[Platypnea-orthodeoxia syndrome: a neglected cause of dyspnea?] / Platypné­ortodeoxisyndrom ­ förbisedd orsak till dyspné.

A 68-year-old woman presented with progressive and severe effort-related dyspnea. Her history included an ischemic stroke at age 43. Routine exams were normal. Cardiopulmonary exercise testing (CPET) showed a reduction in PaO2 from 11.8 kPa to 4.8 kPa. Repeated CPET with 100 % inhaled O2 improved the drop in PaO2 marginally. Transesophageal echocardiography revealed a shunt from right to left through a patent foramen ovale (PFO). A right heart catheterization showed normal pressures and no signs of intrapulmonary shunting. The PFO was closed percutaneously and the patient's symptoms resolved almost completely. Platypnea-orthodeoxia syndrome is an uncommon disorder where the pathophysiological mechanisms include a right-to-left shunt, either intracardiac or pulmonary. The most common intracardiac shunt related to the syndrome is a PFO. Platypnea-orthodeoxia syndrome, although rare, merits our attention, since it is often easily treatable. The key finding is desaturation on standing up.

[Rheumatic heart disease behind life-threatening heart failure in pregnancy]. / Reumatisk hjärtsjukdom bakom livshotande hjärtsvikt hos gravid.

Valvular heart disease constitutes the majority of all causes of heart disease in pregnancy. In the presence of valvular heart disease, the necessary haemodynamic changes of pregnancy might cause heart failure, leading to severe maternal and fetal morbidity and even mortality. In lower-income countries, rheumatic heart disease remains one of the major causes of death related to pregnancy [6]. In low-income countries, rheumatic heart disease is found in 60% to 80% of the pregnant women with heart disease, and 10% to 30% have a congenital disorder including congenital valve disorders [4]. The most common valvular lesion of rheumatic heart disease is mitral stenosis. This valvular lesion can be the cause of extreme disability and even mortality during pregnancy due to an increase in the transvalvular gradient and a rise in left atrial pressure. The maternal mortality associated with mitral stenosis is stratified by New York Heart Association (NYHA) classification: class I, 0.1%; class II, 0.3%; class III, 5.5%; and class IV, 6.0%. Most patients are in class I or II at presentation, but 12% to 25% of patients are in class III or IV [14].

Effect of advanced chronic kidney disease in clinical and echocardiographic outcomes of patients treated with MitraClip system.

BACKGROUND: Data regarding the influence of different levels of renal dysfunction on clinical and echocardiographic results of MitraClip therapy are scarce. We aimed to evaluate the impact of baseline advance renal failure in the outcomes of a cohort of patients treated with MitraClip. METHODS AND RESULTS: We analyzed data from a multicenter registry of 173 patients treated with MitraClip between 2009 and 2012. Patients were classified as advanced chronic kidney disease (CKD, creatinine clearance [CrCl] <30 ml/min, group 1, n=20), moderate CKD (CrCl 30-60 ml/min, group 2, n=78) and normal renal function (CrCl >60 ml/min, group 3, n=75). Twenty patients (11.5%) presented advanced CKD. Procedural success was equal in the 3 groups (95.0% group 1, 100% in group 2 and 96.0% in group 3, p=0.180). Post-procedural MR and NYHA class at 1 month (MR ≥ 3+5.0% vs. 0% vs. 4.0% p=0.190 and NYHA>II 40.0% vs. 21.0% vs. 18.3%, p=0.101) and 6 months (MR ≥ 3+0% vs. 13.0% vs. 2.7%, p=0.330; and NYHA class>II 54.5% vs. 26.9% vs. 25.6%, p=0.298) did not differ between groups. However, patients in group 1 experienced higher frequency of the composite end-point of mortality or readmission at 16.2 ± 11.1 months of follow-up (HR 4.8, CI 95% 1.1-21.3). CONCLUSION: Advanced CKD is linked to an excess of cardiac adverse events. This should be judiciously taken into account when selecting patients for MitraClip.

Effect of gender on results of percutaneous edge-to-edge mitral valve repair with MitraClip system.

