Transcatheter aortic valve implantation in a patient with myelofibrosis and severe thrombocytopenia.

Transcatheter aortic valve implantation (TAVI) has been commonly used to treat patients with aortic stenosis who have a contraindication to, or a high risk of, corrective surgery. Anti-thrombotic treatment is an important part of the TAVI procedure to avoid thrombotic complications during both peri- and post-procedural periods. However, no specific data are available regarding the safety of TAVI with or without anti-thrombotic treatment, either during the surgical procedure or follow up period in patients with thrombocytopenia, such as myelofibrosis. Here, the case is reported of a patient with myelofibrosis and severe thrombocytopenia who underwent a TAVI procedure without anti-thrombotic treatment such as heparin, acetyl salicylic acid, or clopidogrel.

Relationship between Nitrate-Induced Headache and Coronary Artery Lesion Complexity.

OBJECTIVE: The aim of the present study was to investigate the association between nitrate-induced headache (NIH) and the complexity of coronary artery lesions in patients with stable coronary artery disease (CAD). SUBJECTS AND METHODS: Two hundred and seventy-five patients with anginal chest pain who underwent coronary angiography were enrolled in the present study. NIH was defined as the presence of headache due to nitrate treatment (isosorbide mononitrate 40 mg) after excluding confounding factors. Coronary artery lesion complexity was assessed by the SYNTAX score (SXscore) using a dedicated computer software system. RESULTS: The mean SXscore was lower in the patients with NIH than in patients without NIH (7.3 ± 5.2 vs. 14.4 ± 8.5, respectively; p < 0.001). Additionally, patients with NIH had a lower rate of multivessel disease compared with those without NIH (the mean number of diseased vessels was 1.5 ± 0.7 and 2.0 ± 07, respectively; p < 0.001). In multivariate analysis, increasing age (p = 0.02) and headache (p = 0.001) were found to be independent determinants of SXscore. CONCLUSION: The present study demonstrated an independent inverse association between NIH and SXscore. The NIH could provide important predictive information about coronary artery lesion complexity in patients with stable CAD.

Assessment of total cardiac repolarization's spatial distribution among patients with aortic sclerosis.

OBJECTIVE: To measure the Tp-e value, which shows the spatial distribution of cardiac repolarization and is defined as a possible predictor for ventricular arrhythmia among patients with aortic sclerosis (AS), and to compare this parameter's length to QTc length within the same population. METHOD: 60 patients that have been diagnosed with AS have been prospectively included in this study. RESULTS: 60 AS and 64 control patients were evaluated as part of the study. The median age, prevalence for hypertension and diabetes, baseline medications and laboratory results of the groups were similar. The Electrocardiographic QT length of both groups were found similar. In the AS group Tp-e tangent and Tp-e tail values were more longer than control group (P < 0.001). Tp-e tangent index and Tp-e tail index values were also statistically higher among AS patients when compared to the control group. (P < 0.001). CONCLUSION: Our study showed that Tp-e durations had increased in AS patients with no structural coronary heart disease. AS causes local degeneration on the aortic root and also has a negative effect on the total cardiac spatial repolarization.

Relationship between epicardial fat tissue and left ventricular synchronicity: An observational study.

OBJECTIVE: Left ventricular (LV) systolic synchrony is defined as simultaneous activation of corresponding cardiac segments. Impaired synchrony has some adverse cardiovascular effects, such as LV dysfunction and impaired prognosis. Epicardial fat tissue (EFT) is visceral fat around the heart. Increased EFT thickness is associated with some disorders, such as LV dysfunction and hypertrophy, which play a role in the impairment of LV synchrony. However, the relationship between EFT and LV systolic synchrony has never been assessed. Thus, we aimed to evaluate the possible relationship between EFT and LV synchrony in this study. METHODS: The study population consisted of 55 consecutive patients (mean age 46.4±13.4 years, 32 female) without bundle branch block (BBB). EFT and LV systolic synchrony were evaluated by transthoracic echocardiography using 2D and tissue Doppler imaging. Maximal difference (Ts-6) and standard deviation (Ts-SD-6) of time to peak systolic (Ts) myocardial tissue velocity obtained from 6 LV basal segments were used to assess LV synchrony. Multiple regression analysis was used to detect the independently related factors to LV synchrony. RESULTS: The mean values of EFT thickness, Ts-6, and Ts-SD-6 were found to be 2.7±1.6 mm (ranging from 1-7 mm), 20.1±14.2 msec, and 7.7±5.6, respectively. EFT thickness also was independently associated with Ts-6 (ß=0.332, p=0.01) and Ts-SD-6 (ß=0.286, p=0.04). CONCLUSION: EFT thickness is associated with LV systolic synchrony in patients without BBB.

