Tansu Karaahmet

The utility of fragmented QRS complexes to predict significant intraventricular dyssynchrony in nonischemic dilated cardiomyopathy patients with a narrow QRS interval

BACKGROUND Fragmented QRS complexes in the electrocardiograms (ECGs) of patients with coronary artery disease are associated with adverse cardiac events. However, there are limited data on its predictive usefulness in patients with nonischemic dilated cardiomyopathy. Left ventricular dyssynchrony is common in heart failure patients who have wide QRS intervals, but its frequency in patients with narrow QRS intervals is uncertain. OBJECTIVES To investigate the relationship between fragmented QRS complexes and intraventricular dyssynchrony in patients with nonischemic dilated cardiomyopathy in sinus rhythm. METHODS Sixty nonischemic dilated cardiomyopathy patients with sinus rhythm and narrow QRS intervals were recruited. Forty patients had a fragmented QRS in their basal ECG, and 20 patients did not have a fragmented QRS. Patients were analyzed for correlation between fragmented QRS complexes and intraventricular dyssynchrony. RESULTS The maximal difference in time to the peak myocardial systolic velocity between any two left ventricular segments (Max-ASE Sys), and maximal difference between Max-ASE Sys and the mean value of all segments (Max-ASE to Mean Sys) were significantly higher in patients with fragmented QRS complexes (P=0.001 and P=0.003, respectively). Seventy-two per cent of the patients with fragmented QRS complexes had significant left ventricular dyssynchrony; 15% of patients without fragmented QRS complexes had significant left ventricular dyssynchrony (P<0.0001). The presence of fragmented QRS complexes in leads corresponding to the specific ventricular segment in basal ECG was found to detect intraventricular dyssynchrony with 90.6% sensitivity (negative predictive value of 85%). CONCLUSION Fragmentation in the resting ECG is associated with significant intraventricular dyssynchrony in patients with nonischemic cardiomyopathy, narrow QRS and sinus rhythm. Fragmentation in ECG might be useful in identifying patients who could benefit from cardiac resynchronization therapy.

Diffuse Late Gadolinium Enhancement by Cardiovascular Magnetic Resonance Predicts Significant Intraventricular Systolic Dyssynchrony in Patients With Non-Ischemic Dilated Cardiomyopathy

BACKGROUND Left ventricular dyssynchrony and myocardial fibrosis are common findings in patients with nonischemic dilated cardiomyopathy (NDCM). The aim of this study was to investigate the association between myocardial fibrosis and intraventricular systolic dyssynchrony (DYS-sys) in patients with NDCM. METHODS Thirty-nine patients with NDCM and sinus rhythm were enrolled. Intraventricular DYS-sys was evaluated using Doppler tissue imaging, and cardiac fibrosis was assessed with cardiovascular magnetic resonance imaging with a 17-segment cardiac model. Each segment was graded on a 2-point scale (segmental fibrosis score): 0 = absence of late gadolinium enhancement, and 1 = presence of late gadolinium enhancement. A cardiac fibrosis index was calculated as 17/(17 - sum of fibrotic segments). Receiver operating characteristic analysis was performed to determine the utility of the cardiac fibrosis index to predict intraventricular systolic dyssynchrony. RESULTS Patients with DYS-sys had larger left atrial size (P = .004) and left ventricular end-systolic (P = .028) and end-diastolic (P = .034) volumes and lower tricuspid annular Doppler tissue imaging peak systolic velocities (P = .037) compared with patients without DYS-sys. A cardiac fibrosis index > or = 1.4 predicted significant DYS-sys with 92% sensitivity and 60% specificity (area under the receiver operating characteristic curve, 0.703; 95% confidence interval, 0.512-0.893; P = .035). Patients with cardiac fibrosis indexes > or = 1.4 (group 1) had larger left ventricular end-systolic (P = .044) and end-diastolic (P = .034) volumes than those with cardiac fibrosis indexes < 1.4 (group 2). Nine of 11 patients (82%) in group 1 and 6 of 28 patients (21%) in group 2 had significant DYS-sys (Pearsons chi(2) = 12.169, P < .0001). Logistic regression analysis revealed that cardiac fibrosis index > or = 1.4 (odds ratio, 11.2; 95% confidence interval, 1.72-71.4; P = .012) was an independent predictor of DYS-sys. CONCLUSION Patients with NDCM and prominent cardiac fibrosis have significant DYS-sys. The cardiac fibrosis index is a useful tool to predict DYS-sys.

