardiography.

Intravascular volume dependency of left ventricular mass calculation by two-dimensional guided M-mode echocardiography

BACKGROUND Increased left ventricular mass (LVM) is an independent risk factor for cardiovascular morbidity and mortality, and may be used for risk stratification. Two-dimensional echocardiography, the most commonly used technique for estimation of LVM, uses the third power of the left ventricular internal diameter (LVID) for the calculation. OBJECTIVES To determine whether a decrease in intravascular volume after dialysis may cause inaccurate estimation of LVM by echocardiography. METHODS Thirty-eight patients undergoing hemodialysis due to chronic renal failure constituted the study group (14 women [37%] and 24 men [63%], mean age +/- SD 38.7+/-10.9 years). LVID, and interventricular and posterior wall thicknesses were measured by two-dimensionally guided M-mode echocardiography. Stroke volume and cardiac output were calculated using left ventricular outflow tract diameter and the pulsed-wave Doppler time-velocity integral obtained from left ventricular outflow tract. LVM was calculated by using Devereuxs formula, and was indexed for body surface area and height. All echocardiographic parameters were measured or calculated before and after dialysis (on the same day), and then compared. RESULTS There were no significant changes in wall thickness; however, LVID, LVM, the LVM/body surface index and the LVM/height index significantly decreased after dialysis (P<0.001 for each parameter). There was a significant correlation between the change in LVID and the change in LVM (P<0.001, r=0.59). Stroke volume and cardiac output also decreased significantly after hemodialysis (P<0.001 for each parameter). CONCLUSIONS Intravascular volume-dependent change in LVID causes inaccurate estimation of LVM, so volume status should be kept in mind, especially in serial assessment of LVM.

Sustained long-term benefit of sildenafil in primary pulmonary hypertension.

Primary pulmonary hypertension is a rare disease with an ominous prognosis for which new therapeutic options are being developed. Recently, there have been case reports indicating that sildenafil may be of benefit in short-to midterm follow-up. However, long-term clinical data of sildenafil in primary pulmonary hypertensive patients is lacking.We report a patient with primary pulmonary hypertension treated with sildenafil 200mg/day for 50months with a sustained clinical response.

Effect of transvenous cardiac resynchronization therapy device implantation on cardiac troponin I release

Background: Pacemaker and implantable cardioverter defibrillator (ICD) implantation increases cardiac troponin I (cTnI) levels which indicates myocardial injury. During implantation of a cardiac resynchronization therapy (CRT) device, balloon inflation for coronary sinus (CS) venogram, cannulation of CS side branch, and electrode advancement may interfere with CS drainage and, hence, may decrease the washout of toxic metabolites from the heart. Thus, CRT implantation may further increase cTnI levels. In this study, we investigated the effects of CRT implantation on cTnI release.

Gadolinium:Nonionic contrast media (1: 1) coronary angiography in patients with impaired renal function

This study was to test safety and efficacy of 1:1 mixture of gadolinium:nonionic contrast media in avoiding contrast nephropathy during coronary angiography in patients with renal dysfunction. Although “off label” for x-ray angiography, gadolinium has drawn attention for its potential to avoid contrast nephropathy during coronary angiography. Initial data seem promising. Patients with a baseline creatinine of 1.5 mg/dl or more were included. In order to minimize contrast nephropathy risk, all patients were thoroughly hydrated and treated by N-acetylcysteine. After coronary angiography and/or percutaneous coronary intervention, renal function tests were remeasured on days 1, 2, and 3. A rise of 0.5 mg/dl or more in creatinine value in the following 3 days or the need for dialysis were considered as a contrast nephropathy event. Twenty-six patients were enrolled in this study. Ten were women and 16 were men. The mean age was 65.7 ± 11. Baseline creatinine value was 2.47 ± 0.74 mg/dl. The total amount of contrast medium used on 1:1 fashion was 57.1 ± 27.2 ml. No procedure-related cardiac complication or contrast nephropathy event occurred in this study. Although there was a slight loss in image quality, we felt that the results were adequate for interpretation. Although “off label,” using gadolinium contrast media in a 1:1 mixture with standard nonionic low osmolar contrast media seems to be a viable option in decreasing the likelihood of contrast nephropathy. Further evaluation appears to be warranted.

Left sided inferior vena cava with sinus venosus type atrial septal defect

A patient with left sided inferior vena cava and sinus venosus type atrial septal defect is presented. The patient was situs solitus, had abnormal pulmonary venous drainage and the left sided inferior caval vein returned to its usual route after the renal vein junction.