ABSTRACT
Right atrial appendage [RAA] thrombi and dysfunction have been reported in patients with atrial fibrillation [AF]. Although pulmonary embolism was a life-threatening complication of AF, there are little data about RAA and its thrombi in AF. Furthermore, to date there have been no prospective studies designed to examine RAA in patients with rheumatic mitral stenosis [MS]. To define RAA anatomical and functional parameters and to compare them with left atrial appendage [LAA] parameters in patients with moderate MS both in AF and in sinus rhythm [SR] and to study the implications for local thrombus formation. Transthoracic [TTE] and multiplane transesophageal echo [TEE] were performed in 31 patients with moderate MS [16 in SR. Group I and 15 in AF, Group II]. We measured mitral valve area [MVA], mean pulmonary artery pressure [MPAP], left atrial diameter [LAD], LV EDD and ESD, EF%, RAA and LAA neck width, length, area, ratio of neck to area, and emptying velocity. We assessed also the incidence of RA-RAA and LALAA SEC and thrombi. Adequate visualization of RAA was highly feasible by TEE in 31/34 [91%] of patients. RAA anatomic and functional parameters were independent of imaging plane. Patients in AF had significantly increased LAD [p=0.004] and MPAP [p<0.0001] than those in SR. The RAA area was proportional to the LAA area [r=0.87, p<0.0001] only in patients with SR. On the other hand, RAA neck width and ratio of neck width to area were greater than those of LAA while LAA length and area were greater than those of RAA regardless the presence of AF. AF caused more enlargement in LAA [10.21 +/- 4.15 Vs 5.41 +/- 1.78, p<0.0001] compared to RAA [5.37 +/- 2.08 Vs 4.40 +/- 1.44, p=NS] while more dysfunction in RAA / [reduced emptying velocities [0.45 +/- 0.11]-[0.28 +/- 0.08], [40%] p<0.0001] compared to that of the LAA [0.43 +/- 0.08] - [0.32 +/- 0.14], [25.6%] p<0.01/ ]. AF caused higher prevalence of RAA spontaneous echo contrast [SEC] [66.7%] than in SR [37.5%], [p<0.0001]. Also it caused higher RAA thrombosis [46.7%] than in SR [25%], [p=0.001]; and finally RAA SEC was the only independent predictor of RAA thrombosis in SR [p=0.04] while the reduced ejection velocity was the only independent predictor of RAA thrombosis in MS patients with AF [p=0.04]. RAA imaging was highly feasible. RAA anatomic and functional parameters were independent of imaging plane. AF was associated with RAA minimal remodeling, maximal dysfunction and subsequently thrombosis. RAA dysfunction and SEC were independent predictors for RAA thrombosis. RAA SEC and thrombosis were directly proportional to LAA remodeling and dysfunction. Therefore, assessment of not only LAA but also RAA may be important during TEE examination of patients with MS
Subject(s)
Humans , Male , Female , Echocardiography, Transesophageal , Mitral Valve Stenosis/complications , Thrombosis , Atrial FibrillationABSTRACT
Unlike left ventricular [LV] function, right ventricular [RV] function has not been widely studied after myocardial infarction [RVMI]. Furthermore, rapid, accurate, and widely available non-invasive evaluation of RV function still presents a problem. The purpose of this study was to determine whether parameters derived from tissue Doppler imaging [TDI] of tricuspid annulus could be used to detect RV infarction and so to assess RV function in patients with first acute inferior myocardial infarction [AIMI]. Patients and. We examined 27 patients with first AIMI admitted to CCU at El Minia University Hospital between March 2005 and October 2007, 12 with [group I] and 15 without ECG signs of RVMI [group II]. Twenty adults served as controls [group III]. Patients with any cardiovascular risk factor were excluded. Tissue Doppler Echocardiographic [TDE] study included recording of peak systolic [Sm], early diastolic [Em], late diastolic [Am] and [Em/Am] ratio of tricuspid annular velocities at 2 sites corresponding to the septum and RV free wall from apical 4 chamber view. Ejection time [ET], isovolumic relaxation time [IVRT], and isovolumic contraction time [IVCI'] were also recorded, then, Tie index [MPI] was calculated for each site. Standard echo Doppler study, electrocardiogram [ECG] and cardiac enzymes were also performed. Patients with AIMI had significantly reduced peak Sm, Em, Am and Em/Am ratio and increased IVRT, IVCT, ET and Tei index at the 2 sites especially at the RV free wall [infarction site] compared with healthy controls. At septal side of the tricuspid annulus, the peak Sm, Em, and Am were significantly reduced in group I compared with both group II, p=0.032. p<0.0001, p=0.001 respectively and group Ill, p<0.0001 for all velocities, with slightly significantly reduced velocities in group II compared with controls, p=0.012, 0.016, 0.030 respectively. The Sm/Am ratio was significantly decreased in group I compared with both group II, p<0.0001 and group Ill, p<0.0001 without significant difference between the latter two groups. While, the IVRT, IVCT, and ET were significantly increased in group I compared with both group II, p=0.004, 0.043, 0.005 and group Ill, p<0.0001, 0.0001, 0,026 respectively. Apart from ET, both of IVRT and IVCT were also increased in group II compared with group lII, p=0.03, 0.009. The septal MPI was significantly increased in both group I, p=0.002 and group II, 0.003 compared with controls without difference between both groups. On the other hand, at RV free wall, these myocardial velocities and Em/Am ratio were significantly reduced only in group I compared with both group 11, [p<0.0001 for all, p=0.029 for Em/Am ratio] and group Ill, [p<0.0001 for all, p=0.016 for Em/Am ratio] without significant difference between the latter two groups. While, IVRT, IVCT, ET, and RV MPI were significantly increased also only in group I compared with both group II, p<0.0001 for all and group Ill, p<0.0001 for all, without significant difference between the latter two groups. At Sm cutoff value of <12 cm/s, we were able to detect RVMI by 85% sensitivity, 93% specificity, 92% PPV, and 87% NPV, while at RV MPI >0.7, these were 92%, 100%, 100%, and 93% respectively. Systolic and diastolic myocardial velocities at the tricuspid annulus can be easily and quickly recorded by pulsed wave TDE. The decreased velocities and increased MPI seem to be an expression of regionally reduced myocardial function especially at the RV infarction site and so reflects RV systolic and diastolic dysfunction. Therefore, TDE can be used to assess RV systolic and diastolic function in patients with AIMI
