Prognostic value of normal dobutamine stress echocardiography in renal transplant candidates.

BACKGROUND: Renal transplant candidates are at high-risk for cardiovascular events. No definite screening tool has been recommended for the pre-operative evaluation. OBJECTIVE: The authors studied the prognostic value of normal dobutamine stress echocardiography in this population. MATERIAL AND METHOD: Dobutamine stress echocardiography was performed for the pre-operative assessment in 107 renal transplant candidates (age 53.2 +/- 6.2 years, 66.4% male). The mean follow-up time was 2.8 +/- 1.7 years. The primary endpoint was total mortality. RESULTS: During follow-up, 16 (15.0%) died and 26 (24.3%) patients underwent kidney transplantation. The overall survival probabilities at 1, 3 and 5 years were 87, 83 and 79%, respectively. Among those who underwent renal transplantation, the survival probabilities at 1, 3 and 5 years were 100, 100 and 89%, respectively CONCLUSION: In renal transplant candidates, normal dobutamine stress echocardiography portends a good long-term prognosis.

Echocardiography as a simple initial tool to assess right ventricular dimensions in patients with repaired tetralogy of Fallot before undergoing pulmonary valve replacement: comparison with cardiovascular magnetic resonance imaging.

OBJECTIVE: Accurate assessment of the right ventricle (RV) is essential in patients with repaired tetralogy of Fallot (TOF). We proposed a simple echocardiographic method to assess the RV dimensions and evaluated the relationship between linear echocardiographic measures of the RV and RV volumes obtained by cardiovascular magnetic resonance imaging (CMR). METHODS: A total of 45 patients (27.4 ± 11.2 years; 40% male) with repaired TOF underwent CMR and echocardiography. Using echocardiography, RV dimensions were assessed from the parasternal short-axis view using the longest RV internal diameter perpendicular to the mid-interventricular septum. Significant RV dilatation was defined as an RV end-diastolic volume index >160 mL/m(2) on CMR. RESULTS: There were significant correlations between RV dimensions determined by echocardiography and the pulmonary regurgitation fraction, RV size, and function determined by CMR. The cutoff values of echocardiographic RV outflow tract (RVOT), end-systolic and end-diastolic dimension indices, and the combination of RVOT and end-diastolic dimension indices to determine significant RV dilatation were 19.0, 19.4, 24.5, and 45.2 mm/m(2) , respectively. The positive and negative predictive values for significant RV dilatation were 89.7% and 68.8% with RVOT diameter index ≥19.0 mm/m(2) , 85.0% and 52.4% with RV end-systolic dimension index ≥19.4 mm/m(2) , 87.5% and 64.7% with RV end-diastolic dimension index ≥24.5 mm/m(2) , and 92.3% and 80.0% with the combination of RVOT and end-diastolic dimension indices ≥45.2 mm/m(2) , respectively. CONCLUSION: Echocardiography can be used to assess RV size in patients with repaired TOF with acceptable correlations with CMR as the reference standard.

Correlation between left atrial volume index and pulmonary artery pressure in patients with chronic severe mitral regurgitation.

BACKGROUND: Left atrial dilatation is a response to volume overload in chronic mitral regurgitation (MR). Left atrium volume index (LAVI) was associated with mortality, heart failure and atrial fibrillation in patients with MR. The authors do not know the association between LAVI and pulmonary artery pressure in patients with chronic severe primary MR. MATERIAL AND METHOD: The authors retrospectively studied patients with chronic severe MR (either one or both echocardiographic criteria of effective regurgitant orifice area > or = 40 mm2 or regurgitant volume > or = 60 ml by proximal isovelocity surface area method) who underwent transthoracic echocardiography at Siriraj Hospital between January 2005 and December 2009. RESULTS: A total of 181 patients (age 53.1 +/- 17.7 years, 53.6% male) were enrolled. Right ventricular systolic pressure (RVSP) tended to increase when LAVI increased (r(s) = 0.32, p < 0.001). The mean RVSP in 4 different quartiles of LAVI (< or = 48.80 ml/ m2, 48.81-66.00 ml/m2, 66.01-97.40 ml/m2, > 97.40 ml/m2) were 41 +/- 14, 42 +/- 16, 44 +/- 16 and 56 +/-18 mmHg, respectively RVSP in patients with LAVI > 97.40 ml/m2 was significantly higher than those of the other 3 quartiles (p = 0.004). LAVI in patients with RVSP < or = 50 and > 50 mmHg were 74 +/- 53 and 116 +/- 82 ml/m2, respectively (p = 0.001). CONCLUSION: In chronic severe primary MR, RVSP tends to increase when LAVI increases.

