Value of latent outflow obstruction to predict clinical course of patients with hypertrophic cardiomyopathy.

Objective The frequency, significance and prognostic value of left ventricle obstruction (LVO) induced with provocation (latent LVO) is controversial for hypertrophic cardiomyopathy (HC) patients. This study was designed to assess the value of latent LVO in predicting the clinical course in 101 patients with HC. Methods and results Patients were followed for a mean of 82 ± 48 months (range 2 to 148 months) for clinical end points defined as a composite of cardiovascular death resuscitated cardiac arrest, appropriate defibrillator shock or hospitalization due to worsening of heart failure symptoms. Presence of LVO (hazard ratio 3.63; 95% confidence interval, 1.85 to 7.12; P = 0.0001) and log NT-proBNP levels (hazard ratio, 1.40; 95% confidence interval, 1.14 to 1.72; P = 0.001) were the independent variables associated with an increased risk of experiencing clinical end points. HC patients with latent LVO have a trend toward decreased survival when compared with HC patients without LVO (log rank P = 0.027), but better survival than patients with resting LVO (log rank P = 0.007). HC patients with NT-proBNP levels <1,000 pg/ml had also better survival. LVO and NT-proBNP levels are the major determinants of clinical end points in patients with HC. Conclusions Evaluation of patients without resting LVO to demonstrate latent obstruction is of critical importance in respect of outcome and selection of patients for septal reduction therapies, so routine provocative testing with physiological exercise and measurement of NT-proBNP is recommended in this patient population for risk stratification.

Predictive role of left atrial and ventricular mechanical function in postoperative atrial fibrillation: a two-dimensional speckle-tracking echocardiography study.

OBJECTIVE: The aim of this study was to determine the role of left-sided mechanical parameters in postoperative atrial fibrillation (POAF) in patients undergoing coronary artery bypass grafting (CABG). METHODS: Ninety patients with coronary artery disease and normal left ventricular (LV) function in sinus rhythm were enrolled in the study. Preoperative LV and left atrial (LA) mechanics were evaluated by two-dimensional (2D) speckle-tracking echocardiography (STE), including strain and rotation parameters, and volume indices. Patients were monitored in order to detect POAF during the postoperative period. RESULTS: Twenty-three of 90 patients (25.6%) developed POAF. Age (p<0.001) and preoperative beta blocker usage (p=0.001) were the clinical parameters associated with POAF. Left atrial maximum volume index (LAV[max]i) increased, and peak left atrial longitudinal strain (PALS) was impaired in POAF patients (p=0.001, p<0.001, respectively). Left ventricular twist (LVtw) and left ventricular peak untwisting velocity (UntwV) were augmented in POAF patients (p=0.013, p=0.009, respectively). Receiver operating characteristic analysis showed N-terminal pro-brain natriuretic peptide (NT-proBNP) levels above 70 pg/ml and predicted POAF with a sensitivity of 74% and specificity of 78% (area under curve: 0.758, 95% confidence interval [CI] 0.631-0.894, p<0.001). Logistic regression analysis demonstrated that age (odds ratio [OR] 1.1, CI 1.01-1.20, p=0.034), preoperative beta blocker usage (OR 8.84, CI 1.36-57.28, p=0.022), NT-proBNP (values >70 pg/ml, OR 22.377, CI 3.286-152.381, p<0.001), PALS (OR 0.86, CI 0.75-0.98, p=0.023), and UntwV (OR 1.02, CI 1.00-1.04, p=0.029) were the independent predictors of POAF. CONCLUSION: The combination of 2D STE, clinical, and biochemical parameters may help predict POAF.

Right ventricular and atrial functions in patients with nonischemic dilated cardiomyopathy.

