Surrogates of Poor Prognostic Sign in Adult Patients with Homozygous Sickle Cell Disease: An Echocardiographic Study.

Background: Pulmonary Arterial hypertension (PAH) is a late complication in adult patients with homozygous sickle cell Anaemia (SCA). The early identification of PAH may be of paramount importance. Aim: This study is aimed at evaluating the usefulness of NT pro BNP in the assessment of diastolic function of RV in adult patients with sickle cell disease. It is also aimed at the assessment of the predictive risk of serum level of NT pro BNP hormone and ferritin with other pulsed and tissue Doppler indices for the development of pulmonary hypertension in patients with SCA. In addition, we measured the usefulness of tissue Doppler velocity of lateral annulus of tricuspid valve in the assessment of diastolic function of RV in adult patients with SCD. Method: In this cross sectional prospective study, 103 patients with homozygous SCD were studied and compared with age and gender matched healthy control. Every patient had a clinical assessment, pulsed and tissue Doppler evaluation. Blood samples were withdrawn for the level of haemoglobin, ferritin and NT pro BNP hormone. The mean Original Research Article British Journal of Medicine & Medical Research, 4(26): 4431-4443, 2014 4432 difference between the two groups for echo Doppler and biometric variables were assessed. Multiple regression analysis applied for measuring the odds ratio of different biometric and Doppler variables for risk of PAH in SCD. Results: The study group consist of 103 patients with SCA, mean age of 28.52±14.11 year, (range 14-42), with 68 male (66.0%) Patients with SCA compared with control had a significantly low diastolic pressure, lower haemoglobin level but high serum level ferritin and pro BNP hormone. Further, there was a significant increment in the left atrium area (LA), higher right ventricle (RV) wall thickness and diameter. The RV tricuspid annular systolic excursion (TAPSE) was high of 1.42±0.21 vs. 1.11±0.23, P<0.05. RV Pulsed Doppler data showed restrictive filling pattern with significant higher E wave velocity, higher early diastolic filling wave (E)/ atria wave velocity (A) ratio and short Deceleration Time (DT). Further, the ratio of upper pulmonary vein for systolic/diastolic Doppler velocity was significantly lower 1.5±0.12 vs.2.4±0.11, p<0.05. The tissue Doppler of lateral annulus of tricuspid valve in SCA patients showed a significantly lower S wave of 6.7±1.7 vs 11.3±1.9, p<0.01, higher pulsed early velocity( E)/ early Tissue velocity (E-) ratio and lower atria wave velocity (A). The incidence of pulmonary hypertension in SCD patients via tricuspid valve velocity defined as ≥2.5 m/s was 28%. There were positive correlation between the serum level of ferritin, NT pro BNP hormone and tricuspid valve velocity of (r= 0.38) and (r=0.43) respectively. The odds ratio for development of PAH was 3.1 for E/E- ratio ≥13, 2.5 for DT of <160msec, 2.2 for Left ventricle mass Index (LVMI)>121 gm/M2, 1.9 for ferritin ≥600g/l, 1.6cm for left atrial area ≥20cm, 1.3 for pro- BNP ≥150Pmol/L. Conclusion: Adult patients with SCA have normal Systolic function but increase of LV mass and restrictive diastolic dysfunction. RV has increase wall thickness, systolic and diastolic dysfunction of restrictive pattern. The prevalence of pulmonary hypertension in SCA is 28% with positive correlation between ferritin, pro BNP level and tricuspid valve velocity on echo. The risk of PAH in SCA patients is higher if the patient had on echo DT <160msec, LVMI >121gm/M2, cm, E/E- ratio ≥13 or RV wall thickness >3mm.