The relationship between epicardial fat tissue thickness and frequent ventricular premature beats.

BACKGROUND: Ventricular premature beats (VPBs) are one of the most common rhythm abnormalities. Structural heart diseases such as myocardial hypertrophy and left ventricular dysfunction are associated with VPBs. However, the exact mechanism of VPBs in patients without structural heart disease has not been revealed yet. Epicardial fat tissue (EFT) is a visceral fat around the heart. Increased EFT thickness is associated with myocardial structural and ultrastructural myocardial abnormalities, which may play a role in the development of VPBs. AIMS: To evaluate the possible relationship between EFT thickness and frequent VPBs. METHODS AND RESULTS: The study population consisted of 50 patients with VPBs and 50 control subjects. Frequent VPBs were defined as the presence of more than 10 beats per hour assessed by 24-h Holter electrocardiography monitoring. EFT thickness was measured by transthoracic echocardiography. Multivariable logistic regression analysis was used to assess factors related with frequent VPBs. Baseline demographic and biochemical features including age, gender, and rates of hypertension and diabetes mellitus were similar in both groups. EFT thickness was significantly higher in patients with frequent VPBs than in controls (3.3 ± 1.3 mm vs. 2.2 ± 0.8 mm, p < 0.001). In multivariable logistic regression analysis, EFT thickness was independently associated with VPB frequency (B = 1.030, OR = 2.802, p < 0.001). CONCLUSIONS: Patients with frequent VPBs had increased EFT thickness compared to control subjects. EFT thickness was independently associated with frequent VPBs.

Evaluation of therelationship between epicardial adipose tissue and myocardial performance (Tei) index.

AIM: Epicardial adipose tissue (EAT) is a tissue around the heart with visceral adipose properties. It can affect the structure and functions of the myocardium and coronary arteries through inflammatory markers and regulators. The myocardial performance (Tei) index is a parameter capable of globally assessing systolic and diastolic heart functions. This study investigated the relation between EAT thickness and the Tei index. METHODS: The study population was selected from patients without structural heart disease. EAT thickness was measured with two-dimensional imaging in parasternal long axis view and from the anterior face of the right ventricle. Tei index measurement was calculated with tissue Doppler echocardiography from the mitral lateral annulus. The relation between the Tei index and EAT was assessed using multivariate linear regression analysis. RESULTS: Forty-three patients (36 female, 7 male; mean age 50.2 ± 10.6 years) were included in the study. Mean Tei index was 0.39 ± 0.09, and mean EAT thickness 4.7 ± 2.4 mm. A significant correlation was determined between tissue Doppler Tei index and EAT thickness at correlation analysis (r = 0.522, P < 0.001). EAT thickness was independently correlated with Tei index at multivariate linear regression analysis (Beta = 0.443, t = 3.522, P = 0.001). CONCLUSION: EAT thickness is independently correlation with Tei index. Increased EAT thickness may therefore be a predictor of left ventricular dysfunction.

Epicardial adipose tissue thickness is increased in patients with cardiac syndrome X.

BACKGROUND: Cardiac syndrome X (CSX) is defined as normal coronary arteries with angina pectoris and a positive stress test. Epicardial adipose tissue (EAT) plays an important role in inflammatory process in cardiovascular system, therefore EAT may affect the pathogenesis of different cardiovascular disease. The aim of this study was to investigate the EAT thickness in patients with CSX and compare normal subjects. METHODS: We prospectively enrolled 30 consecutive patients with CSX. The control group consisted of 30 age and sex-matched individuals with anginal chest pain and a negative treadmill or myocardial perfusion scan test. EAT thickness was measured by transthoracic echocardiography. RESULTS: There were no differences in baseline clinical, biochemical and echocardiographic characteristics between CSX patients and the control group. Patients with CSX had significantly increased EAT thickness than those of the controls (3.43 ± 0.88 vs. 2.34 ± 0.89 mm, p=0.0001). CONCLUSION: We found that EAT thickness is increased in patients with CSX. This finding suggests that EAT may contribute to the etiopathogenesis of the CSX.

