[Ethnic differences in electrocardiogram between a black African and a white European young adult population under 35 years]. / Différences ethniques de l'électrocardiogramme entre une population de noirs africains et de blancs européens âgés de moins de 35 ans.

BACKGROUND: Few studies have reported racial differences of electrocardiogram. AIM: To compare clinical and electrocardiographic parameters of black African and white European young adults. MATERIALS AND METHODS: Students from Cameroon (black group) and France (white group) were recruited (ratio 2/1). Resting ECG was recorded in supine position using a numerical electrocardiograph. Participants underwent demographic, clinical and ECG measurements. RESULTS: We included 162 black and 81 white students (68% female), mean age 24±3 years. Longest QRS duration, sinus bradycardia, right bundle branch block and slurred pattern of repolarization were more common in whites (P<0.05) while longest PR interval (P<0.05), QRS microvoltage and positive T wave in lead V1 were more common in blacks (P<0.001). CONCLUSION: Most of ECG patterns are similar in these black and white individuals; particularly repolarization features. Positive T wave in V1 lead and isolated R wave microvoltage in aVL lead are predominant in blacks whereas slurring variant of early repolarization is more frequent in whites.

C-reactive protein levels in the brugada syndrome.

Background. Inflammation in the Brugada syndrome (BrS) and its clinical implication have been little studied. Aims. To assess the level of inflammation in BrS patients. Methods. All studied BrS patients underwent blood samples drawn for C-reactive protein (CRP) levels at admission, prior to any invasive intervention. Patients with a previous ICD placement were controlled to exclude those with a recent (<14 days) shock. We divided subjects into symptomatic (syncope or aborted sudden death) and asymptomatic groups. In a multivariable analysis, we adjusted for significant variables (age, CRP ≥ 2 mg/L). Results. Fifty-four subjects were studied (mean age 45 ± 13 years, 49 (91%) male). Twenty (37%) were symptomatic. Baseline characteristics were similar in both groups. Mean CRP level was 1,4 ± 0,9 mg/L in asymptomatic and 2,4 ± 1,4 mg/L in symptomatic groups (P = .003). In the multivariate model, CRP concentrations ≥ 2 mg/L remained an independent marker for being symptomatic (P = .018; 95% CI: 1.3 to 19.3). Conclusion. Inflammation seems to be more active in symptomatic BrS. C-reactive protein concentrations ≥ 2 mg/L might be associated with the previous symptoms in BrS. The value of inflammation as a risk factor of arrhythmic events in BrS needs to be studied.

Mortality meetings: ethical considerations and adherence to evidence-based practice from 6 years of experience in a mixed cardiac department.

OBJECTIVE: Most patients die unexpectedly in cardiac departments. We analyzed the ethical issues raised by poor outcomes and the leading causes of hospital deaths including organic causes of deaths, system failures, and questionable caregivers' attitudes. METHOD: We analyzed reports from 99 mortality conferences in a mixed cardiac department (surgery and interventional cardiology) where 146 patients died from 2002 to 2008. RESULTS: Patients were referred for cardiac surgery (n=115), interventional cardiology (n=25), or medical therapy (n=11). Highly recommended class I interventions were performed in most patients (n=120, 82%). A history of renal failure (25%), peripheral artery disease (21%), diabetes (18%), cancer (16%), or respiratory disease (16%) was frequently noticed. The areas most frequently identified as potentially problematic were preoperative strategy (58%), surgical technique (50%), monitoring (47%), reactivity (43%), drug prescription (32%), difficulties or delays in diagnosis (27%), and transfer (21%). At least one transgression from routine medical practice was identified in 66 (45%) patients, and a causal relationship between this transgression and the patient's death was suggested in 33 cases (23%). Serious errors were identified for five patients (3%), with a suggested causal relationship to death in two cases. Ethical discussions focused on alternatives in treatment (73%), good medical practice (44%), secondary recommendations (18%), information (12%), consent (12%), non-malfeasance (7%), and equity (6%). CONCLUSIONS: Mortality conferences provide an opportunity to identify many system failures. Poor outcome is multifactorial. Technical and ethical aspects should be considered for quality care improvement.

Decreased right ventricular lateral wall velocities early after cardiac surgery.

