Comparison of contrast enhanced magnetic resonance angiography with invasive cardiac catheterization for evaluation of children with pulmonary atresia.

Complete assessment of the source of pulmonary blood supply and delineation of the anatomy of pulmonary arteries are essential for the management and prognostic evaluation of pulmonary atresia (PA) patients. Invasive cardiac catheterization is considered the gold standard imaging modality to achieve this. We investigated the role of contrast enhanced magnetic resonance angiography (MRA) to evaluate the pulmonary blood supply and the anatomy of the pulmonary arteries and compared this with cardiac catheterization in children with PA. We studied 20 children with PA. Median age was 2.5 years (range 6 months-13 years). All patients were examined with cardiac catheterization and contrast enhanced MRA, and the results of both modalities were compared. There was a complete agreement between both modalities in the detection of the main pulmonary artery morphology and determination of the confluence state of the central pulmonary arteries. There was an 88% agreement for patency of the ductus arteriosus and 66% for patency of the surgically placed shunt. There was a complete agreement between both techniques on determining the presence of collaterals more than 2.5 mm. Twenty-eight collaterals of less than 2.5 mm were detected only by contrast enhanced MRA. There was a strong correlation between both modalities in measuring the pulmonary arteries and collaterals diameter (P<0.001). Contrast enhanced MRA is a safe and accurate non-invasive technique to evaluate the pulmonary artery morphology and the sources of pulmonary blood supply in children with PA.

Long-term prognostic value of dobutamine stress echocardiography in diabetic patients with limited exercise capability: a 13-year follow-up study.

OBJECTIVE: To determine the incremental prognostic value of dobutamine stress echocardiography (DSE) at 13-year follow-up (SD 3.2 years) for predicting mortality and cardiac events in diabetic patients. RESEARCH DESIGN AND METHODS: A total of 396 diabetic patients (mean age 61 ± 11 years; 252 men [64%]) with limited exercise capacity who underwent DSE for evaluation of ischemia were studied. End points were all causes of mortality, cardiac death, and hard cardiac events (cardiac death and nonfatal myocardial infarction). RESULTS: During a mean follow-up of 13 years, 230 patients (58%) died (121 cardiac deaths), and 30 patients had nonfatal myocardial infarction. Cumulative survival in patients with an abnormal DSE at 5, 10, and 15 years was 68, 49, and 41%, respectively. In patients with a normal DSE, these respective numbers were 74, 57, and 44%. Multivariate analyses showed that DSE provided incremental value over clinical characteristics and stress test parameters for prediction of mortality and cardiac events. Survival analysis showed that DSE provided optimal risk stratification up to 7 years after initial testing; after that period, the risk of adverse outcome increased comparably in both normal and abnormal DSE patients. CONCLUSIONS: DSE provided restricted predictive value of adverse outcome in patients with diabetes who were unable to perform an adequate exercise stress test. DSE provided optimal risk stratification up to 7 years after initial testing. Repeated DSE at that time might add to its prognostic value.

Clinical and biochemical predictors of increased carotid intima-media thickness in overweight and obese adolescents with type 2 diabetes.

OBJECTIVE: To identify the clinical parameters associated with increased carotid intima-media thickness (CIMT) in overweight and obese adolescents with type 2 diabetes. METHODS: We studied 27 patients (11 males) with type 2 diabetes. Criteria for selection were age (12-19 years), body mass index above the 95th percentile for age and gender, a positive family history of diabetes, normal or high C-peptide, and negative studies for islet cell antibodies. Age- and gender-matched healthy subjects were selected as the control group. Measurements of CIMT, lipid profile, hypersensitive C-reactive protein, hemoglobin A1C (HbA1C), and insulin resistance by homeostasis model of assessment (HOMA) were obtained for all participants. RESULTS: CIMT was higher in diabetic patients than in healthy subjects (0.68 ± 0.16 vs. 0.58 ± 0.1, p < 0.01). The range of HbA1C in the 15 patients with uncontrolled diabetes was 7.6-10.4 (mean: 8.9 ± 0.9). CIMT, HbA1C, systolic blood pressure, triglycerides, HOMA, and C-reactive protein were significantly higher in patients with uncontrolled than with controlled diabetes. In diabetic patients, CIMT correlated positively with body mass index (p < 0.001), duration of diabetes (p < 0.001), systolic (p < 0.001) and diastolic blood pressure (p < 0.01), HbA1C (p < 0.001), HOMA (p < 0.01), and C-reactive protein (p < 0.01). CONCLUSIONS: CIMT is increased in adolescents with type 2 diabetes. Poor glycemic control, HOMA, increased C-reactive protein, body mass index, duration of diabetes, and elevated blood pressure are associated with early atherosclerosis in these patients.