The importance of papillary muscle dyssynchrony in predicting the severity of functional mitral regurgitation in patients with non-ischaemic dilated cardiomyopathy: a two-dimensional speckle-tracking echocardiography study

AIMS In our study, we investigated the impact of papillary muscle systolic dyssynchrony (DYS-PAP) and the configuration of mitral leaflets in the prediction of significant functional mitral regurgitation (MR) with two-dimensional (2D) speckle-tracking strain analysis in non-ischaemic dilated cardiomyopathy (DCM) patients with sinus rhythm. METHODS Thirty-six non-ischaemic DCM patients (left ventricular ejection fraction <40%) with sinus rhythm were recruited. The quantification of functional MR was performed using the proximal isovelocity surface area method. The configuration of mitral leaflets [mitral annulus, coaptation height (CH), and tethering distances for papillary muscles] was evaluated in the parasternal long-axis and apical four-chamber views. The assessment of DYS-PAP was performed by applying 2D speckle-tracking imaging to the apical four-chamber view for anterolateral papillary muscle and to the apical long-axis view for posteromedial papillary muscle. RESULTS Fifteen (41.6%) patients had mild MR and 21 (58.3%) patients had moderate or moderate-to-severe MR. Patients with higher levels of MR had larger mitral annulus size (P = 0.02), tethering-AL (P = 0.04), higher MR volume (P < 0.0001), effective regurgitant orifice area (P < 0.0001), and DYS-PAP (P < 0.0001) values, but lower CH (P = 0.001), global longitudinal (P = 0.005), radial (P = 0.03), and circumferential strain (P = 0.01) than those with mild MR. Receiver operating characteristic analysis was performed to assess the utility of DYS-PAP to predict moderate or moderate-to-severe functional MR. A DYS-PAP value >30 ms predicted moderate-to-severe MR with 85% sensitivity and 87% specificity [area under the curve: 0.897, 95% confidence interval (CI): 0.781-0.999, P < 0.0001]. Logistic regression analysis revealed that DYS-PAP (odds ratio: 3.2, 95% CI: 1.22-47.7, P = 0.037) was the only independent predictor of moderate or moderate-to-severe functional MR. CONCLUSION DYS-PAP is correlated with functional MR in non-ischaemic DCM patients with sinus rhythm. A DYS-PAP cut-off value of 30 ms is a useful tool to identify patients with moderate-to-severe functional MR.

Assessment of atrial electromechanical delay by tissue Doppler echocardiography in patients with nonischemic dilated cardiomyopathy

BACKGROUND Atrial electromechanical delay (AEMD) calculated from tissue Doppler imaging (TDI) echocardiography can be an alternative to invasive electrophysiologic studies. We investigated whether the AEMD obtained from TDI is prolonged in patients with nonischemic dilated cardiomyopathy (DCM). METHODS Fifty-five patients with nonischemic DCM (23 men/32 women; age, 43.9 +/- 14.8 years) and 55 controls (20 men/35 women; age, 41.3 +/- 13.4 years) were included in this study. Atrial electromechanical delay (the time interval from the onset of P wave on electrocardiogram to the beginning of late diastolic wave [Am wave] on TDI) was calculated from the lateral and septal mitral annulus, and lateral tricuspid annulus (PA lateral, PA septum, and PA tricuspid, respectively). P-wave dispersion was calculated from the 12-lead electrocardiogram. RESULTS PA lateral and PA septum duration were significantly longer in patients with nonischemic DCM than the controls (78.4 +/- 19.7 versus 53.8 +/- 6.6 and 55.2 +/- 16.3 versus 40.5 +/- 6.2, P < .0001 for both; respectively). However, PA tricuspid duration was statistically similar between the 2 groups (36.4 +/- 10.9 versus 37.2 +/- 5.7, P > or = .05). P-wave dispersion was significantly higher in nonischemic DCM patients than the controls (53.0 +/- 14.4 versus 37.5 +/- 5.5, P < .0001). PA lateral was correlated with the left atrial maximal volume (r = 0.64, P < .0001), P-wave dispersion (r = 0.65, P < .0001), and log B-type natriuretic peptide (NT proBNP) (r = 0.63, P < .0001). There was a statistically significant and negative correlation between the PA lateral and left ventricular ejection fraction (r = -0.63, P < .0001) and E-wave deceleration time (r = -0.34, P < .0001). Multivariate analysis revealed that left atrial maximal volume and log NT proBNP were the independent predictors of PA lateral (P < .0001 and P = .003, respectively). CONCLUSION The AEMD was significantly prolonged in patients with nonischemic DCM. Left atrial enlargement and log NT proBNP were the independent predictors of this prolongation.