OBJECTIVE: The aim of this study was to assess the right ventricular and right atrial functions in patients with nonischemic dilated cardiomyopathy by novel echocardiographic measures. METHODS: In all, 40 patients with nonischemic dilated cardiomyopathy and 26 healthy subjects were consecutively included. Left ventricular, right ventricular, and right atrial functions were assessed by tissue Doppler imaging and two-dimensional speckle tracking echocardiography. Right ventricular systolic dysfunction was accepted moderated to severe when tissue Doppler peak systolic velocity of tricuspid lateral annulus was < 9 cm/s. RESULTS: In all, 18 of the 40 nonischemic dilated cardiomyopathy patients had peak systolic velocity of tricuspid lateral annulus < 9 cm/s and had significantly lower right ventricular free wall basal segment longitudinal strain, displacement, and right atrial functions assessed by speckle tracking echocardiography. Left ventricular tissue Doppler systolic velocity, global longitudinal and circumferential strain values were also lower in patients with moderated to severe right ventricular systolic dysfunction. Receiver operating characteristic analysis was preformed to assess the utility of right ventricular free wall basal segment longitudinal strain to predict right ventricular systolic dysfunction (peak systolic velocity < 9 cm/s). The cut off value for predicting right ventricular systolic dysfunction was - 20% with a sensitivity of 72% and specificity of 73% (AUC: 0.793; p = 0.002; 95% confidence interval: 0.645-0.941). CONCLUSIONS: Right ventricular systolic function is impaired in nonischemic dilated cardiomyopathy patients. Two-dimensional speckle tracking echocardiography represents a promising noninvasive method to evaluate right ventricular and atrial function in this patient group.

Early Detection of Bi-ventricular and Atrial Mechanical Dysfunction Using Two-Dimensional Speckle Tracking Echocardiography in Patients with Sarcoidosis.

PURPOSE: Sarcoidosis is a systemic inflammatory disease with unknown etiology involving several organs. Myocardial involvement, pericarditis, severe rhythm abnormalities, and heart valve disease due to papillary muscle dysfunction are some of the cardiac manifestations. Conventional echocardiographic methods remain insufficient for the determination of subclinical myocardial dysfunction in patients with sarcoidosis. In our study, we investigated the impact of sarcoidosis on bi-ventricular and atrial functions using two-dimensional (2D) speckle tracking echocardiography (STE). METHODS: Forty patients with sarcoidosis and 20 age and sex-matched controls were recruited into study. All subjects underwent a transthoracic echocardiography for the evaluation of ventricular and atrial functions with 2D STE. RESULTS: Left ventricular (LV) dimensions, LV ejection fraction, and right ventricular (RV) systolic velocity were similar between the two groups. Left atrial (LA) diameter was significantly higher in sarcoidosis patients than controls. Eighteen (45%) patients in the sarcoidosis group and 1 (5%) patient in the control group had LV diastolic dysfunction. LV global longitudinal, radial, circumferential strain, twist, untwists, and RV global longitudinal strain values were significantly lower in sarcoidosis patients compared to controls. LA and RA reservoir functions were also significantly lower in sarcoidosis patients than controls. CONCLUSION: Although impaired LV diastolic function was detected using conventional parameters, only novel advanced echocardiographic modalities demonstrated impaired bi-ventricular and atrial mechanical functions in patients with sarcoidosis.

Apical transverse motion is associated with speckle-tracking radial dyssynchrony in patients with non-ischemic dilated cardiomyopathy.

OBJECTIVE: Apical transverse motion (ATM) is a new parameter for assessing left ventricular (LV) dyssynchrony. Speckle-tracking radial strain analysis seems to be the best method to identify potential responders to cardiac resynchronization therapy. The aim of our study was to investigate the association between ATM and radial dyssynchrony assessed by speckle-tracking echocardiography in patients with non-ischemic dilated cardiomyopathy (NDC). METHODS: We examined 35 NDC patients (mean age 49.2 ± 28.1 years; 21 males). Cardiac dimension and ejection fraction (EF) were measured. Speckle-tracking analysis was performed on two-dimensional greyscale images in the mid-LV short axis view and apical views to calculate global radial, circumferential, and longitudinal strain (GRS, GCS, GLS), as well as rotational indexes (LV twist and torsion). Radial dyssynchrony was defined as a difference in time to peak systolic radial strain between the anteroseptal and posterior segments with a cut-off value of 130 ms. ATM was estimated using motion traces of 2 opposite apical segments. RESULTS: Radial dyssynchrony was significantly correlated with ATMloop (r = 0.78, p < 0.001), ATM4CV (r = 0.71, p = 0.001), ATM3CV (r = 0.67, p = 0.003), GRS (r = -0.51, p = 0.04), GCS (r = -0.55, p = 0.03), LV twist (r = -0.58, p = 0.02), and LV torsion (r = -0.56, p = 0.03). The receiver operating characteristics analysis for ATMloop to distinguish between patients with and without radial dyssynchrony revealed an area under the curve value of 0.88 (CI: 0.73-1.04, p = 0.005). The best cut-off value was 2.5 mm for ATMloop (85% sensitivity and 86% specificity). CONCLUSION: Apical transverse motion is closely associated with radial dyssynchrony assessed by speckle-tracking echocardiography. Quantitative measure of apical rocking has the potential for clinical applications.