BACKGROUND: Right ventricular (RV) function is less often monitored than left ventricular (LV) function and might influence the postoperative period in patients undergoing coronary bypass or heart valve surgery. Our objective was to compare RV lateral wall velocities before and soon after heart surgery. METHODS: We examined 87 patients before and at a median time of 5 days after surgery with tissue Doppler echocardiography. On-pump coronary artery bypass grafting was performed in 40 patients, and valvular surgery in 47 patients. The pulsed Doppler sample was positioned at the midportion of the RV lateral wall, on the septum and on the LV lateral wall to record peak systolic (S), early (E) and late (A) diastolic tissue Doppler velocities. RESULTS: We observed lower values of LV end diastolic volume and left atrial area (P < 0.001) but no differences in RV fractional area change as well as LV ejection fraction between before and after surgery. RV S, E, and A were dramatically lower in the postoperative group (P < 0.001 between before and after surgery), as well as septal S, E, and A (P < 0.005 between before and after). No change occurred on LV lateral S and A, whereas LV lateral wall E velocity was slightly higher in the postoperative group (P < 0.05). CONCLUSIONS: Tissue Doppler velocities of the RV free wall are reduced significantly after cardiac surgery despite no reduction in RV fractional area change.

C-reactive protein in arrhythmogenic right ventricular dysplasia/cardiomyopathy and relationship with ventricular tachycardia.

Background. The relationship between C-reactive protein (CRP) elevation and ventricular tachycardia (VT) in arrhythmogenic right ventricular dysplasia/cardiomyopathy (ARVD/C) is unclear. Methods and Results. In 91 consecutive patients with either ARVD/C with or without VT (cases) or idiopathic right ventricular outflow tract (RVOT) tachycardia (controls), blood sampling were taken to determine CRP levels. In ARVD/C patients with VT, we analyzed the association between VT occurrences and CRP level. Sixty patients had ARVD/C, and 31 had idiopathic RVOT VT. Patients with ARVD/C had a significant higher level of CRP compared to those with RVOT VT (3.5 ± 4.9 versus 1.1 ± 1.2 mg/l, P = .0004). In ARVD/C group, 77%, (n = 46) patients experienced VT. Of these, 37% (n = 17) underwent blood testing for CRP within 24 h after the onset of VT and the remaining 63% (n = 29) after 24 h of VT reduction. CRP level was similar in ARVD/C patients with or without documented VT (3.6 ± 5.1 mg/l versus 3.1 ± 4.1 mg/l, P = .372). However, in patients with ARVD/C and documented VT, CRP was significantly higher when measured within 24 hours following VT in comparison to that level when measured after 24 h (4.9 ± 6.2 mg/l versus 3.0 ± 4.4 mg/l, P = .049). Conclusion. Inflammatory state is an active process in patients with ARVD/C. Moreover, there is a higher level of CRP in patients soon after ventricular tachycardia, and this probably tends to decrease after the event.

Robotically-assisted coronary artery bypass grafting.

Objectives. Robotic surgery enables to perform coronary surgery totally endoscopically. This report describes our experience using the da Vinci system for coronary artery bypass surgery. Methods. Patients requiring single-or-double vessel revascularization were eligible. The procedure was performed without cardiopulmonary bypass on a beating heart. Results. From April 2004 to May 2008, fifty-six patients were enrolled in the study. Twenty-four patients underwent robotic harvesting of the mammary conduit followed by minimal invasive direct coronary artery bypass (MIDCAB), and twenty-three patients had a totally endoscopic coronary artery bypass (TECAB) grafting. Nine patients (16%) were converted to open techniques. The mean total operating time for TECAB was 372 +/- 104 minutes and for MIDCAB was 220 +/- 69 minutes. Followup was complete for all patients up to one year. There was one hospital death following MIDCAB and two deaths at follow up. Forty-eight patients had an angiogram or CT scan revealing occlusion or anastomotic stenoses (>50%) in 6 patients. Overall permeability was 92%. Conclusions. Robotic surgery can be performed with promising results.

Robotic coronary artery bypass grafting.

Robotically assisted surgery enables coronary surgery to be performed totally or partially endoscopically. Using the Da Vinci robotic technology allows minimally invasive treatments. We report on our experience with coronary artery surgery in our department: patients requiring single or double vessel surgical revascularization were eligible. The procedure was performed without cardiopulmonary bypass on a beating heart. From April 2004 to May 2008, 55 consecutive patients were enrolled in the study, and were operated on by a single surgical team. Operative outcomes included operative time, estimated blood loss, transfusions, ventilation time, intensive care unit (ICU) and hospital length of stay. Average operative time was 270 ± 101 min with an estimated blood loss of 509 ± 328 ml, a postoperative ventilation time of 6 ± 12 h, ICU stay of 52 ± 23 h, and a hospital stay of 7 ± 3 days. Nine patients (16%) were converted to open techniques, and transfusion was required in four patients (7%). Follow-up was complete for all patients up to 1 year. There was one hospital death (1.7%) and two deaths at follow-up. Coronary anastomosis was controlled in 48 patients by either angiogram or computed tomography scan, revealing occlusion or anastomotic stenoses (>50%) in six patients. Overall permeability was 92%. Major adverse events occurred in 12 patients (21%). One-year survival was 96%. Our initial experience with robotically assisted coronary surgery is promising: it avoids sternotomy and with a methodical approach we were able to implement the procedure safely and effectively in our practice, combining minimal mortality with excellent survival.