The relationship between dipper/nondipper pattern and cardioankle vascular index in hypertensive diabetic patients.

OBJECTIVE: 24-h ambulatory blood pressure monitoring (24-h ABPM) is a better predictor of cardiovascular events (CVEs) than spot blood pressure (BP) measurements in hypertensive diabetic patients. In this patient group, the underlying mechanism of the relationship between a nondipper pattern determined with 24-h ABPM and increased incidence of CVE is unknown. Cardioankle vascular index (CAVI) is a new index of the overall arterial stiffness from the aorta to the ankle. The objective of the present study was to evaluate the relationship between a dipper/nondipper pattern and arterial stiffness in hypertensive diabetic patients using the CAVI method. METHODS: We enrolled 99 hypertensive patients with type-2 diabetes mellitus. 24-h ABPM and CAVI measurements were performed for all patients. The relationship between a dipper/nondipper pattern and CAVI measurements was analyzed. RESULTS: Sixty-three (63.6%) patients had a nondipper pattern. In univariate analysis, CAVI, mean arterial pressure (MAP)-asleep, overall diastolic BP, overall systolic BP, duration of hypertension, and statin use were significantly higher among patients with a nondipper pattern than that in dippers. Multivariate linear regression analyses showed that the difference between MAP-asleep and MAP-awake was associated independently with CAVI (ß coefficient=0.514, P<0.001). CAVI was correlated negatively with the nocturnal decrease in MAP (%) (r=-0.558 and P<0.001). CONCLUSION: The nondipper pattern determined with 24-h ABPM in hypertensive diabetic patients is associated with an increase in arterial stiffness. This patient group should be monitored closely for CVEs.

Predictive value of total atrial conduction time measured with tissue Doppler imaging for postoperative atrial fibrillation after coronary artery bypass surgery.

OBJECTIVE: Postoperative atrial fibrillation (POAF) complicating coronary artery bypass grafting surgery (CABG) increases morbidity and stroke risk. Total atrial conduction time (PA-TDI duration) has been identified as an independent predictor of new-onset atrial fibrillation (AF). We aimed to assess whether PA-TDI duration is a predictor of AF after CABG. METHODS: In 128 patients who had undergone CABG, preoperative clinical and echocardiographic data were compared between patients with and without POAF. The PA-TDI duration was assessed by measuring the time interval between the beginning of the P wave on the surface ECG and point of the peak A wave on TDI from left atrium (LA) lateral wall just over the mitral annulus. RESULTS: Patients with POAF (38/128, 29.6 %) were older (68.1 ± 11.1 vs. 59.3 ± 10.2 years; p < 0.001), had higher LA maximum volume, had prolonged PA-TDI duration, and had lower ejection fraction compared with patients without POAF. PA-TDI duration was found to be significantly increased in POAF group (134.3 ± 19.7 vs. 112.5 ± 17.7 ms; p = 0.01). On multivariate analysis, age (95 % CI = 1.03-1.09; p = 0.003), LA maximum volume (95 % CI = 1.01-1.06; p = 0.03), and prolonged PA-TDI duration (95 % CI, 1.02-1.05; p = 0.001) were found to be the independent risk factors of POAF. CONCLUSIONS: In this study, LA maximum volume and PA-TDI duration were found to be the independent predictors of the development of POAF after CABG. Echocardiographic predictors of left atrial electromechanical dysfunction may be useful in risk stratifying of patients in terms of POAF development after CABG.

Left ventricular synchronicity is impaired in patients with active acromegaly.