Tissue Doppler and strain rate imaging detect improvement of myocardial function in iron deficient patients with congestive heart failure after iron replacement therapy.

BACKGROUND: Iron deficiency may contribute to diminished exercise tolerance in patients with congestive heart failure (CHF) even in absence of anemia. The aim of this study was to evaluate the effect of correction of iron deficiency on functional capacity and myocardial function in patients with CHF. METHODS: We studied 40 patients with ejection fraction <40%, hemoglobin% >12 g/dL, serum ferritin <100 ug/L, and transferrin saturation <20%. Patients received 200 mg weekly doses of iron dextran complex until serum ferritin level was between 200 and 300 ug/L or transferrin saturation level was between 30% and 40%. Transthoracic echocardiogram, tissue Doppler imaging, peak systolic strain rate, and 6 minute walk test were performed before iron therapy and at 12-week follow up. Peak early diastolic myocardial tissue velocity (E'), peak late diastolic myocardial tissue velocity (A'), and peak systolic myocardial tissue velocity (S') were measured. RESULTS: There was a significant improvement of New York Heart Association functional class (3.0 ± 0.4 vs. 2.1 ± 0.3, P < 0.05) and 6minutes walk distance (322 ± 104 vs. 377 ± 76, P < 0.01) from rest to follow up, respectively. Ejection fraction did not change significantly (32 ± 8% vs. 34 ± 9%, respectively). There was a significant improvement of S'-wave (3.0 ± 0.8 cm/sec vs. 6.0 ± 1.2 cm/sec, P < 0.05), E/E' ratio (22 ± 3 vs. 13 ± 3, P < 0.05), and peak systolic strain rate (-0.72 ± 0.11/s vs. -1.09 ± 0.37/s, P < 0.05) from baseline to follow-up, respectively. CONCLUSION: Correction of iron deficiency improves functional class and walking distance in nonanemic iron deficient patients with systolic heart failure. Tissue Doppler and strain rate demonstrated a significant improvement of diastolic and systolic function after therapy despite lack of improvement of ejection fraction. (Echocardiography 2012;29:13-18).

Prognostic significance of baseline ST-T-wave abnormalities in diagnostic stress echocardiography.

OBJECTIVE: The aim of this study was to determine whether resting ST-T wave abnormalities (ST-Ta) provide incremental prognostic information in patients with no history of coronary artery disease undergoing dobutamine stress echocardiography (DSE). METHODS: We evaluated 1308 consecutive patients without previous myocardial infarction (MI) or revascularization who underwent DSE. Ischemia was defined as new or worsening wall motion abnormalities. End points during follow-up were all-cause death and cardiac death/nonfatal MI. RESULTS: ST-Ta were detected in 162 (12%) patients. The incidence of ischemia was higher in patients with baseline ST-Ta than patients without [74 (46%) vs. 327 (28%), P=0.00001]. During a follow-up of 4.6 ± 3 years, cardiac death/nonfatal MI occurred in 42 (26%) patients with resting ST-Ta and in 157 (14%) patients without resting ST-Ta (P<0.001). Patients with ST-Ta had a higher annual cardiac death/nonfatal MI rate compared with patients without, both in the presence of normal DSE (3.2 vs. 1.4%, P=0.01) as well as abnormal DSE (5.3 vs. 3%, P<0.001). In a Cox proportional modeling, resting ST-Ta added incremental value over clinical and stress echocardiographic data for the prediction of death (global χ 125, 140, 150, respectively; P<0.05) and cardiac death/nonfatal MI (global χ 79, 100, 111, respectively; P<0.05). CONCLUSION: Baseline ST-Ta are associated with an increased risk of cardiac death/nonfatal MI and all-cause mortality, incremental to clinical data and DSE results. The associated risk is persistent among patients with normal DSE.

Prognostic implications of asymptomatic left ventricular dysfunction in patients undergoing vascular surgery.