Right ventricular function in hypertrophic cardiomyopathy: A speckle tracking echocardiography study.

OBJECTIVE: The aim of this study was to explore right ventricular (RV) mechanical function in patients with hypertrophic cardiomyopathy (HCM) by 2-D speckle tracking echocardiography (2-D-STE). METHODS: Forty-three patients with HCM (mean age 48, 17 females) and 40 healthy subjects were consecutively included in this cross-sectional study. The diagnosis of HCM was based on the presence of typical clinical, electrocardiographic (ECG), and echocardiographic features. Patients with LV systolic impairment, significant valvular disease, history of coronary artery disease, hypertension, malignancy, and chronic obstructive pulmonary disease were excluded. Right and left ventricular (LV) function was assessed by tissue Doppler imaging (TDI) and 2-D-STE. Hypertrophic cardiomyopathy patients were divided into two groups according to ACC/ESC guidelines (LVOT gradient below and above 30 mm Hg). Student t-test was used to compare differences between groups. Non-parametric tests (Mann-Whitney U) were used in cases of abnormal distribution. RESULTS: Hypertrophic cardiomyopathy patients had a significantly larger right atrium and RV diameters compared to controls. Mean pulmonary artery pressures (mPAB) were significantly higher in HCM patients (19.01±13.09 mm Hg vs. 8.40±4.50 mm Hg; p<0.001). Although RV Sm measurements were similar, RV strain measurements (-28.51±5.36% vs. -32.06±7.65%; p=0.016) were significantly lower in HCM patients. Left ventricular global longitudinal, radial, and circumferential strain values were also significantly different between the two groups (-20.50±3.58% vs. -24.12±3.40%; p<0.001, 38.18±12.67% vs. 44.80±10.15%; p=0.012, -21.94±4.28% vs. -23.91±3.95%; p=0.036 consecutively). Rotational movement of LV in each apical, mid-, and basal left ventricular segment was determined, and only mid-ventricular rotation of the HCM patients was more clockwise (-1.71±2.16 ° vs. 0.04±1.72 °; p<0.001). Although mPAP measurements were higher in HCM patients with significant LVOT obstruction (21.52±13.26 mm Hg vs. 12.31±10.53 mm Hg; p=0.049), none of the other TDI or 2-D-STE parameters was significantly different between groups. CONCLUSION: Speckle tracking echocardiography-derived right ventricular systolic function is impaired in HCM patients when compared with healthy subjects. However, RV systolic function is not affected form LVOT obstruction and left ventricular rotation dynamics in HCM patients.

Aortic elastic properties predict occult coronary artery disease: a multidetector row computed tomography study.

BACKGROUND: Multidetector row computed tomography (MDCT) is an attractive noninvasive imaging modality to detect coronary atherosclerotic plaques which may be underestimated by conventional angiography. However, its routine clinical use is limited due to contrast-associated problems, high cost, inapplicability at bedside and exposure to radiation. Thus, exploring safer and more practical measurements to predict occult coronary artery disease (CAD) is required. AIM: To demonstrate the predictive value of aortic elastic properties for occult CAD diagnosed by MDCT. METHODS: Forty subjects with angiographically normal coronary arteries were consecutively included in our study. They underwent MDCT including indications and were divided into a no CAD group (23 subjects, 11 males, 46 ± 8 years) and an occult CAD group (17 subjects, 12 males, 48 ± 10 years), with respect to the presence of coronary plaque. As a control group, 19 consecutive patients with angiographically proven CAD (16 males, 52 ± 6 years) were included. Aortic stiffness index (ASI), aortic distensibility and aortic strain were calculated from the aortic diameters measured by echocardiography and blood pressure obtained by sphygmomanometry. RESULTS: It was found that ASI, aortic distensibility and aortic strain were significantly different in the occult CAD group compared to the no CAD group (p = 0.008, p = 0.01, p = 0.03, respectively) and to the evident CAD group (p = 0.01, p = 0.02, p = 0.02). They also differed significantly between the no CAD and the evident CAD groups. Receiver operating characteristics analysis for ASI, to distinguish between the occult CAD group and the no CAD group, revealed an area under the curve of 0.80 (confidence interval 0.68-0.94, p = 0.004) and that the cut-off value of 3.42 could significantly predict patients with occult CAD (sensitivity: 78%; specificity: 63%). CONCLUSIONS: Measurement of ASI is an easily applicable and safe method with its non-radiographic ability for the assessment of aortic stiffness, and it may be useful to predict subclinical atherosclerosis in clinical practice. A cut-off value of 3.42 for ASI may guide to refer individuals to preventive strategies to reduce atherosclerosis progression.