Clinical Significance of High-Density Lipoprotein Cholesterol in Left-Sided Infective Endocarditis

Decreased serum levels of high-density lipoprotein (HDL) cholesterol have been shown to be of prognostic significance in patients with severe infectious diseases. Serum HDL cholesterol levels were therefore investigated as a possible parameter for the prediction of clinical outcomes in patients with left-sided infective endocarditis (IE). Fifty-four patients with IE with available admission serum HDL cholesterol levels were included in the study. A clinical outcome was defined as a complicated course during hospitalization. Forty-two patients had complicated courses during their in-hospital stays. The median serum HDL cholesterol level was significantly lower in patients with IE (n = 54) than healthy controls (n = 26) (26 vs 47 mg/dl, p <0.0001). In the 42 patients with complicated courses, the median serum HDL cholesterol level was lower compared with that in 12 patients with uneventful courses (24 vs 36 mg/dl, p = 0.011). A cut point of serum HDL cholesterol level of 25 mg/dl had sensitivity of 62%, specificity of 75%, and a positive predictive value of 90% for predicting clinical outcomes. In conclusion, serum HDL cholesterol levels measured at admission were markedly reduced in patients with left-sided IE. Furthermore, low serum HDL cholesterol levels predicted complicated clinical courses in these patients.

Incidence and Predictors of Radial Artery Spasm at the Beginning of a Transradial Coronary Procedure

OBJECTIVES Our aim was to establish the frequency of radial artery spasm (RAS) and its predictors at the beginning of a transradial approach (TRA). METHODS This was a single-center prospective study. A total of 1,722 consecutive patients undergoing their first transradial coronary procedure were recruited. After radial artery puncture, a hydrophilic sheath was used to complete arterial puncture, then 500 μg glycerol trinitrate and 2.5 mg verapamil were injected into radial artery along the sheath. After retrograde radial arteriography spasm was defined angiographically as a stenosis greater than 25%. Patient demographics, procedural data such as total procedural duration, the number of catheters and guidewires used, the amount of contrast media usage, dose area product (DAP) and fluoroscopy time, and vascular complications were recorded. RESULTS The overall spasm incidence was 10.3%. The procedural success rate was lower in patients with spasm than in patients without spasm (80% vs. 95.7%, P < 0.001). The patients with spasm were older (mean age 63.9 ± 9.4 years vs. 60.0 ± 11.2 years, P < 0.001) and more commonly female (51.3% vs. 34.4%, P < 0.001). Spasm was more common in hypertensive patients (66% vs. 56%, P < 0.009). Surprisingly, smoking was less common in patients with spasm (17% vs. 29%, P < 0.001). Multiple logistic regression analysis showed that female gender (OR = 1,524, 95% CI: 1.033-2.248, P = 0.034) was the only independent predictor of RAS at the beginning of the procedure. CONCLUSIONS The incidence of RAS was 10,3%, and female gender was the sole independent predictor of RAS at the very beginning of the procedure in patients undergoing a TRA.

Role of Left Ventricular Dyssynchrony in Predicting Remodeling after ST Elevation Myocardial Infarction

Background: Intraventricular dyssynchrony is associated with worsening systolic function, adverse remodeling, and clinical events. The aim of this study is to investigate whether intraventricular dyssynchrony assessed by tissue Doppler imaging (TDI) can predict left ventricular (LV) remodeling after first ST segment elevation myocardial infarction (STEMI) treated successfully with primary percutaneous coronary intervention (pPCI). Methods: Fifty‐two consecutive patients who presented with first acute STEMI were included in the study. All patients underwent successful pPCI. Standard echocardiography was performed within 48 hours of admission. LV dyssynchrony was assessed by color‐coded TDI. Dyssynchrony (Ts‐diff) was calculated by maximal temporal difference between time to peak systolic velocities (Ts) of six basal segments. Echocardiographic examination was repeated after 6 months to reassess LV volumes. LV remodeling was defined as >15% increase in LV end‐systolic volume index (LVESVI) after 6 months. Results: Eleven patients (23%) developed LV remodeling. Baseline dyssynchrony was found to be correlated with percent change in LVESVI and LV end‐diastolic volume index (LVEDVI) after 6 months. Ts‐diff, creatine kinase‐MB and mitral inflow E‐wave deceleration time (DT) were the independent predictors of remodeling after STEMI in multivariate logistic regression analysis. Receiver operating characteristic curve analysis showed that Ts‐diff >56 msec had 72.7% sensitivity and 83.8% specificity for predicting remodeling. Conclusions: LV dyssynchrony is a strong predictor of LV remodeling after acute myocardial infarction (AMI). It could be useful in risk stratification of patients after AMI. (Echocardiography 2012;29:165‐172)

The effect of myocardial fibrosis on left ventricular torsion and twist in patients with non-ischemic dilated cardiomyopathy.