BACKGROUND: The prognostic value of heart failure symptoms on postoperative outcome is well acknowledged in perioperative guidelines. The prognostic value of asymptomatic left ventricular (LV) dysfunction remains unknown. This study evaluated the prognostic implications of asymptomatic LV dysfunction in vascular surgery patients assessed with routine echocardiography. METHODS: Echocardiography was performed preoperatively in 1,005 consecutive vascular surgery patients. Systolic LV dysfunction was defined as LV ejection fraction less than 50%. Ratio of mitral-peak velocity during early and late filling, pulmonary vein flow, and deceleration time was used to diagnose diastolic LV dysfunction. Troponin-T measurements and electrocardiograms were performed routinely perioperatively. Multivariate regression analyses evaluated the relation between LV function and the study endpoints, 30-day cardiovascular events, and long-term cardiovascular mortality. RESULTS: Left ventricular dysfunction was diagnosed in 506 (50%) patients of which 80% were asymptomatic. In open vascular surgery (n = 649), both asymptomatic systolic and isolated diastolic LV dysfunctions were associated with 30-day cardiovascular events (odds ratios 2.3, 95% confidence interval [CI] 1.4-3.6 and 1.8, 95% CI 1.1-2.9, respectively) and long-term cardiovascular mortality (hazard ratios 4.6, 95% CI 2.4-8.5 and 3.0, 95% CI 1.5-6.0, respectively). In endovascular surgery (n = 356), only symptomatic heart failure was associated with 30-day cardiovascular events (odds ratio 1.8, 95% CI 1.1-2.9) and long-term cardiovascular mortality (hazard ratio 10.3, 95% CI 5.4-19.3). CONCLUSIONS: This study demonstrated that asymptomatic LV dysfunction is predictive for 30-day and long-term cardiovascular outcome in open vascular surgery patients. These data suggest that preoperative risk stratification should include not only solely heart failure symptoms but also routine preoperative echocardiography to risk stratify open vascular surgery patients.

Abnormal spatial QRS-T angle predicts mortality in patients undergoing dobutamine stress echocardiography for suspected coronary artery disease.

OBJECTIVE: To investigate the association between (cardiac) mortality and spatial QRS-T angle in patients undergoing dobutamine - atropine stress echocardiography (DSE) for evaluation of known or suspected coronary disease. METHODS: Between 1990 and 2003, 2347 patients underwent DSE for evaluation of coronary disease at the Erasmus Medical Center. Echocardiographic images were analyzed offline using a 16-segment, 5-point scoring model for regional function. Twelve-lead resting ECGs were analyzed and patients were grouped in three categories according to their spatial QRS-T angle: normal (0-105 degrees), borderline (105-135 degrees), and abnormal (135-180 degrees). RESULTS: Mean age was 61+/-13 years, 66% were male, 32% had hypertension, 26% had hypercholesterolemia, 28% were smokers, and 12% were diabetic. During a mean follow-up of 7+/-3.4 years, 26.5% (623) of the patients died; 15.3% (359) died due to a cardiac cause. Abnormal QRS-T angle (135-180 degrees ) was present in 21% of the patients. Abnormal QRS-T angle was a predictor of cardiac death [hazard ratio: 3.2 (2.6-4.1)] and all-cause mortality [hazard ratio: 2.2 (1.8-2.6)]. After multivariate analysis abnormal and borderline QRS-T angle, peak wall motion score, age, male sex, history of diabetes, history of heart failure, smoking, and hypertension were independent predictors of (cardiac) death. CONCLUSION: Abnormal QRS-T angle is an independent predictor of (cardiac) death in patients undergoing DSE. Abnormal QRS-T angle should be considered as a risk factor in stable patients evaluated for coronary disease.

Prognostic significance of QRS duration in patients with suspected coronary artery disease referred for noninvasive evaluation of myocardial ischemia.