Patients with non-sT-segment elevation myocardial infarction present with more severe systolic and diastolic dysfunction than patients with unstable angina.

BACKGROUND: Patients with non ST-segment elevation acute coronary syndrome (NSTEACS) present with diverse clinical, electrocardiographic, cardiac biomarker, echocardiographic and angiographic characteristics. We sought to determine whether there was any difference in the indices of left ventricular systolic and diastolic function among subgroups of patients with NSTEACS. MATERIAL AND METHOD: We studied 121 consecutive patients (mean age 68.6 +/- 11.3 years, 45% male) with NSTEACS who underwent comprehensive echocardiography within 48 hours of admission. Two-dimensional and Doppler echocardiography was performed for the evaluation of left ventricular systolic and diastolic function. RESULTS: Non ST-segment elevation myocardial infarction (NSTEMI) and unstable angina (UA) were reported in 59% and 41% of patients, respectively. Clinical characteristics (such as age, gender, cardiovascular risk factors, prior myocardial infarction and revascularization, medication) were not significantly different between patients with NSTEMI and UA. Patients with NSTEMI were more likely to have wall motion abnormalities and lower left ventricular ejection fraction (p < 0.05) as compared to those with UA. Diastolic dysfunction was significantly more frequent and more severe in patients with NSTEMI than in those with UA. CONCLUSION: Among patients with NSTEACS, left ventricular systolic and diastolic dysfunction was more frequent and more severe in patients with NSTEMI that in those with UA. These findings may be used to characterize the sicker group among patients with NSTEACS.

Effectiveness of deferiprone in transfusion-independent beta-thalassemia/HbE patients.

Beta-thalassemia/HbE (beta-thal/HbE) is a thalassemia intermedia (TI) which encompasses a broad spectrum of severity. Here, we used deferiprone (DFP) as an iron chelating agent in TI patients receiving intermittent blood transfusion who are asymptomatic for cardiovascular disease in order to evaluate the effectiveness in iron overload and reduce the possibility of cardiovascular complications. Thirty transfusion-independent beta-thal/HbE patients with iron overload were treated with DFP for 1 year. Hematological, biochemical, oxidative stress and echocardiographic parameters were determined. Serum ferritin, non-transferrin-bound iron, and malondialdehyde decreased significantly (P<0·05) after 1-year treatment with DFP. For echocardiographic results, mean pulmonary arterial pressure and pulmonary vascular resistance were diminished significantly (P<0·05). All those parameters were still improved after subgroup analysis was done for the high ferritin group (>2500 ng/ml). DFP therapy alone improved iron overload and oxidative stress and compliance was good. We propose that prevention of pulmonary hypertension is also possible for TI undergoing intermittent blood transfusion.

Clinical presentation and echocardiographic findings of Thai patients with Marfan syndrome.

OBJECTIVE: Marfan syndrome is an inherited disorder with systemic connective tissue involvement. The condition is clinically diverse and extremely pleiotropic. Though several articles had been published, no data from Thai individuals has ever been reported. Here we presented clinical manifestations and echocardiographic findings of Thai patients with Marfan syndrome. MATERIAL AND METHOD: Clinical and echocardiographic data were collected from series of Thai index cases with diagnosis of Marfan syndrome at Siriraj Hospital between 1995 and 2009. Demographic data, clinical presentations, and echocardiographic data were reviewed and analyzed. RESULTS: Fifty individuals and thirty echocardiograms were identified. Thirty eight individuals (76%) fulfilled clinical criteria for definite Marfan syndrome and twelve individuals (24%) were incomplete Marfan syndrome. The majority of those individuals had significant organ involvement including dilatation of ascending aorta (78%), ectopia lentis (54%), and skeletal involvement (96%). CONCLUSIONS: In summary, this is the first report of clinical manifestation and echocardiographic findings of Thai patients with Marfan syndrome.