BACKGROUND Left ventricular (LV) rotation, twist, and torsion are important aspects of the cardiac performance. Myocardial fibrosis can be identified as the late gadolinium enhancement (LGE) in cardiac magnetic resonance (CMR). In this study, we investigated the association between myocardial fibrosis and LV rotational parameters in patients with nonischemic dilated cardiomyopathy (NDC). METHODS Twenty-two NDC patients were enrolled. LV dimensions, volumes and ejection fraction (EF) were measured, conventional tissue Doppler imaging data was acquired. Speckle tracking imaging was performed to measure LV deformation, LV rotational parameters. Blood samples were obtained for NT-proBNP. Late gadolinium enhanced cardiac magnetic resonance (LGE-CMR) was used to assess cardiac fibrosis index. RESULTS Myocardial deformation was similar between LGE+ and LGE- groups. LGE+patients have significantly higher basal and lower apical systolic rotation, lower twist and torsion when compared to LGE- patients. However, untwisting rate was similar between the groups. Torsion was significantly correlated with LVEF and MR-index. Patients with reversed apical systolic rotation had significantly greater NT-proBNP values, basal systolic rotation and significantly lower apical systolic rotation, torsion, and MR-index. CONCLUSIONS Cardiac fibrosis index is closely related with myocardial torsion and LV systolic function and may be used for the evaluation of cardiac condition. Reversed apical systolicrotation indicated more extensive cardiac fibrosis as it may reflect severe LV dyssynchrony andpoor LV performance.

Impact of systemic sclerosis on electromechanical characteristics of the heart.

Primary myocardial involvement is common in systemic sclerosis (SSc). We evaluated the atrial and ventricular electromechanical characteristics by using tissue Doppler echocardiography in SSc patients with subclinical cardiac involvement. Twenty-seven consecutive patients (24 women; mean age ± SD 49.9 ± 11.3 years) presenting with SSc without pulmonary arterial hypertension or symptomatic heart failure were prospectively studied. Electrocardiographic P-wave dispersion (Pd), corrected QT dispersion (QTcd), interatrial, intra-atrial, interventricular, and intraventricular electromechanical delays were analyzed by tissue Doppler echocardiography, and brain natriuretic peptide levels were measured. Results were compared with 17 healthy controls. There was no difference in conventional and tissue Doppler parameters between the two groups. However, patients with SSc had higher mean Pd (mean [±SD] 46.8 ± 15 and 36 ± 8 ms, respectively, P = 0.004) and mean interatrial electromechanical delay time (DT) (mean [±SD] 32.2 ± 9.2 and 24.7 ± 9.7 ms, respectively, P = 0.01), mean electromechanical delay time for all segments (Mean Ts) (mean [±SD] 148.8 ± 18.8 and 129.3 ± 13.4 ms, respectively, P < 0.001), and intraventricular DT (mean [±SD] 27.6 ± 12.5 and 16.2 ± 7.2 ms, respectively, P < 0.001). Intraventricular DT was the only parameter that correlated significantly with the Mean Ts. Brain natriuretic peptide levels were within normal limits in both groups; however, they were higher in patients with SSc than in controls (mean [±SD] 37.5 ± 28.5 and 23.1 ± 16.0 pg/ml, respectively, P = 0.03). The evaluation of atrial and ventricular electromechanical parameters by using tissue Doppler echocardiography seems to be useful for detection of subclinical cardiac involvement in SSc patients with normal conventional echocardiographic findings.

Aortic elastic properties in nonalcoholic fatty liver disease.

BackgroundRecent studies have shown that patients with nonalcoholic fatty liver disease (NAFLD) have an increased risk of developing cardiovascular disease. Aortic stiffness, an early marker of arteriosclerosis, is associated with cardiovascular mortality. In this study, the aortic elastic properties of nondiabetic, normotensive NAFLD patients were evaluated. MethodsThirty-five patients with NAFLD and 30 age-matched and sex-matched healthy controls were enrolled. Aortic distensibility, aortic strain, aortic stiffness index (ASI), left ventricular mass index (LVMI), homeostasis model assessment of insulin resistance (HOMA-IR) and fasting lipid parameters were assessed in both the groups. ResultsASI was higher in NAFLD patients (7.1±2.0) than in the control group (3.8±1.0) (P<0.01). Aortic distensibility and aortic strain were also significantly decreased in NAFLD patients as compared with the control group (2.9±0.7 cm2/dyn vs. 6.3±2.4 cm2/dyn, P<0.0001 and 7.1±1.7 vs. 14.5±4.0, P<0.0001, respectively). Although ASI was significantly correlated with age, HOMA-IR, waist circumference, body mass index and LVMI, a stepwise multiple linear regression analysis showed that HOMA-IR and LVMI were the only variables associated with ASI index [(standardized β coefficient= 0.41, P=0.004, overall R2=0.17) and (standardized β coefficient=0.31, P=0.02, overall R2=0.10), respectively]. ConclusionOur data suggest that aortic elasticity is significantly impaired and is also associated with insulin resistance and LVMI in NAFLD patients, which may contribute to the relationship between NAFLD and the increased risk of cardiovascular disease among these patients.