Subject(s)
Humans , Male , Female , Ventricular Function, Right , Echocardiography, Doppler , PrognosisABSTRACT
Standard coronary angiography [SA] has some limitations and complications. Technology has been developed to perform rotational coronary angiography [RA] that may overcome SA limitations and complications while keeping the diagnostic accuracy. RA is a technique that provides with one contrast injection, a panoramic or dynamic cineangiogram of the coronary tree, during up to 180 rotation of the gantry. The purpose was to compare RA and SA regarding diagnostic accuracy and patient safety. Our study included 20 patients with a clinical indication for diagnostic coronary angiography [CA] at Cardiology Department, El Minia University Hospital. Patients were subjected to: SA [4 fixed projections for LCA and 2 for RCA] and RA [2 projections for LCA [RAO 60- LAO 60- caudal and cranial] and [1 projection for RCA [RAO 30- LAO 90- cranial]]. Acquisition of additional static angiographic projections was done for better diagnostic assessment whenever needed after SA and/or RA. QCA analyses were performed on two views [first from SA and second from RA] showing a significant lesion. Radiation dose [RD], contrast volume [CV], total number of frames [TNF], total number of image acquisitions [TNIA], additional projections [AP], reference vessel diameter [RVD], minimal lumen diameter [MLD], lesion percent stenosis [LPS] and lesion length [LL] were evaluated and compared between the two angiographic techniques. We analyzed 38 lesions. Their distributions were: 19[50%] in LAD, 9[23.68%] in RCA, 7[18.42%] in circumflex and 3 [7.89%] in the diagonals. There were no statistically significant differences between SA and RA derived QCA data in MLD[1.197 +/- 0.651 Vs 1.175 +/- 0.642], RVD[2.8l9 +/- 0.961 Vs 2.752 +/- 0.99], LPS [65.495 +/- 16.225 Vs 64.989 +/- 16.426], and in LL [12.575 +/- 6.392 Vs 12.406 +/- 6.338], p ns for all. At the same time, RA derived QCA data strongly correlated with SA derived QCA data with correlation coefficient, 0.99 1, 0.975, 0.994, and 0.996 respectively. On the other hand, RD was 44% less [245.83 +/- 132.17 Vs. 442.23 +/- 272.55 mGy], CV was 45% lower. [24.28 +/- 10.78 Vs. 43.98 +/- 20.77 ml], TNF was 45% fewer [162 +/- 65.54 vs. 293.21 +/- 142.83], TNIA was 59% lower [1.82 +/- 0.67 vs. 4.46 +/- 1.88], and AP was 82% lower beyond the pre specified protocol [0.21 +/- 0.49 vs. 1.179 +/- 1.249] in the RA compared to the SA technique, p<0.0001 for all. RA-derived QCA has similar diagnostic accuracy and strongly correlates with SA derived QCA. Furthermore, RA has better safety as it leads to a significant reduction in radiation exposure and contrast use. In the future therefore, RA may replace SA and should be compared with MSCT CA in diagnosis of CAD especially if coupled with minimally invasive approaches such as radial access and use of 4 French devices
Subject(s)
Humans , Male , Female , Coronary Artery Disease/diagnosis , Diagnostic Techniques and Procedures , Comparative StudyABSTRACT
Patients with nephrotic syndrome [NS] are assumed to be at increased risk for atherosclerosis and coronary heart diseases [CHD], probably because of NS associated with hyperlipidemia, hypertension and steroid therapy. This study was aimed at evaluation of the carotid intimal thickness as a predictor of developing atherosclerosis in children and young adolescents with nephritic syndrome. Twenty-five children and young adolescents attending the pediatric nephrology outpatient clinic of El- Minia university hospital were enrolled in this study. They were 16 males and 9 females. Their age range between 8 and 14 years with a mean of 11 +/- 2.1 years. They were subdivided into 2 subgroups; one included 15 patients [60%] having proteinuria and not responding to steroid therapy and the other included 10patients [40%] having proteinuria and responding to steroid therapy. Fifteen healthy age and sex matched young adolescent served as a control group. All patients were subjected to thorough history taking and clinical examination. All subjects in the study underwent laboratory investigations including urinalysis, 24-hour protein in urine, serum creatinine, Triglycerides [TGs], cholesterol, low and high density lipoproteins [LDL and HDL], as well as carotid duplex. The results showed that carotid intimal thickness was significantly higher in nephritic patients than the results showed that carotid intimal thickness was significantly higher in nephritic patients than controls [p<0.001]. Serum LDL and cholesterol were significantly higher in nephritic patients than controls [p<0.01, p<0.02 respectively]. Carotid intimal thickness was directly correlated to relapse rates and serum HDL, LDL and cholesterol [p<0.001 for each]. Nephrotic patients with long duration of illness. Resistant to steroid therapy, have a history of hypertension and hyperlipidemia are more susceptible to early development of atherosclerosis and subsequent cardiovascular complications so they must be properly controlled especially early use of statins in children and young adolescent in those with high risk factors. Follow up of the high-risk nephrotic adolescent for possible development of CHD in young adulthood is recommended