Prognostic value of selected presenting features of acute coronary syndrome in predicting in-hospital adverse events: insight from the Thai Acute Coronary Syndrome Registry.

OBJECTIVE: To evaluate the relationship of the presenting features of acute coronary syndrome (ACS) to in-hospital adverse events (total and cardiac deaths, heart failure and serious dysrhythmia) and the effects of coronary intervention. BACKGROUND: Patients with ACS may present with dyspnea, shock and/or cardiac arrest with or without accompanying chest pain. METHODS: We evaluated 9,373 patients (age 65+/-12 years and 60% males) enrolled in the Thai ACS Registry. Cardiac dyspnea included shortness of breath on exertion, and/or at rest, orthopnea, or paroxysmal nocturnal dyspnea presumed from cardiac sources. Shock was present if systolic blood pressure was <90 mmHg for >30 min with symptoms of end-organ hypoperfusion. Post cardiac arrest was identified if cardiopulmonary resuscitation was required. We calculated the frequencies of these presenting features and assessed their contribution toward in-hospital adverse events (total and cardiac deaths, heart failure and serious arrhythmias) for the whole ACS and each entity of ACS and the effects of in-hospital interventions, both coronary and medicinal. RESULTS: Cardiac dyspnea, shock and post cardiac arrest were seen in 32.7%, 9.3%, and 4.2% of patients, respectively. In-hospital adverse events occurred more frequently in patients with these presenting features than those without (p<0.05). Cardiac dyspnea and shock were independent predictors of heart failure and death, respectively, while post cardiac arrest independently identified patients at risk of arrhythmia, total and cardiac death, regardless of the subgroup of ACS. Coronary revascularization significantly reduced the risk of total and cardiac death. CONCLUSION: These 3 presenting features of ACS portend a poor prognosis, regardless of the subgroup of ACS and should be considered as important early indicators for early intervention.

Adipose tissue of atrial septum as a marker of coronary artery disease.

BACKGROUND: Paracrine effects of epicardial adipose tissue may promote coronary atherosclerosis. Adipose tissue is the main determinant of atrial septum thickness. The association between atrial septum thickness and coronary artery disease (CAD) has never been studied. METHODS: We studied 75 patients who underwent coronary angiography and echocardiography within 1 week (mean [+/- SD]duration, 2.0 +/- 2.0 days). Atrial septum thickness, representing adipose tissue, was identified and measured with two-dimensional transthoracic echocardiography. Angiographic data were analyzed for the presence, extent, and severity of CAD, using a standardized 27-segment classification. Any CAD was defined as the presence of stenosis of any severity in at least one coronary vessel. The number of segments with a coronary artery with at least 20% stenosis (coronary artery greater even than 20 [CAGE >or= 20] score) was recorded. RESULTS: The mean atrial septum thickness was 1.5 +/- 0.4 cm (median, 1.42 cm; range, 0.74 to 2.55 cm). In a simple linear regression analysis, we found no significant correlation between atrial septum thickness and clinical variables (p > 0.05). However, we found a significant correlation between atrial septum thickness and any CAD (p = 0.03), which persisted after controlling for age, gender, and body mass index (p = 0.03). Patients in the lowest quartile of atrial septum thickness had a lower proportion of subjects with any CAD (p = 0.02) and a lower median CAGE >or= 20 score compared to other quartiles (p = 0.04). CONCLUSION: Adipose tissue of the atrial septum, represented by atrial septum thickness, is associated with the presence of CAD.

Dobutamine stress echocardiography for the evaluation of coronary artery disease in Thai population: Siriraj experience.