Acromegaly is associated with a variety of cardiovascular disturbances such as left ventricular hypertrophy, diastolic cardiac dysfunction, and hypertension. Left ventricular (LV) dyssynchrony means the impairment of synchronicity and is defined as the loss of the simultaneous peak contraction of corresponding cardiac segments. The objective of this study was to investigate whether acromegalic patients have left ventricular dyssynchrony. Dyssynchrony was evaluated in 30 patients with active acromegaly and 30 controls. All the patients and controls were subjected to a tissue synchronization imaging. The time to regional peak systolic tissue velocity (Ts) in LV by the six-basal-six-mid-segmental model was measured on ejection phase TSI images and four TSI parameters of systolic dyssynchrony were computed. All TSI parameters of LV dyssynchrony increased in patients with acromegaly compared to the controls: the standard deviation (SD) of the 12 LV segments Ts (43.5 ± 13.5 vs 26.2 ± 12.5, p < 0.001); the maximal difference in Ts between any 2 of the 12 LV segments (133.3 ± 38 vs 84.6 ± 37.6, p < 0.001); the SD of the 6 basal LV segments (41.1 ± 15.9 vs 25.4 ± 14.8, p = 0.001); and the maximal difference in Ts between any 2 of the 6 basal LV segments (102.6 ± 37.5 vs 65.2 ± 36.9, p = 0.001). In addition, there were significant relationships between the levels of growth hormone/insulin-like growth factor-1 and Ts-SD-12. LV synchronicity has been impaired in patients with acromegaly. Left ventricular dyssynchrony is associated with disease activity and it may contribute to the harmful cardiovascular effects of acromegaly.

Relationship between Duke Treadmill Score and coronary artery lesion complexity.

PURPOSE: The purpose of this study was to investigate the relationship between the Duke Treadmil Score (DTS) and coronary artery disease (CAD) complexity in patients with suspected coronary artery disease (CAD). METHODS: Sixty five patients who had positive exercise testing for CAD were enrolled. Coronary angiography was performed and Syntax score (SxScore), a marker of CAD complexity, was determined. The relationship between DTC and SxScore then evaluated. RESULTS: There was a strong negative correlation between DTS and SxScore (r = - 0.91, p < 0.001). In addition, patients with higher and intermediate risk as evaluated by DTS had increased SxScore compare to those that were low risk (23 ± 6, 6 ± 5 and 0 ± 0 respectively). CONCLUSIONS: A strong negative correlation was seen between DTS and coronary lesion complexity. By assessing DTS important information about coronary artery lesion complexity can be obtained before invasive coronary angiography.

Left ventricular dyssynchrony and its effects on cardiac function in patients with newly diagnosed hypertension.

OBJECTIVES: Left ventricular (LV) systolic synchrony, defined as simultaneous peak contractions of corresponding cardiac segments, is well documented to be impaired in hypertension but its effect on LV function is not clear. The aim of this study was to assess the impacts of LV systolic dyssynchrony on LV function in newly diagnosed hypertensives. METHODS: Forty-eight newly diagnosed hypertensive patients and 33 controls were enrolled. All study population underwent a comprehensive echocardiographic evaluation including tissue synchrony imaging. The time to regional peak systolic tissue velocity (Ts) in LV by 12 segmental models was measured and two parameters of systolic dyssynchrony were computed. RESULTS: Baseline demographic characteristics were similar in both study groups. Dyssynchrony parameters prolonged in newly diagnosed hypertensive patients compared to controls: the standard deviation (SD) of 12 LV segments Ts (40.2 ± 21 vs. 26.2 ± 13.4, P = 0.003); the maximal difference in Ts between any 2 of 12 LV segments (123.3 ± 61.5 vs. 79.8 ± 37.9, P = 0.001). In multivariable analysis, Ts-SD-12 was found to be an independent predictor for systolic function (ß=-0.29, P = 0.008). But, both diastolic and global functions were not independently related to Ts-SD-12. CONCLUSION: LV synchronization is impaired in newly diagnosed hypertensive patients. LV dyssynchrony is one of the independent predictors of systolic function in hypertensive patients.

Patients with ankylosing spondylitis have evidence of left ventricular asynchrony.