Effect of increased severity of mitral regurgitation and preprocedural right ventricular systolic dysfunction on biventricular and left atrial mechanical functions following percutaneous mitral balloon valvuloplasty.

BACKGROUND: Severe mitral stenosis (MS) may impair left atrial (LA) pump function, and increase LA and pulmonary venous pressure resulting in right ventricular (RV) systolic dysfunction. The aim of this study was to evaluate biventricular and LA function after percutaneous mitral balloon valvuloplasty (PMBV) by tissue Doppler (TDI) and speckle tracking echocardiography (STE). METHODS: Twenty-eight consecutive patients with severe symptomatic rheumatic MS (11 men, mean age: 39 ± 7 years) who were referred for PMBV were included in the study. In addition to conventional echocardiography, all patients underwent TDI and two-dimensional (2D) (STE) to assess left ventricular (LV), LA, and RV function before and 3 months after PMBV. Severity of mitral regurgitation (MR) was graded by the ratio of MR jet area to LA area (JA/LAA) method and any postprocedural progression of the JA/LAA ratio was defined as worsening of MR. Peak systolic velocity of tricuspid lateral annulus (RVs) <11.5 cm/sec was accepted as RV dysfunction. RESULTS: Left atrial diameter and area were decreased, while LV dimensions were unchanged following the valvuloplasty. PMBV improved STE-based LV mechanical indices, LA reservoir and conduit function, and RV free wall basal longitudinal strain (LS) and displacement. Increased severity of MR was detected in 6 patients, and PMBV did not improve the STE-based RV or LV function in these patients, while LA reservoir and conduit function were both improved independent of MR worsening. There was significant improvement in RVs and RV basal LS in the 15 patients with preprocedural RV systolic dysfunction, while the improvement in patients with normal preprocedural RV function was not significant. CONCLUSION: Percutaneous mitral balloon valvuloplasty may improve both LA and biventricular function in patients with severe symptomatic MS. Both TDI and STE are useful to determine biventricular and LA function after PMBV. Although the number of patients was insufficient, worsening of MR after PMBV may limit the improvement in RV and LV function, while preprocedural RV dysfunction does not seem to limit the improvement in RV function and pulmonary artery systolic pressure. Large scale follow-up studies are required to see whether the changes observed in cardiac mechanics are persistent.

Left ventricular and atrial functions in hypertrophic cardiomyopathy patients with very high LVOT gradient: a speckle tracking echocardiographic study.