Knowledge regarding gender-specific results of percutaneous edge-to-edge mitral valve repair is scarce. The aim of this study was to investigate gender differences in outcomes in a cohort of patients treated with MitraClip implantation. A multicenter registry of 173 patients treated with MitraClip prostheses from 2009 to 2012 at 3 experienced centers was performed. One hundred nine patients (63%) were men. Men were younger (mean age 73 ± 10 vs 79 ± 9 years, p = 0.001) and had a higher prevalence of previous coronary bypass graft surgery (34% vs 13%, p = 0.002), previous myocardial infarction (46% vs 20%, p = 0.001), and diabetes mellitus (26% vs 11%, p = 0.020). There were no differences regarding New York Heart Association (NYHA) functional class before the intervention (NYHA class III or IV in 95% of men vs 97% of women, p = 0.472) or the cause of mitral regurgitation (MR) (functional in 58% of men vs 48% of women, p = 0.233). Men exhibited significantly larger ventricles (mean indexed left ventricular end-systolic diameter 2.4 ± 0.8 vs 2.0 ± 1.6 cm/m(2), p = 0.002, and mean indexed left ventricular end-diastolic volume 92.7 ± 46.1 vs 59.9 ± 24.6 ml/m(2), p <0.001). At 1 month, there were no differences between groups in the reduction of MR or NYHA functional class (MR grade ≤2+ in 98.2% of men vs 96.8% of women, p = 0.586, and NYHA class ≤II in 78.3% of men vs 77% of women, p = 0.851). At 6 months, results were maintained (MR grade ≤2+ in 89.5% of men vs 96.8% of women, p = 0.414, and NYHA class ≤II in 73.1% of men vs 74.2% of women, p = 0.912). After a mean follow-up period of 16.1 ± 11.1 months, no difference was found between groups in the incidence of death or admission for heart failure (log-rank p = 0.798). In conclusion, MitraClip implantation seems to be an equally safe and effective treatment of MR in men and women.

Echocardiographic and clinical outcomes of central versus noncentral percutaneous edge-to-edge repair of degenerative mitral regurgitation.

OBJECTIVES: This study aimed to assess the clinical and echocardiographic results of MitraClip implantation in noncentral degenerative mitral regurgitation (dMR) compared with central dMR. BACKGROUND: It is unknown whether the use of MitraClip therapy in noncentral dMR is as safe and effective as in central dMR. METHODS: We analyzed a multicenter registry of 173 patients treated with the MitraClip and compared results of central and noncentral dMR. RESULTS: Seventy-nine patients (age 79.2 ± 8.0 years, 58.2% men) had dMR. Forty-nine patients (62%) had central dMR, with the remainder classified as noncentral dMR (n = 30, 38%). Patients with noncentral dMR had a wider pre-procedural vena contracta (8.5 ± 2.0 mm vs. 6.9 ± 2.2 mm, p = 0.039) and higher systolic pulmonary pressure (57.9 ± 18.0 vs. 47.3 ± 13.0 mm Hg, p = 0.019). Procedural success was the same in both groups (95.5% central vs. 96.7% noncentral, p = 0.866). Post-procedural MR and New York Heart Association (NYHA) functional class at 1 month (MR ≤2, 96.0% vs. 96.6%, p = 0.866, and NYHA functional class ≤II, 81.6% vs. 90.0%, p = 0.335) and 6 months (95.2% central vs. 91.7% noncentral, p = 0.679; and NYHA functional class >II, 21.1% vs. 0%, p = 0.128) did not differ between groups. There were also no differences in serious post-procedural adverse events: partial clip detachment (central n = 1 [2.0%] vs. noncentral n = 1 [3.3%], p = 1.000), death (5.4% central vs. 13.0% noncentral, p = 0.298), or heart failure admission (10.8% central vs. 8.7% noncentral, p = 0.791). CONCLUSIONS: In experienced centers, MitraClip treatment can be performed safely and effectively in both central and noncentral dMR.

Cardiac fatigue in long-distance runners is associated with ventricular repolarization abnormalities.

BACKGROUND: Prolonged exercise can induce cardiac fatigue, which is characterized by biomarker release and impaired myocardial function. The impact on ventricular electrophysiology is largely unknown. OBJECTIVE: The objective of this study was to examine changes in ventricular repolarization after a 30-km cross-country race in runners aged >or=55 years. METHODS: Fifteen healthy participants (62 +/- 5 years) were assessed using biomarkers (N-terminal pro-brain natriuretic peptide [NT-proBNP], troponin T [TnT]), tissue Doppler echocardiography, and vectorcardiography at baseline, within 1 hour postrace and on days 1 and 6 postrace. RESULTS: During the race, NT-proBNP increased from 42 ng/L (interquartile range 25-117) to 187 ng/L (113-464), and TnT increased from undetectable levels to 0.03 microg/L (0.015-0.05). Global strain (19.1% +/- 2.2%) decreased on day 1 (17.2% +/- 1.8%) and day 6 (17.9% +/- 1.5%; P <.01). QT(c) increased from 431 +/- 15 ms prerace to 445 +/- 22 ms postrace and 445 +/- 15 ms on day 1 (P <.05), mainly because of an increased T(peak-end) interval (prerace 108 +/- 13 ms, postrace 127 +/- 43 ms, day 1 127 +/- 43 ms; P <.05). Postrace, T(area) (baseline 75 +/- 26 microVs) peaked on day 1 (105 +/- 42 microVs) and remained high on day 6 (89 +/- 37 microVs; P <.05). Runners with higher baseline NT-proBNP developed greater impairment of myocardial velocities (rho = -0.68 to -0.54; P <.05) and a larger increase in T(area) (rho = 0.73; P <.01). CONCLUSION: Cardiac fatigue induced by prolonged exertion is associated with sustained abnormalities in ventricular repolarization. Runners with higher baseline NT-proBNP are especially liable to such alterations of cardiac function.

