Victor F. Huckell

Femoral vein delivery of contrast medium enhances transthoracic echocardiographic detection of patent foramen ovale

OBJECTIVES We postulated that femoral vein delivery of contrast medium because of streaming, might enhance precordial echocardiographic detection of patent foramen ovale. BACKGROUND Although precordial contrast echocardiography is widely used to diagnose patent foramen ovale, this method is limited by poor sensitivity. Previous investigators have demonstrated enhanced detection of atrial defects by the dye-dilution technique after delivery of contrast medium into the inferior rather than the superior vena cava. METHODS Transthoracic contrast examinations were performed in a randomly selected group of 70 patients (without previous history of cerebral or systemic embolus) undergoing cardiac catheterization. Paired contrast agent injections (10 ml dextrose in water/0.25 ml air) were administered from an upper extremity vein and femoral vein in each patient during spontaneous respiration, cough and Valsalva maneuvers. Studies were interpreted by an experienced echocardiographer unaware of the sequence and site of injections. Positive studies were semiquantitatively graded from +1 (minimal left ventricular opacification) to +4 (intense left ventricular opacification). Catheterization and echocardiographic assessment of patent foramen ovale were compared in 21 subjects. RESULTS Patent foramen ovale was detected significantly more often during femoral vein versus upper extremity contrast delivery (23 of 70 patients [prevalence 33%] vs. 9 of 70 patients [prevalence 13%], p < 0.001). The intensity of left ventricular opacification was also greater during femoral vein contrast injection. Precordial echocardiography combined with femoral contrast delivery was significantly more sensitive than cardiac catheterization for assessment of patent foramen ovale (8 of 21 patients vs. 2 of 21 patients, p < 0.05). CONCLUSIONS Femoral vein contrast delivery significantly enhances the ability of precordial contrast echocardiography to diagnose patent foramen ovale. Physiologic patency of the foramen ovale is more common (prevalence 33%) than previously documented.

Canadian Cardiovascular Society Guidelines for the Diagnosis and Management of Stable Ischemic Heart Disease

This overview provides a guideline for the management of stable ischemic heart disease. It represents the work of a primary and secondary panel of participants from across Canada who achieved consensus on behalf of the Canadian Cardiovascular Society. The suggestions and recommendations are intended to be of relevance to primary care and specialist physicians with an emphasis on rational deployment of diagnostic tests, expedited implementation of long- and short-term medical therapy, timely consideration of revascularization, and practical follow-up measures.

Left ventricular abnormalities in arrhythmogenic right ventricular dysplasia

Abstract Right ventricular (RV) dysplasia is a condition in which the RV myocardium is partially or totally absent and replaced with fibrous or fatty tissue. Dysplasia may be mild or there may be total absence of myocardium, with apposition of endocardium to epicardium.1–4 When associated with ventricular arrhythmias the condition has been termed arrhythmogenic RV dysplasia.4 This condition was believed to involve exclusively the right ventricle.5,6 Recently, however, left ventricular (LV) abnormalities have been described in association with RV dysplasia.7 From patients presenting over a 2-year period to the electrophysiology service at our institution, we identified 4 patients with recurrent ventricular tachycardia (VT) of RV origin and morphologic features typical of RV dysplasia. This report describes our findings (Table I).

Anaesthetic management and non-invasive monitoring for Caesarean section in a patient with cardiomyopathy

This paper describes the anaesthetic management of a 29-year-old woman for an elective repeal Caesarean section. A diagnosis of peripartum cardiomyopathy (PPCM) had been made after her first delivery by Caesarean section three years earlier. Although the patient was currently asymptomatic, recent echocardiography demonstrated persistent left ventricular dilatation. The choice of haemodynamic monitors and the clinical significance of PPCM in this situation are discussed.RésuméCette étude décrit la conduite anesthésique chez une femme de 29 ans subissant une deuxiàme césarienne élective. Trois ans auparavant on avait diagnostiqué une cardiomyopathie péripartum (CMPP) à la suite de son premier accouchement par césarienne. Bien que la patiente fut présentement asymptomatique, une échocardiographie récente démontrait une dilatation ventriculaire gauche persistante. On discute du choix de moniteurs hêmodynamiques et de ľimportance clinique de la CMPP dans cette situation.