BACKGROUND: Determination of myocardial deformation (strain) by two-dimensional (2D) speckle tracking echocardiography (STE) is a new method for evaluating left ventricular (LV) regional function in patients with hypertrophic cardiomyopathy (HCM). The aim of this study was to assess LV and left atrial (LA) functions with 2DSTE in HCM patients and to investigate relation between strain analysis and LV outflow tract (LVOT) gradient. METHODS: Forty consecutive HCM patients (26 male, mean age: 47.7 ± 15.2 years), and 40 healthy volunteers (22 male, mean age: 46.6 ± 11.2 years) were included in the study. All subjects underwent a transthoracic echocardiography for evaluation of LV and LA functions with 2DSTE. The HCM patients were divided into 2 groups according to the presence of resting LVOT gradient >100 mmHg. RESULTS: Left ventricular global longitudinal strain (GLS), global radial strain (GRS), and global circumferential strain (GCS) were significantly lower in patients with HCM compared with controls (-20.3 ± 3.6% vs. -24.1 ± 3.4% P < 0.001, 38.1 ± 12.8% vs. 44.8 ± 10.2% P = 0.012, and -22.0 ± 4.4% vs. -23.9 ± 4.0% P = 0.045, respectively). Although basal and apical rotation were similar between the groups, mid-rotation was significantly clockwise in HCM patients (-1.53 ± 2.06° vs. 0.05 ± 1.7° P < 0.001). Both LA reservoir functions and LA conduit functions were significantly lower in HCM patients (21.6 ± 9.1% vs. 39.4 ± 10.6% P < 0.001, and 10.5 ± 4.3% vs. 15.7 ± 5.3%, P < 0.001). Fifteen patients had a resting LVOT gradient of >100 mmHg and they had significantly decreased GLS, twist and untwist compared to the HCM patients with lower resting LVOT gradient (-18.7 ± 2.3% vs. -21.2 ± 3.9% P = 0.016, 19.4 ± 4.3° vs. 23.5 ± 7.4° P = 0.038 and -94.0 ± 29.1°/sec vs. -134.9 ± 55.8°/sec, 0.005, respectively). Although basal and apical rotation were similar between the 2 groups, mid-rotation was significantly clockwise in HCM patients with higher LVOT gradient (-2.52 ± 1.76° vs. -0.96 ± 2.03°, P = 0.018). Correlation analysis revealed that LVOT peak velocity was associated with GLS (r = -0.358, P = 0.023), LV mid-rotation (r = -0.366, P = 0.024), and LV untwist (r = -0.401, P = 0.013). CONCLUSIONS: Left ventricular and LA functions are impaired in patients with HCM. 2DSTE is useful in determining patients with impaired myocardial mechanics. High LVOT gradient may be one of the responsible factors that trigger deterioration of LV longitudinal strain and twist mechanics in patients with HCM. Further studies are required to clarify the preliminary results of this study.

Soluble CD40 ligand release in patients with stable coronary artery disease during elective stent implantation: effect of drug-eluting stent over bare metal stent.

OBJECTIVES: We aimed to determine the effect of drug-eluting stent (DES) implantation on soluble CD40 ligand (sCD40L) levels in patients with stable coronary artery disease undergoing stent replacement. STUDY DESIGN: Eighty-nine consecutive patients (33 women, 56 men; mean age 61±10 years) with stable coronary artery disease undergoing stent replacement were recruited. Pre- and post-procedural blood samples were collected for sCD40L analysis, and differences in plasma levels were calculated and expressed as delta sCD40L. Total size and length of implanted stents and pre- and post-dilatation procedures were recorded for each patient, for possible impact on sCD40L release. Patients were followed for one year following procedures for possible adverse cardiac events such as death, myocardial infarction and revascularization. RESULTS: Forty-nine patients received bare metal stent (BMS) and 40 patients received DES. There were no differences between BMS- and DES-implanted patients in terms of age, stent size and length, and delta sCD40L plasma levels. Delta sCD40L was correlated only with total implanted stent length (r=0.374, p<0.001). Delta sCD40L levels were divided into quartiles for better determination of the procedural parameters that are effective on biomarker release. Total stent length (p=0.008), stent size (p=0.038) and pre-dilatation procedure (p=0.034) were the statistically differing parameters between delta sCD40L quartiles. Although statistically non-significant, all three adverse events were observed in patients with the highest quartile (p=0.179). CONCLUSION: Procedural sCD40L release did not differ between DES- and BMS-implanted stable coronary artery disease patients. Total implanted stent length, stent size and pre-dilatation procedure were the influential parameters on procedural sCD40L release.

The effect of myocardial fibrosis on left ventricular torsion and twist in patients with non-ischemic dilated cardiomyopathy.

BACKGROUND: Left ventricular (LV) rotation, twist, and torsion are important aspects of the cardiac performance. Myocardial fibrosis can be identified as the late gadolinium enhancement (LGE) in cardiac magnetic resonance (CMR). In this study, we investigated the association between myocardial fibrosis and LV rotational parameters in patients with nonischemic dilated cardiomyopathy (NDC). METHODS: Twenty-two NDC patients were enrolled. LV dimensions, volumes and ejection fraction (EF) were measured, conventional tissue Doppler imaging data was acquired. Speckle tracking imaging was performed to measure LV deformation, LV rotational parameters. Blood samples were obtained for NT-proBNP. Late gadolinium enhanced cardiac magnetic resonance (LGE-CMR) was used to assess cardiac fibrosis index. RESULTS: Myocardial deformation was similar between LGE+ and LGE- groups. LGE+patients have significantly higher basal and lower apical systolic rotation, lower twist and torsion when compared to LGE- patients. However, untwisting rate was similar between the groups. Torsion was significantly correlated with LVEF and MR-index. Patients with reversed apical systolic rotation had significantly greater NT-proBNP values, basal systolic rotation and significantly lower apical systolic rotation, torsion, and MR-index. CONCLUSIONS: Cardiac fibrosis index is closely related with myocardial torsion and LV systolic function and may be used for the evaluation of cardiac condition. Reversed apical systolicrotation indicated more extensive cardiac fibrosis as it may reflect severe LV dyssynchrony andpoor LV performance.