The purpose of this study was to evaluate the prognostic significance of QRS duration in patients with suspected coronary artery disease (CAD) referred for noninvasive evaluation of myocardial ischemia by dobutamine stress echocardiography. QRS duration is a prognostic marker in patients with previous myocardial infarction and/or heart failure. The relation between QRS duration and outcome of patients without known heart disease has not been evaluated. A total of 1,227 patients (707 men, mean age 61 +/- 14 years) with suspected CAD underwent dobutamine stress echocardiography for evaluation of myocardial ischemia. Patients were followed to determine predictors of cardiac events and to assess the incremental significance of QRS duration compared to clinical and dobutamine stress echocardiographic data. During a mean follow-up of 4.2 +/- 2.4 years, 280 patients (23%) died (129 cardiac deaths), and 60 (5%) had a nonfatal infarction. Annualized cardiac death rates were 2.0% in patients with QRS duration <120 ms and 4.4% in patients with QRS duration >or=120 ms, respectively (p <0.0001). Annualized event rates for cardiac death/nonfatal infarction were 2.8% in patients with QRS duration <120 ms and 4.8% in patients with QRS duration >or=120 ms (p = 0.0001). Multivariate models identified age, male gender, smoking, QRS duration >or=120 ms, and an abnormal dobutamine stress echocardiogram as independent predictors of cardiac death and the combined end point cardiac death/nonfatal infarction. In conclusion, QRS duration is an independent predictor of cardiac death and cardiac death/nonfatal infarction in patients with suspected CAD. This risk is persistent after adjustment for clinical variables, left ventricular function, and myocardial ischemia.

Prognostic value of left atrial volume in patients who underwent dobutamine stress echocardiography for known or suspected coronary artery disease.

BACKGROUND: Left atrial volume indexed (LAVI) has been reported as a predictor of cardiovascular events. We sought to determine the prognostic value of LAVI for predicting the outcome of patients who underwent dobutamine stress echocardiography (DSE) for known or suspected coronary artery disease (CAD). METHODS: From January 2000 to July 2005, we studied 981 patients who underwent DSE and off-line measurements of LAVI. The value of DSE over clinical and LAVI data was examined using a stepwise log-rank test. RESULTS: During a median follow-up of 24 months, 56 (6%) events occurred. By univariate analysis, predictors of events were male sex, diabetes mellitus, previous myocardial infarction, left ventricular ejection fraction (LVEF), left atrial diameter indexed, LAVI, and abnormal DSE. By multivariate analysis, independent predictors were LVEF (relative risk [RR] = 0.98, 95% CI 0.95-1.00), LAVI (RR = 1.04, 95% CI 1.02-1.05), and abnormal DSE (RR = 2.70, 95% CI 1.28-5.69). In an incremental multivariate model, LAVI was additional to clinical data for predicting events (chi(2) 36.8, P < .001). The addition of DSE to clinical and LAVI yielded incremental information (chi(2) 55.3, P < .001). The 3-year event-free survival in patients with normal DSE and LAVI < or =33 mL/m(2) was 96%; with abnormal DSE and LAVI < or =33 mL/m(2), 91%; with normal DSE and LAVI >34 mL/m(2), 83%; and with abnormal DSE and LAVI >34 mL/m(2), 51%. CONCLUSION: Left atrial volume indexed provides independent prognostic information in patients who underwent DSE for known or suspected CAD. Among patients with normal DSE, those with larger LAVI had worse outcome, and among patients with abnormal DSE, LAVI was still predictive.

Comparison of outcome after myocardial infarction in patients with and without abnormalities on previous stress Tc-99m tetrofosmin myocardial perfusion imaging.

BACKGROUND: Acute myocardial infarction (MI) can occur in patients with previously normal stress myocardial perfusion imaging (MPI). It is not known whether the prognosis of these patients differ from those with MI who had an abnormal MPI on an earlier testing. The aim of this study was to compare the outcome of patients who sustained a MI during follow-up after stress MPI based on the presence or absence of perfusion abnormalities on the earlier test. METHODS: We studied 109 patients (age 62 +/- 11 years, 73 men) who developed MI 2.1 +/- 2.7 years after exercise or dobutamine stress Tc-99m tetrofosmin MPI. Subsequently, a follow-up was done for the occurrence of death during or after the acute event. RESULTS: Myocardial perfusion was normal in 31 patients and was abnormal in 78 (45 had reversible defects). During a mean follow-up of 3.1 +/- 2.4 years after MI, death occurred in 35 (32%) patients. The death rate was 19% in patients with previously normal versus 33% in patients with abnormal perfusion (P < 0.01). In a Cox model, independent predictors of death were age (risk ratio (RR) 1.06, 95% CI: 1.02-1.10), heart failure (RR 2.7, CI: 1.3-5.5), and abnormal MPI (RR 2.5, CI: 1.3-4.5). CONCLUSION: Patients with a previously normal stress MPI are less likely to die after acute MI than patients who had an abnormal MPI.