OBJECTIVES: Ankylosing spondylitis (AS) is a chronic inflammatory disease that often leads to cardiovascular complications including aortic regurgitation and conduction disturbances. Left ventricular (LV) systolic asynchrony is defined as loss of the simultaneous peak contraction of corresponding cardiac segments. The aim of this study was to evaluate LV systolic asynchrony noninvasively in patients with AS by using tissue synchrony imaging (TSI). METHODS: Asynchrony was evaluated in 77 AS patients (61 male, mean age 36.4 ± 10 years) and 40 controls (35 male, mean age 39.1 ± 8.2 years). All study population underwent a comprehensive echocardiographic evaluation including TSI. The time to regional peak systolic velocity (Ts) during the ejection phase in LV was measured from TSI images by the six-basal and six-midsegmental model, and four TSI parameters of systolic asynchrony were computed. RESULTS: The baseline demographic and echocardiographic characteristics were similar between the patients enrolled and controls. All TSI parameters of LV asynchrony were prolonged in patients with AS compared to controls: the standard deviation (SD) of the 12 LV segments Ts (39.6 ± 19.6 vs. 24.7 ± 11.6, P < 0.001); the maximal difference in Ts between any 2 of the 12 LV segments (122.1 ± 52.9 vs. 82.2 ± 38.6, P < 0.001); the SD of the six basal LV segments (33.5 ± 20.2 vs. 23 ± 13.3, P = 0.008); and the maximal difference in Ts between any two of the six basal LV segments (84.6 ± 48.1 vs. 60.4 ± 34.6, P = 0.008). The asynchrony parameters were significantly correlated with index of myocardial performance (Tei index) and peak systolic mitral annular velocity. CONCLUSION: TSI showed presence of LV systolic asynchrony in patients with AS which may account for the cardiovascular complications of AS.

Factors affecting left ventricular synchronicity in hypertensive patients: are arterial stiffness and central blood pressures influential?

OBJECTIVES: Left ventricular (LV) dyssynchrony is a common finding in patients with hypertension and is associated with LV hypertrophy. Arterial stiffness (AS) and central (aortic) blood pressures play a significant role in end-organ damage such as LV hypertrophy caused by hypertension. The objective of this study was to investigate the relationship between AS, central blood pressures (BP) and LV dyssynchrony. STUDY DESIGN: Thirty-five newly diagnosed hypertensive patients and 40 controls were enrolled in the study. The entire study population underwent a comprehensive echocardiographic study including tissue synchrony imaging. The 12 segmental model was used to measure the time to regional peak systolic tissue velocity (Ts) in the LV and two dyssynchrony indices were computed. Parameters of AS including pulse wave velocity (PWV), augmentation index (AIx@75), and central systolic and diastolic BP were evaluated by applanation tonometry. RESULTS: The baseline clinical and echocardiographic parameters of both groups were similar except for their BPs. Dyssynchrony indices were prolonged in patients with hypertension as compared to the controls. The standart deviation of Ts of 12 LV segments in patients with hypertension and the controls were 48.7±18.8 vs. 25.8±13.1, respectively (p<0.001), and the maximal difference in Ts between any 2 of 12 LV segments was 143.9±52.2 for hypertension patients vs. 83.8±39.4 for controls (p<0.001). PWV (11.9±2.5 vs. 9.5±1.4, p<0.001), AIx@75 (27.4±8.3 vs. 18.3±9, p=0.009), and central systolic (147.6±20.8 vs. 105.4±11, p<0.001) and diastolic (99.8±14.4 vs. 72.8±9.5, p<0.001) pressures were higher in patients with hypertension than in the controls, respectively. In multivariable analysis, central systolic BP (ß=0.496, p=0.03), LV mass index (ß=0.232, p=0.027), and body mass index (ß=0.308, p=0.002) were found to be independently related to dyssynchrony. CONCLUSION: Central systolic BP is an independent predictor of LV dyssynchrony, but Aix@75 did not have an independent effect on LV synchronicity in patients with newly-diagnosed hypertension.

The assessment of left ventricular systolic asynchrony in patients with primary hyperparathyroidism.