Incidence and predictors of radial artery spasm at the beginning of a transradial coronary procedure.

OBJECTIVES: Our aim was to establish the frequency of radial artery spasm (RAS) and its predictors at the beginning of a transradial approach (TRA). METHODS: This was a single-center prospective study. A total of 1,722 consecutive patients undergoing their first transradial coronary procedure were recruited. After radial artery puncture, a hydrophilic sheath was used to complete arterial puncture, then 500 µg glycerol trinitrate and 2.5 mg verapamil were injected into radial artery along the sheath. After retrograde radial arteriography spasm was defined angiographically as a stenosis greater than 25%. Patient demographics, procedural data such as total procedural duration, the number of catheters and guidewires used, the amount of contrast media usage, dose area product (DAP) and fluoroscopy time, and vascular complications were recorded. RESULTS: The overall spasm incidence was 10.3%. The procedural success rate was lower in patients with spasm than in patients without spasm (80% vs. 95.7%, P < 0.001). The patients with spasm were older (mean age 63.9 ± 9.4 years vs. 60.0 ± 11.2 years, P < 0.001) and more commonly female (51.3% vs. 34.4%, P < 0.001). Spasm was more common in hypertensive patients (66% vs. 56%, P < 0.009). Surprisingly, smoking was less common in patients with spasm (17% vs. 29%, P < 0.001). Multiple logistic regression analysis showed that female gender (OR = 1,524, 95% CI: 1.033-2.248, P = 0.034) was the only independent predictor of RAS at the beginning of the procedure. CONCLUSIONS: The incidence of RAS was 10,3%, and female gender was the sole independent predictor of RAS at the very beginning of the procedure in patients undergoing a TRA.

Role of left ventricular dyssynchrony in predicting remodeling after ST elevation myocardial infarction.

BACKGROUND: Intraventricular dyssynchrony is associated with worsening systolic function, adverse remodeling, and clinical events. The aim of this study is to investigate whether intraventricular dyssynchrony assessed by tissue Doppler imaging (TDI) can predict left ventricular (LV) remodeling after first ST segment elevation myocardial infarction (STEMI) treated successfully with primary percutaneous coronary intervention (pPCI). METHODS: Fifty-two consecutive patients who presented with first acute STEMI were included in the study. All patients underwent successful pPCI. Standard echocardiography was performed within 48 hours of admission. LV dyssynchrony was assessed by color-coded TDI. Dyssynchrony (Ts-diff) was calculated by maximal temporal difference between time to peak systolic velocities (Ts) of six basal segments. Echocardiographic examination was repeated after 6 months to reassess LV volumes. LV remodeling was defined as >15% increase in LV end-systolic volume index (LVESVI) after 6 months. RESULTS: Eleven patients (23%) developed LV remodeling. Baseline dyssynchrony was found to be correlated with percent change in LVESVI and LV end-diastolic volume index (LVEDVI) after 6 months. Ts-diff, creatine kinase-MB and mitral inflow E-wave deceleration time (DT) were the independent predictors of remodeling after STEMI in multivariate logistic regression analysis. Receiver operating characteristic curve analysis showed that Ts-diff >56 msec had 72.7% sensitivity and 83.8% specificity for predicting remodeling. CONCLUSIONS: LV dyssynchrony is a strong predictor of LV remodeling after acute myocardial infarction (AMI). It could be useful in risk stratification of patients after AMI.

Cardiovascular involvement in patients with systemic sclerosis: insights from electromechanical characteristics of the heart.