Atrial Paralysis in a Patient with Emery-Dreifuss Muscular Dystrophy

Emery‐Dreifuss disease is a benign X‐linked muscular dystrophy characterized by a distinct pattern of muscle weakness, which is of insidious onset and slow progression. It is associated with atrial paralysis that results in sudden death in early adulthood if left untreated. The authors report the documentation of electrical and mechanical silence confined to the atria in a patient with this disease. Electrocardiography and electrophysiological study document the absence of electrical atrial activity, and inability to pace the atria, Hemodynamic studies demonstrate the absence of A waves, and angiography revealed immobility of the atria. This patient has done well following the institution of permanent ventricular pacing. His brother, who also had muscular dystrophy, died a sudden cardiac death at the age of 29 after refusing medical intervention. Emery‐Dreifuss muscular dystrophy is particularly worthy of recognition because of the preventable occurrence of sudden death in young patients with an otherwise excellent prognosis. Permanent ventricular pacing is indicated.

Cardiovascular Physiology: Similarities and Differences between Healthy Women and Men

Abstract We have falsely assumed that the response of the cardiovascular system to external stimuli is die same in men and women; however, normal cardiovascular physiology in women and men differs in several important ways. This article outlines the key known differences between cardiovascular responses in women and men. It will include blood pressure, heart rate, stroke volume, cardiac output, and response to exercise training. Cardiovascular disease is the leading cause of death in both women and men; therefore, it is important to focus research and investigations on these differences.

Validity of algorithm for estimating left sided filling pressures on echocardiography in a population referred for pulmonary arterial hypertension

The determination of LV filling pressure is integral to the diagnosis of pulmonary arterial hypertension (PAH). The American Society of Echocardiography (ASE) has devised algorithms for their estimation. We aimed to test these algorithms in a population referred for suspected PAH. In our retrospective study, we evaluated the accuracy of the ASE Algorithms compared to right heart catheterization done within three months, in patients seen during 2006–2014. All echocardiograms were classified as showing normal, elevated or indeterminate filling pressures. Those with indeterminate pressures were excluded. We evaluated the diagnostic properties of this algorithm to predict a pulmonary artery wedge pressure (PAWP) and left ventricular end diastolic pressure (LVEDP) >15 mmHg. A total of 94 patients were included. The ASE algorithms yielded indeterminate results in 50 (53.2%) patients. This occurred more commonly in older patients and patients with cardiovascular comorbidities. The algorithm had a high sensitivity for predicting an elevated PAWP at 89.5% (95% confidence interval [CI] = 66.9–98.7) and an elevated LVEDP at 100% (95% CI = 76.8–100). The algorithm had a negative predictive value of 81.8% and 100% for predicting an elevated PAWP (95% CI = 52.4–94.8) and LVEDP, respectively, but a poor positive predictive value. The ASE algorithm for predicting LV filling pressures often cannot be applied in populations with suspected PAH. When they are interpretable, they have a high negative predictive value for elevated PAWP and LVEDP. We recommend caution when using these algorithms in populations with suspected PAH.

Comparison of thermodilution and indirect Fick cardiac outputs in pulmonary hypertension

BACKGROUND The accurate measurement of cardiac output (CO) is required in patients with pulmonary hypertension (PH).While both the thermodilution (TDCO) and indirect Fick (IFCO) methods are commonly used, there is little data comparing them in patients with PH. METHODS We performed a retrospective analysis of patients evaluated at our center. All patients who had right heart catheterization (RHC) within 3 months of an echocardiogram, and CO assessment by both TDCO and IFCO methods were included. Bland-Altman analysis was used to assess agreement between the two methods. We further evaluated their agreement in each sex, and within tertiles of age, BMI and TR severity. We investigated the correlation between each method of CO and objective parameters of right ventricular function on echocardiography. RESULTS In a cohort of 168 patients, the correlation between IFCO and TDCO was modest at (r = 0.61). On average, values for CO were lower with IFCO than with TDCO, by 0.62 L/min (95% CI -0.82, -0.40). This difference was greater for females: 0.86 L/min (95% CI -1.08, -0.63) and in the highest tertile of BMI: 0.97 L/min (95% CI -1.4, -0.55). Moderate and severe TR did not in general result in lower TDCO values. Echocardiographic parameters of right ventricular function were correlated more strongly with TDCO than with IFCO. CONCLUSION In PH patients, IFCO was substantially lower than TDCO on average, suggesting that these two techniques cannot be used interchangeably. TDCO correlated more strongly with echocardiographic measures of RV function, suggesting that it may be preferred over IFCO.

Cardiovascular Non-Disease and Disease in Pregnancy

Abstract Pregnancy produces dramatic changes in all aspects of female physiology. The cardiovascular system is not excluded from these extraordinary changes. All parameters of history, physical examination, and laboratory evaluation must be modified based on our understanding of the normal or physiologic responses to pregnancy. This article reviews the normal physiology of pregnancy and expected changes in the symptoms and signs of a normal pregnancy versus cardiovascular disease in pregnancy. Cardiac lesions of low, medium, and high risk are outlined.