Prognostic significance of myocardial ischemia by dobutamine stress echocardiography in patients without angina pectoris after coronary revascularization.

The clinical utility of stress testing in patients without angina pectoris after revascularization has been questioned. Dobutamine stress echocardiography (DSE) is an established technique for detection of myocardial ischemia and cardiac risk stratification. We studied the prognostic value of DSE in 393 patients without typical angina pectoris after coronary revascularization. Ischemia was incremental to clinical data in predicting all-cause death (hazard ratio 3.5, 95% confidence interval 1.8 to 6.7) and cardiac death (hazard ratio 4.2, 95% confidence interval 1.8 to 9.8). In conclusion, myocardial ischemia during DSE is independently associated with an increased risk of all-cause mortality and cardiac death in these patients after adjustment for clinical data.

Renal insufficiency and mortality in patients with known or suspected coronary artery disease.

It remains unclear whether mild renal dysfunction is associated with adverse cardiovascular outcome. We investigated whether estimated glomerular filtration rate (eGFR) was associated with mortality and cardiac death among 6447 patients with known or suspected coronary artery disease over a mean follow-up of 7 yr. Cumulative 5- and 10-yr survival rates decreased in a graded fashion from 88% and 70%, respectively, for those with normal renal function to 43% and 33% for those with eGFR <30 ml/min. Compared with patients with normal renal function, the multivariable adjusted hazard ratios for all-cause mortality among patients with mild, moderate, and severe renal impairment were 1.33 (95% confidence interval [CI], 1.21-1.48), 1.67 (95% CI, 1.44-1.93), and 3.38 (95% CI, 2.73-4.19), respectively. Similar relationships between cardiac death and decreasing renal function were found. In conclusion, renal function is a graded and independent predictor of long-term mortality in patients with known or suspected coronary artery disease. Intense treatment and close surveillance of these patients is encouraged.

Significance of hypotensive response during dobutamine stress echocardiography.

BACKGROUND: In patients undergoing exercise testing a hypotensive response is associated with a poor prognosis. There is limited information regarding the prognostic significance of hypotension during dobutamine stress test. This study investigates the association between a severe hypotensive response during DSE and long-term prognosis. METHODS: Patients (3381) underwent dobutamine stress echocardiography (DSE). Blood pressure was measured automatically at rest and at the end of every dose-step. Wall motion was scored using a 16-segement, 5-point score. Ischemia was defined by the presence of new wall motion abnormalities. Hypotensive response during DSE was defined as mild (MHR) when systolic blood pressure (SBP) dropped <20 mmHg between rest and peak stress, and severe (SHR) when SBP dropped <20 mmHg. During follow-up all cause mortality and MACE (cardiac death or non-fatal myocardial infarction) were noted. RESULTS: MHR and SHR occurred in 936 (28%) and 521 (15%) patients, respectively. Independent predictors of SHR were older age, new or worsening wall motion abnormalities and history of hypertension. During follow-up of 4.5 (+/-3.3) years, 920 patients died, of which 555 due to cardiac causes, and 713 patients experienced a MACE. After adjustment for baseline characteristics and DSE results SHR during DSE was independently associated with increased long-term cardiac death (HR: 1.3, 95% CI: 1.03-1.6) and MACE (HR: 1.34, 95% CI: 1.1-1.6), while MHR was not associated with a worse outcome. CONCLUSIONS: Severe hypotensive response during DSE independently predicts cardiac death and MACE in patients with known or suspected coronary artery disease.

Real-time dobutamine stress myocardial perfusion echocardiography predicts outcome in the elderly.