Systemic sclerosis is a severe, life threatening autoimmune disease involving the skin and visceral organs, including the lungs, gastrointestinal tract, kidneys and heart. Cardiac involvement in systemic sclerosis, which is an important mortality predictor may involve myocardium, conduction system, vascular wall, pericardium, pulmonary vessels causing pulmonary hypertension. Thus, the detection of cardiac involvement is necessary in systemic sclerosis. With the more widespread use of novel non-invasive imaging techniques, the cardiac involvement is more frequently encountered in daily practice. Noninvasive evaluation can offer an advantage in early prediction of poor prognosis and give a chance to apply new therapeutic approaches for cardiac involvement. In this review, we intend to present cardiac involvement of systemic sclerosis and clinical diagnostic modalities, including electromechanical properties of the atrium and ventricles, for assessment this involvement.

The predictive value of flow-mediated dilation and carotid artery intima-media thickness for occult coronary artery disease.

BACKGROUND: Multidetector row computed tomography (MDCT) is an attractive noninvasive alternative to assess overall coronary artery disease (CAD) burden and may reveal coronary plaques, which may be underestimated by conventional coronary angiography. The aim of this study was to determine whether brachial artery flow-mediated dilation (FMD) and carotid artery intima-media thickness (CIMT) might accurately predict patients with occult coronary plaques whose conventional coronary angiographies revealed normal coronary arteries (NCA). METHODS: Thirty-five patients with angiographically NCA were consecutively recruited into the study. They underwent MDCT and were divided into NCA group (18 patients; 8 male; 47 ± 9 years) and occult CAD group (17 patients; 11 male; 50 ± 10 years) according to presence of coronary plaque. Nineteen consecutive patients with evident CAD (16 male; 54 ± 7 years) and 19 healthy subjects (10 male; 50 ± 6 years) were included as control groups. FMD and CIMT were measured by brachial and carotid artery ultrasonography. RESULTS: Occult CAD group had significantly lower FMD and insignificantly higher CIMT than NCA group whereas they had significantly higher FMD and insignificantly lower CIMT than evident CAD group. NCA group had significantly lower CIMT than evident CAD group. Receiver operating characteristic curve analysis demonstrated FMD < 8% (sensitivity: 94.4%; specificity: 73.0%; PPV: 77.3%; NPV: 93.1%) and CIMT ≥ 0.65 cm (sensitivity: 72.2%; specificity: 62.2%; PPV: 65.0%; NPV: 69.7%) could predict patients with CAD. FMD and CIMT were independent predictors of CAD (P < 0.001; OR: 45.630; 95%CI: 5.38-386.983 and P = 0.015; OR: 14.226; 95%CI: 1.666-121.467, respectively). CONCLUSION: FMD and CIMT might predict patients with occult CAD and be helpful in selecting patients for MDCT.

Intraventricular and papillary muscle dyssynchrony is related to the diastolic phase of functional mitral regurgitation in patients with non-ischemic dilated cardiomyopathy.

BACKGROUND AND AIM OF THE STUDY: Functional mitral regurgitation (FMR) is commonly encountered in patients with heart failure, and is associated with an adverse prognosis. It is hypothesized that left ventricular (LV) and papillary muscle systolic dyssynchrony causes diastolic mitral regurgitation (DMR) in non-ischemic dilated cardiomyopathy (DC) patients. METHODS: A total of 77 patients with non-ischemic DC was enrolled, of whom 25 were without DMR (group I) and 52 with DMR (group II). Mitral valve apparatus measurements were calculated using two-dimensional echocardiography, while LV/papillary muscle (Pap-index) systolic dyssynchrony parameters were calculated using tissue Doppler echocardiography. RESULTS: The FMR volumes were similar between the two groups (19.4 +/- 10.6 and 22.4 +/- 11.1 ml/beat in groups I and II, respectively). Both groups had similar mitral valves, as assessed by the geometry of the mitral valve apparatus parameters, including tent area, mitral annulus diameter, and tethering distance. However, the maximal intraventricular mechanical delay (MIMD; p < 0.001), peak (+/- SD) myocardial sustained systolic velocity (Ts-SD; p < 0.001) and Pap-index (p < 0.001) were each significantly increased in group II. Strong correlations were apparent between DMR and dyssynchrony parameters [(Ts-SD; r = 0.74, p < 0.001), MIMD (r = 0.78, p < 0.001) and Pap-index (r = 0.78, p < 0.001)]. Linear regression analysis revealed the MIMD (OR 2.94, 95% CI 2.7-6.6, p < 0.001), Ts-SD (OR 3.6, 95% CI 1.2-3.5, p < 0.001) and Pap-index (OR 2.2, 95% CI 1.27-1.35, p = 0.001) to be independent predictors of DMR. CONCLUSION: In patients with non-ischemic DC, DMR may serve as a useful indicator of mechanical LV/papillary muscle dyssynchrony, especially when used in combination with the other echocardiographic parameters.