OBJECTIVE: No previous report of dobutamine stress echocardiography in the Thai population has been available. The present study seeks to document the protocol, indications, results and safety of dobutamine stress echocardiography performed at Siriraj Hospital. MATERIAL AND METHOD: The authors studied 421 [mean age 67.7 +/- 11.0 years, 179 (43%) men] consecutive Thai patients undergoing dobutamine stress echocardiography at Siriraj Hospital. The protocol, indications and echocardiographic analysis were described. Clinical characteristics, hemodymanics, results and adverse effects were recorded at the time of dobutamine stress echocardiography. RESULTS: Dobutamine stress echocardiography was performed for preoperative assessment before non-cardiac surgery in 212 patients (50%), for the diagnosis of suspected Coronary Artery Disease (CAD) in 179 patients (43%), for risk stratification of CAD in 24 patients (6%), and for other reasons in six patients (1%). The results were normal and positive for inducible ischemia in 276 (66%) and 80 (19%) patients, respectively. Limiting side effects were observed in 3%. No death, myocardial infarction or life-threatening arrhythmias occurred. Transient stress-associated tachyarrhythmias, such as atrialfibrillation, nonsustained ventricular tachycardia or supraventricular tachycardia, occurred in 3.5% of patients. CONCLUSION: Dobutamine stress echocardiography was considered a safe and tolerable technique for the evaluation of CAD in Thai population.

Outcomes after normal dobutamine stress echocardiography and predictors of adverse events: long-term follow-up of 3014 patients.

AIMS: Normal exercise echocardiography predicts a good prognosis. Dobutamine stress echocardiography (DSE) is generally reserved for patients with comorbidities which preclude exercise testing. We evaluated predictors of adverse events after normal DSE. METHODS AND RESULTS: We studied 3014 patients (1200 males, 68+/-12 years) with normal DSE, defined as the absence of wall motion abnormality at rest or with stress. During median follow-up of 6.3 years, all-cause mortality and cardiac events, defined as myocardial infarction and coronary revascularization, occurred in 920 (31%) and 231 (7.7%) patients, respectively. Survival and cardiac event-free probabilities were 95 and 98% at 1 year, 78 and 93% at 5 years, and 56 and 89% at 10 years, respectively. Age, diabetes mellitus, and failure to achieve 85% age-predicted maximal heart rate were independent predictors of mortality and cardiac events. Patients with all three of these characteristics had a 13% probability of cardiac events within the first year and higher risk throughout follow-up. CONCLUSION: Prognosis after normal DSE is not necessarily benign, but depends on patient and stress test characteristics. Careful evaluation, using clinical and stress data, is required to identify patients with normal DSE who are at increased risk of adverse outcomes during long-term follow-up.

Dobutamine stress echocardiography in patients with diabetes mellitus: enhanced prognostic prediction using a simple risk score.

OBJECTIVES: We sought to determine the prognostic value of dobutamine stress echocardiography (DSE) for predicting long-term outcomes in a large cohort with diabetes mellitus and to develop a simple risk score using clinical and echocardiographic data. BACKGROUND: Neither risk scores nor long-term prognostic value of DSE has been described in a large diabetic population. METHODS: We studied 2,349 patients with diabetes mellitus (1,338 men, 67 +/- 11 years of age) during a follow-up of 5.4 +/- 2.2 years. RESULTS: Mortality and morbidity (myocardial infarction and late coronary revascularization) occurred in 1,044 (44%) and 309 (13%) patients, respectively. Addition of stress echocardiographic variables to the clinical and rest echocardiographic model provided incremental prognostic information for predicting mortality (chi-square = 243 to 270, p < 0.0001) and morbidity (chi-square = 38 to 78, p < 0.0001). For each end point, a simple risk score was derived according to the estimated values of beta coefficients of multivariate predictors (insulin therapy, smoking, failure to achieve target heart rate, percentage of ischemic segments, and impaired left ventricular systolic function) and resulted in an assessment of risk among all age groups. The C-statistic values were 0.60 to 0.64, indicating modest discrimination. The estimated five-year event-free survivals of patients in three risk categories were 94%, 86%, and 80% for morbidity (p < 0.00001) and 69%, 60%, and 47% for mortality (p < 0.0001). CONCLUSIONS: In patients with diabetes mellitus, a simple and practical risk score using clinical variables and results of DSE stratified patients into three risk groups for mortality and cardiovascular morbidity.

