validity of pulse wave tissue doppler imaging in predicting elevated left ventricular end diastolic pressure in patients with coronary artery disease

Background: Elevated left ventricular filling pressures are the main physiological consequence of diastolic dysfunction and carry a prognostic significance in different cardiovascular diseases including coronary artery diseases, and cardiomyopathies. Filling pressures are considered elevated when the mean pulmonary capillary wedge pressure is >12mmHg or when the left ventricular end diastolic pressure is >/= 16 mm Hg. a reliable noninvasive method for the estimation of LVEDP is needed

Objective: The aim of this study was to evaluate the correlation between the Tissue Doppler Imaging derived E/e ratio, and Left Ventricular End Diastolic Pressure [measured during left ventricular catheterization] in patients with significant Coronary artery Disease, and to identify the optimal cutoff value of the E/e ratio to predict elevated LVEDP

Patients and Methods: This study included 87 patients scheduled for elective coronary angiography at Ibn-Albitar Hospital catheterization laboratory between December 2012 and April 2013.Transthoracic echocardiography was performed to all patients within 2 hours before left heart catheterization, using Philips echocardiography system and S5-1 probe. Mitral valve inflow velocities were assessed by Pulsed-wave Doppler performed in the apical 4-chamber view. Ejection fraction [EF] was measured with biplane Simpson's method from the apical 4-chamber view. PW TDI was performed in the apical 4-chamber view to measure mitral annular velocities from the medial and lateral mitral annuli

Results: The mitral inflow velocities [E, and A] were not correlated to LVEDP while the E/A ratio had a weak positive and the DT of the E wave had a weak negative correlations with LVEDP. E/e ratio showed intermediate to good positive correlation with LVEDP especially those derived from the medial mitral annulus. The correlation between E/e ratio and LVEDP was similar in the patients with or without significant CAD. The ROC curve showed that the cutoff point of E/ e ratio for predicting LVEDP higher than 15mm Hg was from medial mitral annulus > 15 [sensitivity 77.5 %, specificity 84.6%; P<0.001] and from lateral mitral annulus >10 [sensitivity 79 %, specificity 80.3 %; P < 0.001]. On subgroup classification according to EFs, the E/e medial showed significant but weaker correlation with LVEDP in patients with EF >/= 50%, as compared to patients with EF < 50 %. E/e lateral and E/e average had poor correlation with LVEDP in patients with EF >/= 50 %, while they have intermediately significant correlation in patients with EF < 50%

Conclusion: The TDI derived E/e ratio is better than mitral inflow doppler velocities and intervals for predicting elevated LVEDP in patients with or without significant CAD, especially in patients with reduced EF. The E/e medial > 15 and E/e lateral > 10, predict LVEDP > 15 mm Hg with good sensitivity and specificity

Long term effect of permenant right ventricular pacing on left ventricular systolic function

Background: Right ventricular apical pacing is associated with alterations of left ventricular contraction sequence and dilatation and may have a deleterious effect on left ventricular function

Objective: The study investigates the correlation between left ventricular function and long term right ventricular pacing

Methods: In this study, 80 patients with permanent right ventricular apical [VDD and DDD] randomized to assess left ventricular systolic function particular LVEF%. primary end point was LVEF% after 1 year of pacing

Results: In this study, the mean LVEF% was reduced after hear of right ventricular pacing from [67.47 +/- 2.94 to 55.89 +/- 8.41, p value 0.0001], with absolute reduction of about 12%. Patients with LV systolic dysfunction [EF% less than or equal to 45%] which constitute 10 patients [12.5%] have mean baseline LVEF% [66.70 +/- 4.03 reduced to 3.50=6.38, P value 0.0001]. Cumulative percentage of RV pacing and duration are predictors of LVEF% reduction

Conclusion: Conventional right ventricular apical pacing resulted in a significant reduction in the left ventricular ejection fraction, particularly in patients with high percentage of right ventricular pacing and should be suspected in any patients after long term pacing of right ventricular. Functional rather than topographic criterion should be considered for optimal pacing

Correlation of angiographic findings and clinical presentations in unstable angina

Unstable angina is usually related to acute thrombosis superimposed on a disrupted plaque. The highest; level of Braunwald classification of unstable angina can be used to assess the severity of clinical presentation. However the highest classes have not been directly correlated with thrombotic and complex lesions. The study was done to clarify the correlation between angiographic findings and the most acute and / or severe clinical presentation in unstable angina. We conducted a prospective study of 110 patients of unstable angina at Ibn-Albitar Center for Cardiac Surgery. All of these patients underwent cardiac catheterization, culprit lesion was identified in 80 patients and in 30 patients there was no an identifiable culprit lesion.Complex lesions including complex morphology, intracoronary thrombus, or total occlusion were also quantitatively analyzed and Thrombolysis in Myocardial Infarction [TIMI] flow grade was assessed. Patients were classified according to Braunwald classification in instable angina.We compared patients with and those with no culprit lesions in regarding Braunwald classification. We sequentially compared the highest Braunwald classes II, C, 3 with classes

Experience in ICD implantation and follow-up in Ibn-Albitar Hospital

Survivals of sudden cardiac death [SCD] episodes have recurrence rate of 30-50% within two years, with malignant ventricular arrhythmias most often responsible. The overall survival rate for SCD in USA is 5%. Ninety-five percent of patients suffering their initial event fail to survive to become candidate for secondary prevention. Because of the wide spread acceptance of implantable cardioverter defibrillator [ICD] as a method treating the survivals of SCD, attention has turned to primary prevention. Implantable cardioverter-defibrillator [ICD] is highly effective in primary and secondary prevention of SCD due to life threatening ventricular tachycardia [VT]. To register and interpret the results of implantation and follow-up of ICD during the period between 2002-2007 in Ibn Al-Bitar hospital. Sixty patients with standard indications for ICD; data were pooled from patients history, ECG, Echocardiography, Holter, blood investigation and coronary angiography.75% males and 25% females. After implantation, class III anti-arrhythmic drugs [Amiodarone] were stopped, except for patients with a history of supraventricular tachycardia or recurrent VT. Coronary artery disease [CAD] was the most common presentation of patients for whom implantation was done; coronary artery disease [CAD] 43%, dilated cardiomyopathy [DCM] 26%, and hypertrophic obstructive cardiomyopathy [HOCM] 16%. Sixty-three of them had moderate-severe LV dysfunction [LVEF<40%]. Recurrent VT was the most common cause of implantation [76%]. Primary prevention was aimed in [60%] of patients and secondary prevention in 40%. Sixty percent of those with ICD implanted due to primary prevention fulfil MADIT II [Multicenter Automatic Defibrillator Implantation Trial II] criteria. The majority of patients had structural heart disease. Most non-sustained VTs reverted to sinus rhythm by antitachycardia pacing [ATP] therapy from ICD [90%].A11 VF events reverted to sinus rhythm by high energy shock from ICD devices. ICD is highly effective in primary and secondary prevention of life threatening VT/VF