AIMS: Although there is an increasing number of studies showing the value of perfusion imaging with real-time contrast echocardiography (RTCE) for detecting coronary artery disease (CAD), no data exist regarding the value of this technique for detecting CAD and predicting outcome in the elderly. METHODS AND RESULTS: We examined the outcome of 399 patients > or =70 years old who underwent dobutamine stress RTCE for known or suspected CAD. Myocardial perfusion imaging (MPI) was performed using low mechanical index pulse sequence schemes following intravenous small bolus injections of ultrasound contrast. Quantitative coronary angiography (QCA) was performed within 1 month of the stress test in 60 patients. Events were defined as cardiac death or non-fatal myocardial infarction (MI). Sensitivity of MPI for detecting CAD by QCA was 94% [confidence interval (CI) 91-99], specificity was 67% (CI 36-74), and accuracy was 90% (CI 82-95). During a median follow-up of 21 months, 46 events occurred (31 cardiac deaths, 15 non-fatal MI). Univariate predictors of outcome were diuretic use (P = 0.03), abnormal stress wall motion (P < 0.0001), and abnormal stress MPI (P < 0.0001). Abnormal stress MPI, however, was the most significant predictor of outcome (chi(2) 7.5; P = 0.006). CONCLUSION: Myocardial perfusion analysis during dobutamine stress RTCE provides incremental predictive value in determining the outcome of elderly patients being evaluated for the presence of CAD.

Prognostic significance of renal function in patients undergoing dobutamine stress echocardiography.

BACKGROUND: Dobutamine stress echocardiography (DSE) is used for risk stratification of patients with suspected coronary artery disease (CAD). However, the prognostic value of DSE among the entire strata of renal function has yet to be determined. We assessed the prognostic value of renal function relative to DSE findings. METHODS: We studied 2292 patients, divided into 729 (32%) patients with normal renal function [creatinine clearance (CrCl) >90 ml/min] and 1563 (68%) with renal dysfunction, classified as mild (CrCl: 60-90 ml/min) in 933, moderate (CrCl: 30-60 ml/min) in 502 and severe (CrCl < 30 ml/min) in 128 patients. All patients underwent DSE for the evaluation of known or suspected CAD and were followed for a mean of 8 years. RESULTS: New wall motion abnormalities during DSE and mildly, moderately and severely abnormal CrCl were powerful independent predictors for all-cause mortality, cardiac death and hard cardiac events (cardiac death and non-fatal myocardial infarction). Kaplan-Meier curves demonstrated that patients with normal DSE and renal dysfunction have greater probability for cardiac death and hard cardiac events compared to those with normal renal function. The warranty of a normal DSE in the presence of moderate renal dysfunction was 15 and 36 months for 10 and 20% risk for cardiac death and hard cardiac events, respectively. CONCLUSIONS: The presence and severity of renal dysfunction has additional independent prognostic value over DSE findings. The low-risk warranty period after a normal DSE is determined by the severity of renal dysfunction.

A prognostic risk index for long-term mortality in patients with peripheral arterial disease.

BACKGROUND: Prognostic information in peripheral arterial disease (PAD) may provide the basis for optimal management strategies at an early stage. This study aimed to develop a prognostic risk index for long-term mortality in patients with PAD. METHODS: In a single-center observational cohort study, 2642 patients with an ankle-brachial index of 0.90 or lower were randomly divided into derivation (n = 1332) and validation (n = 1310) cohorts. Cox regression analysis with stepwise backward elimination identified predictors of 1-year, 5-year, and 10-year mortality in the derivation cohort. Weighted points were assigned to each predictor. Index discrimination was determined in both the derivation and validation cohorts. RESULTS: During 10 years of follow-up, 42.2% and 40.4% of patients died in the derivation and validation cohorts, respectively. The risk index for 10-year mortality (+ points) included renal dysfunction (+12), heart failure (+7), ST-segment changes (+5), age greater than 65 years (+5), hypercholesterolemia (+5), ankle-brachial index lower than 0.60 (+4), Q-waves (+4), diabetes (+3), cerebrovascular disease (+3), and pulmonary disease (+3). Statins (-6), aspirin (-4), and beta-blockers (-4) were associated with reduced 10-year mortality. Patients were stratified into low (<0 points), low-intermediate (0-5 points), high-intermediate (6-9 points), and high (>9 points) risk categories, according to risk score. Ten-year mortality rates were 22.1%, 32.2%, 45.8%, and 70.4%, respectively (P < .001) and comparable to mortality in the validation cohort. C statistics demonstrated good discrimination in both the derivation (0.72) and validation cohorts (0.73). CONCLUSIONS: A prognostic risk index for long-term mortality stratified patients with PAD into different risk categories. This may be useful for risk stratification, patient counseling, and medical decision making.