The prevalence of echocardiographic accretions on the leads of patients with permanent pacemakers.

BACKGROUND: The aim of this study was to investigate the prevalence and clinical significance of echocardiographic "accretions" on intracardiac leads in patients with permanent pacemakers. METHODS: Two hundred eleven patients with permanent cardiac pacemakers implanted between 1988 and 2005 were called by telephone to participate in this study. The cohort was identified retrospectively and followed prospectively after recruitment. Seventy-five patients who agreed to participate in the study were examined by using transthoracic and transesophageal echocardiography for the detection of pacemaker lead accretions. Blood samples were also obtained for aerobic and anaerobic cultures, high-sensitivity C-reactive protein, erythrocyte sedimentation rate, and complete blood count. The medical records of the patients were analyzed carefully, and patients were called by telephone to investigate mortality and clinical events after 5 years of follow-up. RESULTS: The initial study group included 28 women and 47 men (mean age, 60 ± 15 years). At least one echocardiographic accretion on the pacemaker leads was identified in 16 subjects (21%) by transthoracic echocardiography and in 21 subjects (28%) by transesophageal echocardiography. All accretions were in the right atrial portion of the leads, whereas the ventricular segments of the leads were free of accretions. Patients with pacemaker lead accretions were significantly younger than those without accretions (P = .03). At 5-year follow-up, information could be obtained from 60 of the 75 patients. Among these 60 patients, 28 (46%) had died. There was no difference in mortality between patients who did and did not have lead accretions (P = .96). Patients who died during follow-up were older (P < .001), had shorter time intervals from pacemaker implantation to study enrollment (P = .002), had increased left atrial (P = .007) and right atrial (P = .04) sizes, and had higher pulmonary artery systolic pressures (P = .012) than those who were alive at 5 years. Logistic regression analysis revealed that age and pulmonary artery systolic pressure were independent predictors of mortality. CONCLUSIONS: Accretions on permanent pacemaker leads can be detected by both transthoracic and transesophageal echocardiography. Follow-up data did not demonstrate any effect of these accretions on 5-year survival.

The role of isovolumic acceleration in predicting subclinical right and left ventricular systolic dysfunction in hypertensive obese patients.

OBJECTIVES: Isovolumic acceleration assessed by tissue Doppler imaging has been proposed as a preload-independent indicator of left ventricular contractility. We investigated the utility of isovolumic acceleration in the prediction of preclinical right and left ventricular systolic dysfunction in hypertensive and obese subjects. STUDY DESIGN: Seventy-eight obese subjects (BMI >30 kg/m2; 57 women, 21 men; mean age 51±8 years) were prospectively enrolled. Fifty patients (64.1%) had hypertension and 33 patients (42.3%) had diabetes mellitus. All the subjects were assessed by conventional and tissue Doppler echocardiography. Myocardial velocities of the left ventricular septal and lateral mitral annulus and lateral tricuspid annulus were determined. Isovolumic contraction wave was defined as the preceding wave of the systolic wave that began before the peak of the R wave on the electrocardiogram. Myocardial isovolumic acceleration was measured by dividing the peak velocity by the time passed from the onset of the wave (zero-crossing) during isovolumic contraction to the peak velocity of the wave. RESULTS: Waist circumference was in positive correlation with left ventricular end-systolic (r=0.22, p=0.047) and end-diastolic (r=0.384, p=0.001) diameters, and in negative correlation with the peak systolic velocity of the tricuspid annulus (r=-0.311, p=0.006). Although hypertensive and normotensive (n=28) obese subjects had similar myocardial velocities, lateral tricuspid annular isovolumic acceleration (p=0.027), septal isovolumic acceleration (p=0.026), and septal isovolumic contraction myocardial velocity (p=0.018) were significantly lower in hypertensive patients. CONCLUSION: Isovolumic acceleration and isovolumic contraction myocardial velocity analysis may be useful in the diagnosis of subclinical left and right ventricular dysfunction in hypertensive obese patients.