Velocity tracking, a new and user independent method for detecting regional function of the left ventricle.

BACKGROUND: The use of two-dimensional echocardiography (2D echo) for detection of ischaemia is limited due to high user dependency. Longitudinal motion is sensitive for ischaemia and usable for quantitative measurement of longitudinal myocardial function but time consuming. Velocity tracking (VeT) is a new method that gives an easy three-dimensional understanding of both systolic and diastolic regional motion, using colour coded bull's eye presentation of longitudinal velocity, derived from colour coded tissue Doppler. The aim of this study was to test the accuracy of VeT in detecting ischaemia in non-ST-segment elevation myocardial infarction (NSTEMI) patients bedside. METHODS: Twenty patients with NSTEMI and 10 controls were included. Echocardiography was performed within 24 h of symptoms and prior to coronary angiography. Bull's eye plots presenting the peak systolic velocity (PSV) and the sum of PSV and the E-wave-velocity (PSV+E) were created using our developed software. VeT was compared to expert wall motion scoring (WMS) and bedside echo. We used the clinical conclusion based on ECG, angiography and clinical picture as 'gold standard'. RESULTS: Sensitivity for ischaemia with VeT (PSV+E) was 85% and specificity 60%. The corresponding sensitivities for expert WMS were 75% (specificity 40%). For regional analysis VeT and WMS showed comparable results with correct regional outcome in 11/20 of patients both superior to bedside echo. CONCLUSION: Velocity tracking is a promising technique that provides an easily understandable three-dimensional bull's eye plot for assessment of regional left ventricular longitudinal velocity with great potential for detection of regional dysfunction and myocardial ischaemia.

Magnitude, reproducibility, and association with baseline cardiac function of cardiac biomarker release in long-distance runners aged > or =55 years.

Cardiac biomarker release after endurance exercise has been described in young athletes. Although older athletes are increasingly active in such sports, they have not previously been studied. Therefore, the aim of this study was to assess the magnitude and reproducibility of biomarker release in athletes aged > or =55 years. Forty-three healthy athletes (mean age 61 +/- 3.6 years) were assessed before and immediately after a 30-km cross-country race and studied with echocardiography at rest. The median N-terminal pro-brain natriuretic peptide (NT-proBNP; normal <194 ng/L) level was 42 ng/L (interquartile range 30 to 95) at baseline and 191 ng/L (interquartile range 114 to 308) after the race. Troponin T (normal <0.03 microg/L) was elevated in 19 subjects (44%) after the race. Twenty-two subjects had also been studied 3 years before at the same race, using an identical test protocol. Between the 2 races, strong correlations were seen for individual runners' postrace biomarker levels (NT-proBNP: r = 0.82, log transformed data; troponin T: Spearman's rho = 0.84; p <0.001 for both). The coefficient of variation for NT-proBNP release was 8.1%. Levels of NT-proBNP after the race were correlated with levels at baseline (r = 0.93, p <0.001) and with left ventricular mass index (r = 0.32, p = 0.03). Moreover, participants with elevated postrace NT-proBNP were significantly older (62.0 vs 59.8 years, p = 0.04). In conclusion, long-distance runners aged > or =55 years released NT-proBNP and troponin T in a reproducible fashion. The magnitude of NT-proBNP release during the race was correlated strongly with NT-proBNP baseline levels and was associated with left ventricular mass and age. These findings may suggest a potential adverse effect of long-distance running on cardiac function in certain participants in this age group.

Velocity tracking--a novel method for quantitative analysis of longitudinal myocardial function.

Doppler tissue imaging is a method for quantitative analysis of longitudinal myocardial velocity. Commercially available ultrasound systems can only present velocity information using a color Doppler-based overlapping continuous color scale. The analysis is time-consuming and does not allow for simultaneous analysis in different projections. We have developed a new method, velocity tracking, using a stepwise color coding of the regional longitudinal myocardial velocity. The velocity data from 3 apical projections are presented as static and dynamic bull's-eye plots to give a 3-dimensional understanding of the function of the left ventricle. The static bull's-eye plot can display peak systolic velocity, late diastolic tissue velocity, or the sum of peak systolic velocity and early diastolic tissue velocity. Conversely, the dynamic bull's-eye plot displays how the myocardial velocities change over one heart cycle. Velocity tracking allows for a fast, simple, and intuitive visual analysis of the regional longitudinal contraction pattern of the left ventricle with a great potential to identify characteristic pathologic patterns.