Left and right atrial appendage function in patients with chronic atrial fibrillation

Transoesophageal echocardiography [TEE] has been shown to be a useful technique for assessing left atrial appendage [LAA] function by measuring LAA flow velocities. Recently, right atrial appendage [RAA] thrombi and depressed RAA function have been reported in patients with atrial fibrillation [AF]. To assess right atrial appendage flow and its possible relationship to left atrial appendage flow in patients with chronic AF; also to assess RAA function and its relation to early detection of new right atrial thrombi. This study included 90 patients presenting to the National Heart Institute and to Mataria Teaching Hospital for cardiovascular assessment by TEE: 40 patients with chronic non valvular AF, 40 patients with chronic valvular AF and 10 normal individuals acting as controls. All patients included in the study were subjected to the following: careful history taking, complete clinical examination, resting 12 lead ECG, plain chest X-ray, transthoracic echocardiography [TTE] and transoesophageal echocardiography [TEE]. Patients with chronic nonvalvular AF were significantly older, and the duration of AF was significantly longer than those with chronic valvular AF. Patients with chronic nonvalvular AF had significantly larger RA and RAA area than those with chronic valvular AF. Patients with chronic valvular AF had larger LA and LAA area than those with chronic nonvalvular AF. RAA and LAA emptying velocities were both reduced in valvular and non-valvular AF patients. TEE showed that 15% of patients with chronic valvular AF had left atrial thrombus 10% of patients with non-valvular AF had atrial thrombus, while none of the controls showed atrial thrombosis. Left atrial spontaneous echo contrast [SEC] was shown in 80% of chronic valvular AF and in 35% of chronic non-valvular AF, while right atrial SEC was shown in 25% of all patients. Our findings suggest that AF can affect both atria equally in nonvalvular AF, in contrast to valvular AF which affects the left atrium only. Therefore, the assessment of RAA and LAA function as well as atrial SEC may be important in patients with chronic nonvalvular AF and are especially so as predictors to intra-atrial thrombosis

Relation of papillary muscle traction to autonomic nervous system dysfunction as evaluated by head-up-tilt-test in mitral valve prolapse

Mitral valve prolapse [MVP] is one of the commonest valvular abnormalities and is characterized by systolic superior leaflet displacement. This results in abnormal tension on the papillary muscles which may lead to, or is associated with alteration in the autonomic functions. The aim of this work is to detect and assess papillary muscle traction [PMT] in patients with idiopathic MVP in a trial to correlate it with any autonomic dysfunction as evaluated by head-up-tilt test [HUTT]. Thirty symptomatic MVP patients and a control group of 15 persons [cardiologically free], aged 15-35 years, were enrolled in the study. They were all thoroughly evaluated clinically, radiologically, electrocardiographically and by ECHO-Doppler. Patients with secondary causes for MVP were excluded. PMT was measured by 2-dimentional ECHO in all patients and controls who were subsequently subjected to HUTT. The obtained results showed both groups to be comparable. The MVP patients showed mitral regurgitation [MR] in 13 cases [43.3%]. Seventeen patients [56.7%] had MVP with no MR. PMT was greater in patients than in controls [5.7+/-3 versus 0.85+/-0.7mm], p value <0.001. Leaflet displacement as well as PMT index were also significantly higher in patients than in controls [p<0.001]. HUTT was positive [provoking syncope or presyncope associated with hypotension, bradycardia, or both] in six MVP patients [20%] and in none of the controls. HUTT appeared to be predictable by four of the studied parameters, namely, leaflet displacement, PMT, traction index and MR. Ten patients had PMT >/=6mm and 20 patients had it <6mm as shown by ECHO. Six out of the 10 patients who had PMT of >/=6mm had abnormal response to HUTT, while none of the 20 patients with PMT <6mm, and none of the controls had an abnormal response to HUTT. A statistically derived predictor value of >/=6mm PMT should be considered as an indicator to perform HUTT to MVP patients in a trial to detect asymptomatic patients prone to syncope. We recommend that PMT be a part of routine ECHO examination of MVP patients. Those with MR or PMT of 6 mm or more should be evaluated by HUTT for the occurrence of syncope or other manifestations of autonomic dysfunction aiming at avoidance or decrease of morbidity in this group of patients

Left ventricular outflow tract pre-systolic flow velocity in hypertensive patients: a correlation with left ventricular hypertrophy and left ventricular filling patterns