Echocardiographic evaluation during weaning from mechanical ventilation

INTRODUCTION: Echocardiographic, electrocardiographic and other cardiorespiratory variables can change during weaning from mechanical ventilation. OBJECTIVES: To analyze changes in cardiac function, using Doppler echocardiogram, in critical patients during weaning from mechanical ventilation, using two different weaning methods: pressure support ventilation and T-tube; and comparing patient subgroups: success vs. failure in weaning. METHODS: Randomized crossover clinical trial including patients under mechanical ventilation for more than 48 h and considered ready for weaning. Cardiorespiratory variables, oxygenation, electrocardiogram and Doppler echocardiogram findings were analyzed at baseline and after 30 min in pressure support ventilation and T-tube. Pressure support ventilation vs. T-tube and weaning success vs. failure were compared using ANOVA and Student's t-test. The level of significance was p<0.05. RESULTS: Twenty-four adult patients were evaluated. Seven patients failed at the first weaning attempt. No echocardiographic or electrocardiographic differences were observed between pressure support ventilation and T-tube. Weaning failure patients presented increases in left atrium, intraventricular septum thickness, posterior wall thickness and diameter of left ventricle and shorter isovolumetric relaxation time. Successfully weaned patients had higher levels of oxygenation. CONCLUSION: No differences were observed between Doppler echocardiographic variables and electrocardiographic and other cardiorespiratory variables during pressure support ventilation and T-tube. However cardiac structures were smaller, isovolumetric relaxation time was larger, and oxygenation level was greater in successfully weaned patients.

Quantitative Evaluation of Right-Ventricular Function in Patients with Tricuspid Regurgitation

BACKGROUND: Tricuspid regurgitation (TR) is a common finding that can be detected with use of Doppler echocardiographic technique in patients with right ventricular dysfunction as well as in normal children, adolescents and adult. It is difficult to evaluate the right ventricular function by conventional method, including echocardiography, especially in case with TR. METHOD: To determine the degree and relationship of right ventricular function and duration of TR, we examined the 41 patients with TR associated with heart disease, group 2 (n=19) with no definitive evidence of right ventricular dysfunction nor significant pulmonary hypertension, and group 3 (n=22) with right ventricular dilatation or wall motion abnormality, or history of longstanding pulmonary hypertension or moderate or severe TR, and compared 59 normal subjects (group 1) with trivial or mild TR without definitive heart disease. Using Doppler echocardiography, duration of TR (TRD) and pulmonary ejection period (ET) is measured, and calculated the TR time interval (RTI) by the difference of TRD and ET divided by ET. RESULT: Pre-ejection period (PEP), ET and systolic time interval (STI, PEP/ET) of right ventricle are significantly prolonged in group 2 and 3 compare to those of group 1 (p<0.001 respectively), TRD is significantly prolonged in group 3 compare to those of group 1 and 2, and isovolumic contraction time (IRT), isovolumic relaxation time (IRT) and RTI are significantly different in each group and prolonged in group 2 and 3. RTI is significantly correlated to STI (r=0.56), ICT (r=0.75) and IRT (r=0.94), but independent to heart rate. CONCLUSION: We conclude that Doppler measurement of RTI (TRD-ET)/ET{=(ICT+IRT)/ET} is a simple and useful new index for the evaluation of RV function including systolic and diastolic function.

Doppler echocardiographic assessment of left ventricular function in Kawasaki syndrome

To investigate the effect of Kawasaki syndrome on left ventricular function, we studied 52 patients with Kawasaki syndrome at initial visit and after 3 months (36 patients). Using Pulsed Doppler echocardiogram,we obtained aortic velocity (peak and mean), acceleration time(AT),ejection time(ET), ratio of AT to ET(AT/ET), acceleration (peak and mean) and velocity time integral and mitral velocity of E and A waves(peak and mean) and velocity time integral. Mitral time for peak velocity time integral. Mitral time for peak velocity was significantly prolonged in Kawasaki syndrome,being a mean(+/-SD) of 66.2(+/-14) msec in the control group, 79.2(+/-13)msec at initial vist(p<0.05) and 79.4(+/-13) msec after 3 months (p<0.05). Aortic peak acceleration was significantly decreased in Kawasaki syndrome being a mean(+/-SD) of 2590(+/-785) cm/sec2 after 3 months (P<0.05).Aortic mean acceleration was also significantly decreased in Kawasaki syndrome being a mean(+/-SD) of 1575( +/-542)cm/sec2 in the control group, 1198(+/-351)cm/sec2at initial visit(p<0.05)and 1124 +/-275cm/sec2 after 3 months(p<0.01). Aortic acceleration time was significantly prolonged in Kawasaki svndrome being a mean(+/-SD) of 62(+/-13) msec in the control group, 72(+/-13) msec at initial visit(p<0.05) and 76(+/-16) msec in the control group, 72(+/-13) msec at initial visit(p<0.05) and 76(+/-16) msec after 3 months (p<0.01). We conclude that early abnormalities of left ventricular function, as assessed by echocardiograpy,gencrally persist after 3 months of onset.