Subepicardial adipose tissue and the presence and severity of coronary artery disease.

BACKGROUND: Mechanistic studies suggest that paracrine effects of subepicardial adipose tissue may promote coronary atherosclerosis, but this has not been confirmed in clinical studies. METHODS AND RESULTS: Of 180 consecutive patients who underwent echocardiography and coronary angiography within 1 week (mean 2.5+/-2.0 days), 139 (80 men, 68+/-13 years) were studied. Subepicardial adipose tissue on the free wall of right ventricle was measured at end-diastole from parasternal long- and short-axis views of three cardiac cycles. Angiograms were analyzed for the presence, extent and severity of coronary artery disease (CAD), using a 27-segment classification. The number of segments with at least 20% (CAGE > or = 20) and 50% (CAGE > or = 50) stenosis was recorded. Age showed a significant correlation with subepicardial adipose tissue thickness measured from parasternal long- (r=0.25, p=0.003) and short-axis view (r=0.23, p=0.01). No significant correlation was found between subepicardial adipose tissue thickness and any angiographic or other clinical variables (p>0.05). Neither the proportion of patients with significant or any CAD nor the severity score, CAGE > or = 20, and CAGE > or = 50 among each of four quartiles was significantly associated with subepicardial adipose tissue thickness. CONCLUSIONS: In this selected population, the amount of subepicardial adipose tissue thickness was not associated with the severity of CAD. Whether subepicardial adipose tissue has any atherosclerotic effect remains to be proven.

Pulmonary hypertension in patients with idiopathic pulmonary fibrosis.

STUDY OBJECTIVES: To determine the impact on survival and clinical correlates of pulmonary hypertension (PH) occurring in patients with idiopathic pulmonary fibrosis (IPF). DESIGN: Retrospective study. SETTING: Tertiary care, referral medical center. PATIENTS: Among 487 consecutive patients with IPF, we identified 136 patients who underwent transthoracic echocardiography within 3 months of their initial evaluation at our institution. Patients with left ventricular dysfunction, valvular heart disease, incomplete follow-up, and those in whom pulmonary artery pressures could not be assessed were excluded; the remaining 88 patients were included in this study. Correlations were performed between echocardiographic measures of PH and clinical variables including survival. MEASUREMENTS AND RESULTS: The mean (+/- SD) estimated systolic pulmonary artery pressure (SPAP) for the 88 patients was 48 +/- 16 mm Hg (range, 28 to 116 mm Hg). Among pulmonary function parameters, SPAP correlated best with diffusing capacity of the lung for carbon monoxide (D(LCO)), to which it was inversely related. For survival analysis, patients were stratified into three groups: < or = 35 mm Hg (14 patients), 36 to 50 mm Hg (47 patients), and > 50 mm Hg (27 patients). Using the Kaplan-Meier method, the median survival rates for these three groups were 4.8 years, 4.1 years, and 0.7 years, respectively. Those patients with SPAP > 50 mm Hg had significantly worse survival compared to other subgroups (p = 0.009). CONCLUSION: In patients with IPF, PH correlates inversely with D(LCO) and has a significant adverse impact on survival, particularly when SPAP is > 50 mm Hg.

Calcified right ventricular mass and pulmonary embolism in a previously healthy young woman.

A 20-year-old woman with a recent episode of pulmonary embolism was found by echocardiographic examination to have a calcified apical right ventricular intracavitary mass. She had a history of cigarette smoking and had been taking oral contraceptive pills. At age 17 years, she had sustained substantial blunt chest injury during a motor vehicle accident. The intracardiac mass was resected and represented an old calcified mural thrombus. It is postulated that its development was related to cardiac trauma. These intracavitary masses have been referred to as cardiac calcified amorphous tumors and generally represent old organized and focally calcified mural thrombus. They should be distinguished from calcified benign or malignant neoplasms of the heart.