Introduction: Abnormal left ventricular [LV] filling may exist in early stages of hypertension. Whether this finding is related to LV hypertrophy [LVH] is currently controversial. Doppler echocardiography is a noninvasive technique that can be used for measurement of diastolic filling and identification of different patterns of LVH. Four distinct early filling/late diastole [E/A] ratio patterns [normal, delayed relaxation, pseudonormal, restrictive] can be discerned. Consideration of the level of LV mass and of the LV wall thickness/chamber radius ratio [relative wall thickness] has identified four different geometric patterns of LV adaptation to hypertension: concentric LVH, eccentric hypertrophy, concentric remodeling and normal LV geometry. The blood entering the LV during atrial systole produces a countercurrent along the septum towards the aortic valve. This results in a presystolic wave in the LV outflow tract [LVOT]. The magnitude of this countercurrent should be significantly affected by the compliance of LV at the time of atrial systole

Aim of Work: Assess the relation between LVH, LV filling patterns, and LVOT pre-systolic peak flow velocity [LVOTV] in hypertensive patients

Patients and Methods: 50 patients with hypertension were subdivided into two groups according to the presence or absence of LVH by echocardiography. Each patient was subjected to a careful history analysis, complete clinical examination, resting electrocardiogram and an echocardiogram. The following M-mode parameters were recorded: end-diastolic and end-systolic thickness of interventricular septum, of LV posterior wall and of LV cavity, left atrial dimension at end systole, ejection fraction, fractional shortening, LV mass and relative wall thickness. Peak E and A velocities, E/A ratio, deceleration time [DT] and LVOTV were calculated by pulsed Doppler. All patients' data were tabulated and statistically analyzed

Results: There was no statistically significant difference between the E wave of patients with LVH and those without; while the A, E/A ratio and DT were statistically different between the two groups. Identical findings were also found when correlating the previous Doppler measurements with each of the different patterns of LVH. Comparing the LV filling patterns in different groups of LVH, a statistically significant difference was found. Also, LVOTV was positively correlated with LVH patterns, being highest with concentric hypertrophy and lowest with concentric remodeling. It was also strongly correlated to all filling parameters, being highest with abnormal relaxation and lowest with the restrictive pattern. This finding was valid in all Doppler measurements except the E wave, where no correlation could be found

Conclusion: Hypertension is the most common risk factor for heart failure [HF]. LV relaxation is often abnormal with or without LVH, suggesting that abnormal relaxation may be an early response to cardiac pressure overload. There is a strong relation between the patterns of LV filling and of LVH. LV dimensions and LV mass index have an effect on the intraventricular pressure and flow velocity: Thus, they strongly affect the LVOTV. The latter can be used as a good marker of impaired LV compliance during atrial contraction. It can also be used to differentiate between normal and pseudo-normal LV filling patterns, but more work is needed to establish the exact status of this preliminary observation

Relative ischemic burden in different patients populations in Mataria district: a pilot study

In diabetic patients, cardiovascular disease remains the leading cause of death, and myocardial infarctions tend to be more extensive and have a poorer outcome than in age, weight and sex matched individuals without diabetes. Diabetes mellitus, which is one of the major risk factors for ischemic heart disease [IHD], is increasing all over the world especially in developing countries, raising with it the incidence of IHD. Most of the ischemic burden on the myocardium is silent, especially in diabetics, due to the presence of autonomic neuropathy. The aim of this study is to evaluate the relative incidence of silent ischemic episodes and the total ischemic burden in diabetic and non diabetic patients, whether known to be ischemic or not, in Mataria district. This study includes four groups of male individuals, aged 45 to 60 years, attending the outpatient clinic of Mataria Teaching Hospital. Group I includes 20 diabetic patients known to be ischemic; group II includes 20 diabetic patients clinically free from IHD; group III includes 20 non diabetic patients known to be ischemic and group IV includes 20 non diabetic non ischemic individuals. A 24-hours ambulatory ECG recording was done for all individuals and analyzed for significant ST-segment deviation. The results of this study show that ischemic patients whether diabetic or not, are significantly more hypercholesterolemic than non ischemic individuals. The number of patients showing ischemic episodes are greater in the diabetic ischemic group than in the ischemic non diabetic group [60% versus 45%], and the total number of episodes, whether manifest or silent was also greater in the former than in the latter group [71: 49]. The study confirms also the fact that the number of silent ST shifts is much more than the symptomatic ones [81.7% versus 18.3% in diabetic ischemic patients, and 65.3% versus 34.7% in ischemic non diabetic patients]. Moreover, diabetic patients who are not known to be ischemic show more silent episodes than the control group. These findings confirm that episodes of silent ischemia are present in a good percentage of patients with angina and a higher prevalence of these episodes is present in diabetic patients. This should urge us to give more care to the diabetic patients, whether already diagnosed as ischemic or not. The proper and early detection of diabetic patients with silent ischemia will result in a more rapid initiation of appropriate treatment and a much more favorable outcome