OBJECTIVES: Primary hyperparathyroidism (PHP) is associated with a variety of cardiovascular disturbances such as left ventricular (LV) hypertrophy, diastolic cardiac dysfunction, and hypertension. LV asynchrony is defined as the loss of the simultaneous peak contraction of corresponding cardiac segments. The objective of this study was to assess systolic asynchrony in patients with overt hyperparthyroidism. METHODS: Asynchrony was evaluated in 22 patients with PHP and 24 controls. All the patients and controls were subjected to a tissue synchronization imaging (TSI). The time to regional peak systolic tissue velocity (Ts) in LV by the six-basal-six-midsegmental model was measured on ejection phase TSI images and four TSI parameters of systolic asynchrony were computed. RESULTS: All TSI parameters of LV asynchrony increased in patients with PHP patients compared to the controls: the standard deviation (SD) of the 12 LV segments Ts (37.3±20.6 vs. 21.5±11.1, P=0.01); the maximal difference in Ts between any 2 of the 12 LV segments (111.2±59.8 vs. 70.2±32.1, P=0.01); the SD of the 6 basal LV segments (42.9±36.4 vs. 18.5±13, P=0.003); and the maximal difference in Ts between any 2 of the 6 basal LV segments (89.6±50.5 vs. 48±31.1, P=0.003). CONCLUSION: Patients with PHP show an evidence of LV asynchrony by TSI. Asynchrony may contribute to the harmful cardiovascular effects of PHP.

Intra-left ventricular systolic asynchrony in patients with overt hyperthyroidism.

Hyperthyroidism causes a variety of adverse effects on the cardiovascular system. Left ventricular (LV) asynchrony is defined as loss of the simultaneous peak contraction of corresponding cardiac segments. The aim of this study was to assess systolic asynchrony in patients with overt hyperthyroidism. Asynchrony was evaluated in 27 patients with overt hyperthyroidism and 21 controls. All the patients and controls were subjected to a tissue synchronization imaging (TSI). The time to regional peak systolic tissue velocity (Ts) in LV by the six-basal-six-mid-segmental model was measured on ejection phase TSI images and four TSI parameters of systolic asynchrony were computed. All TSI parameters of LV asynchrony increased in hyperthyroid patients compared to controls: the standard deviation (SD) of the 12 LV segments Ts (35.7±14.4 vs 20.1±10.1, P<0.0001); the maximal difference in Ts between any 2 of the 12 LV segments (111.9±40.7 vs 65.9±30.7, P<0.0001); the SD of the 6 basal LV segments (31.2±18.2 vs 16.8±9.7, P=0.01); and the maximal difference in Ts between any 2 of the 6 basal LV segments (76.6±42.0 vs 44.4±25.7, P=0.005). Patients with overt hyperthyroidism present evidence of LV asynchrony by TSI.

Assessment of left ventricular systolic asynchrony in patients with clinical hypothyroidism.

BACKGROUND: Hypothyroidism has a large number of adverse effects on the cardiovascular system such as impaired cardiac contractility. Left ventricular (LV) asynchrony is defined as loss of the simultaneous peak contraction of corresponding cardiac segments. OBJECTIVE: To assess systolic asynchrony in patients with overt hypothyroidism. METHODS: Asynchrony was evaluated in 31 patients with overt hypothyroidism and 26 controls. Clinical hypothyroidism was defined as serum thyroid-stimulating hormone (TSH) more than 4.2 microIU/mL with reduced free T4 less than 1.10 ng/dL. All the patients and controls were subjected to an echocardiographic study including tissue synchronization imaging (TSI). The time to regional peak systolic velocity (Ts) in LV via the six-basal-six-mid-segmental model was measured on ejection phase TSI images, and four TSI parameters of systolic asynchrony were computed. LV asynchrony was described by these four TSI parameters. RESULTS: The demographic characteristics and conventional echocardiographic parameters of both groups were similar (except total and LDL cholesterol, TSH, free T3, and free T4). All TSI parameters of LV asynchrony were prolonged in hypothyroid patients compared to controls. The standard deviation (SD) of the 12 LV segments Ts was (53.5 +/- 14.1 vs. 29.3 +/- 15.5, P < 0.0001); the maximal difference in Ts between any 2 of the 12 LV segments was (154.5 +/- 37.3 vs. 91.9 +/- 45.2, P < 0.0001); the SD of Ts of the 6 basal LV segments was (47.9 +/- 15.9 vs. 27.1 +/- 16.4, P < 0.0001); and the maximal difference in Ts between any 2 of the 6 basal LV segments was (118.4 +/- 37.9 vs. 69.3 +/- 39.0, P < 0.0001). The prevalence of LV asynchrony was significantly higher in patients with hypothyroidism compared with controls (83.9% vs. 26.9%, P < 0.0001). CONCLUSION: Patients with overt hypothyroidism show evidence of LV asynchrony by TSI.