Prognostic significance of chronotropic response to dobutamine stress echocardiography in patients with peripheral arterial disease.

Chronotropic response is important during exercise stress testing. Less is known about its role after dobutamine stress echocardiography. In addition, limited information exists regarding the long-term prognostic value of dobutamine stress echocardiography in patients who have peripheral arterial disease. We studied 2,138 patients who had peripheral arterial disease (1,317 men, 70 +/- 10 years old) and who underwent dobutamine stress echocardiography. Follow-up was completed for all-cause mortality and cardiovascular morbidity (nonfatal myocardial infarction and coronary revascularization). Death and cardiovascular morbidity occurred in 961 patients (45%) and 348 patients (16%), respectively, during a follow-up of 6.1 +/- 2.7 years. Failure to achieve 85% of age-predicted maximal heart rate (hazard ratio [HR] 1.34, 95% confidence interval [CI] 1.16 to 1.54, p = 0.0001) and percent of abnormal segments at peak stress (HR/10% increment 1.04, 95% CI 1.01 to 1.07, p = 0.02) were independent predictors of mortality and morbidity (HR 1.35, 95% CI 1.06 to 1.71, p = 0.01 and HR 1.14, 95% CI 1.08 to 1.20, p <0.0001, respectively). The effect of not achieving the target heart rate during normal dobutamine stress echocardiography on 1-, 3-, 5-, and 10-year survival probabilities was comparable to that of ischemia (86% vs 88%, 75% vs 71%, 62% vs 59%, and 33% vs 32%, respectively; p = 0.8). In a stepwise multivariate model, dobutamine stress echocardiography had incremental value over clinical data and echocardiographic data at rest for predicting rates of mortality (model chi-square increase from 301 to 322, p <0.0001) and morbidity (model chi-square increase from 37 to 118, p <0.0001). In conclusion, chronotropic response and extent of abnormal segments at peak dobutamine stress provide incremental prognostic information in patients who have peripheral arterial disease.

Echocardiographic and clinical characteristics of pulmonary hypertension complicating pulmonary Langerhans cell histiocytosis.

OBJECTIVE: To determine the echocardiographic characteristics and impact on survival of pulmonary hypertension (PH) and correlations between echocardiographic and clinical variables in patients with pulmonary Langerhans cell histiocytosis (PLCH). PATIENTS AND METHODS: Of 123 adults seen at our institution between January 1976 and December 2002 with histologically proven PLCH, 17 underwent echocardiographic evaluation. Correlations were performed between echocardiographic measures of PH and clinical variables. Cumulative survival probabilities for patients with PH were estimated using the Kaplan-Meier method and were compared to a historical cohort of patients with PLCH using time-dependent proportional hazard regression. RESULTS: Of the 17 patients, PH (estimated pulmonary artery systolic pressure [PASP] at rest, > 35 mm Hg) was present in 15. Thirteen patients (6 men; median PASP, 67 mm Hg; range, 41.2-90.6 mm Hg) had no other known causes of PH. All patients were smokers. Nine patients had a PASP of more than 50 mm Hg. An inverse correlation was found between the forced vital capacity and PASP (r = -0.61; P = .03); no correlation was found between PASP and other pulmonary function parameters. Seven patients with a PASP greater than 65 mm Hg had an enlarged right ventricle with impaired systolic function. The development of PH in patients with PLCH was associated with increased mortality (hazard ratio, 22.8; 95% confidence interval, 7.6 to > 68.9; P < .001). CONCLUSION: Severe PH occurs in PLCH, correlates with the forced vital capacity, and has a significant impact on survival. Clinicians should consider echocardiographic screening for PH in all dyspneic patients with PLCH.

Carcinoid heart disease associated with primary ovarian carcinoid tumor.

Because the venous drainage of the ovary bypasses the portal circulation, carcinoid heart disease in patients with primary ovarian carcinoid tumors may develop in the absence of liver metastasis. We describe 4 patients who presented with symptomatic carcinoid heart disease in association with primary ovarian carcinoid tumor.