Efficacy and outcome of transmyocardial revascularization [TMR]: initial egyptian experience

In this study, 37 patients [with age 52 +/- 10.1, 31 males and 6 females] with severe coronary artery disease [CAD] and intractable angina were subjected to TMR. Nineteen patients had prior myocardial infarction [MI]. The mean angina class was 3.4 +/- 0.5. All patients were subjected to stress-redistribution reinjection [ST-RD-RI] Thallium SPECT protocol and rest 99 mTc-RBG MUGA just before, 3, 6, 9 and 12 months after TMR, aiming to assess the degree of change in perfusion in the ischemic area using semiquantitative score [I = normal and 4 = absent uptake] and to assess the function. The study concluded that TMR can be used effectively in cases of severe CAD, which could not be managed by either CABG or PTCA. Myocardial perfusion imaging is a good method to assess TMR results

Transmyocardial revascularization [TMR] versus medical treatment in patients with exensive coronary artery disease [12 months follow-up]

The aim of this study was to compare the efficacy of TMR versus medical management in cases of severe CAD not amenable to percutaneous transluminal coronary angioplasty [PTCA] or coronary artery bypass grafting [CABG]. Sixty-six patients with severe CAD were treated randomly, either by TMR or medical treatment. Accordingly, they were divided into two groups: Group 1 included 26 patients who were treated medically, while group 2 included 40 patients who were treated by TMR. All patients were subjected to clinical assessment and stress-redistribution-reinjection [ST-KD-RI] Thallium SPECT protocol pre and post TMR [3, 6, 9 and 12 months]. The study concluded that TMR has been proved to be effective in the management of severe cases of CAD concerning the quality of life and survival. Transmyocardial revascularization is a treatment option for patients with medically refractory angina who are not candidates for conventional revascularization

Complete heart block complicating acute myocardial infarction [pattern, management and in-hospital outcome]

852 consecutive patients admitted to the CCU in Matareia Teaching Hospital [MTH] were studied to assess the incidence of complete heart block [CHB] in acute myocardial infarction [AMI], and evaluate its outcome and the type of therapy applied. Out of 605 patients with AMI, 24 developed CHB. Inferior wall infarction was present in 18, anterior AMI in 4, and subendocardial in 2 cases. The onset of block in all cases was in the first 2 days. Fifteen patients were treated medically and 9 required temporary pacing. Only 3 cases had persistent block and required permanent pacing. The overall outcome was good, whatever the therapeutic modality adopted

Role of stress exercise ECG testing in evaluation of saphenous vein coronary artery bypass grafts

In this study, 50 patients [forty-six males and four females aged 32 to 60 years] were evaluated six months to five years after saphenous vein coronary artery bypass surgery [CARG]. The clinical picture was compared with the results of exercise test and with coronary angiographic studies before and after surgery. In the stress test, emphasis was put on the degree of effort tolerance, precipitation of chest pain by exercise, ST changes and cardiac arrhythmias. In conclusion, although ECG stress testing can be used to evaluate the patency of venous grafts post CABG, yet it has its limitations. The golden standard at present remains the coronary angiogram

Stress test in the evaluation of patients with aortic regurgitation subjected to valve replacement [pre - and post - operative study]

Fifty patients with rheumatic aortic regurge aged 18-40 years who were operated upon by aortic valve replacement in the National Heart Institute were included in the study. They were classified according to their effort tolerance into 2 groups. Group A, functional class I- NYHA and group B, functional class II NYHA. Group A included 30 patients and group B 20 patients. All patients were clinically assessed, had an ECG, Chest X-ray, ECHO and treadmill exercise test pre and postoperatively. Most patients improved postoperatively except 3 patients who died in group B; 1 from pump failure and the other 2 from infective endocarditis within 5 months of surgery. Maximum achieved heart rate during stress test, chronotropic reserve, max systolic blood pressure and total effort tolerance were studied and compared in both groups pre and postoperatively