First-in-human feasibility and safety study of a true bifurcated stent for the treatment of bifurcation coronary artery lesions (DBS stent): six month angiographic results and five year clinical follow-up.

AIMS: To evaluate the safety and long-term efficacy of a true dedicated bifurcation bare metal stent (DBS) for the treatment of bifurcation coronary artery lesions. METHODS AND RESULTS: Thirty-four patients were enrolled in this prospective multicentre study. The majority of culprit lesions were located on the left anterior descending artery/diagonal bifurcation (n=19) followed by the distal protected left main (n=7), the left circumflex artery/obtuse marginal (n=4) and the distal right coronary artery/posterior descending artery (n=4). Successful delivery of the DBS stent at the bifurcation site was achieved in 32 patients (94%). Angiographic follow-up at six months was complete in 29 patients (91%). Clinical follow-up was achieved at five years in all DBS patients. There were no cardiac deaths or stent thrombosis. At six months, the MACE rate was 6/32 (19%) and the total binary restenosis rate was 10/29 (34%). MACE at 5 years consisted only in target vessel revascularisation and occurred in eight patients (25%). CONCLUSIONS: The DBS bare metal true bifurcated stent can be delivered successfully and safely in selected bifurcated lesions and has demonstrated long-term efficacy in most patients.

When should the aortic arch be replaced in Marfan patients?

BACKGROUND: The purpose of this study was to assess the prevalence, indications, and results of aortic arch replacement in Marfan patients with and without acute dissection. METHODS: Between January 1993 and December 2005, our group performed 76 aortic replacements in 54 Marfan patients (mean age, 38.3 years), of whom 20 had already undergone one or two replacements of the thoracic aorta, and 3 required one late procedure each in other institutions. So, the 54 patients underwent a total of 100 aortic operations. Indication for initial surgery was elective aortic root replacement in 25 patients (46%), acute type A dissection in 19 (35%), acute type B dissection in 2 (4%), and chronic type B dissection in 8 (15%). Indication for reoperation was residual chronic dissection in the proximal aorta in 14 patients (36%), in the distal aorta in 22 (56%), and acute retrograde type A dissection in 3 (8%). RESULTS: At initial operation, the aortic arch was not involved in the 25 patients with aneurysm of the aortic root and was replaced in only 1 of the 19 patients with acute type A dissection (1/44 patients, 2.3%). At the second or third operation, the arch had to be replaced in 4 (16%) of 25 patients initially operated on for aortic root aneurysm, in 14 (73%) of 19 patients operated on for acute type A dissection, and in 3 (30%) of 10 patients with previous acute or chronic type B dissection. The difference between patients with initial elective aortic root replacement and patients with acute dissection was highly significant (p < 0.001). Overall in-hospital mortality was 13%. The risk of death was 9.6% per procedure. CONCLUSIONS: Aortic arch replacement in Marfan patients is not indicated during elective aortic root replacement. In contrast, the significant rate of aneurysmal dilatation of the aortic arch after surgery for acute type A dissection may be an incentive for a more aggressive approach toward the aortic arch during initial surgery.

[Morbidity/mortality reviews: assessment of their implementation in one hospital]. / Bilan de la mise en place de revues de mortalité morbidité au sein d'un établissement hospitalier.

OBJECTIVES: The objective of this study was to describe the steps involved in establishing a morbidity/mortality review committee (MMRC) to analyze the causes of avoidable deaths or life-threatening complications and the development of plans and protocols to avoid their recurrence. METHODS: The MMRC included physicians from each hospital department. Each member was responsible for organizing departmental meetings to analyze its avoidable deaths and life-threatening complications. RESULTS: During its meetings three times a year, the MMRC developed a method for analysis of these serious events. Each department organized 3 (range: 1-12) meetings a year and analyzed 1-3 cases at each. Over 30 months, 35,817 patients were admitted to the hospital and 341 (1%) died. The unexpected mortality rate varied by department and specialty (median: 27%, range: 6-65%). In all, 92 cases were referred to MMRC meetings (27%; range: 6-70% of hospital deaths), and 30% of them involvement nosocomial diseases. Heart disease was the primary cause of unexpected deaths. DISCUSSION: The principal improvements involved medical and surgical strategies, surgical techniques, drug prescriptions, and patient monitoring.

Renewed interest in preejectional isovolumic phase: new applications of tissue Doppler indexes: implications to ventricular dyssynchrony.

There is renewed interest in isovolumic contraction (IC) in tissue Doppler echocardiography of the myocardial walls, which is revisited in this editorial with new regional velocity data. The aims are to recall traditional background information and to emphasize the need to master the rapidly evolving tissue Doppler procedures for the accurate display of brief IC. IC, a preejectional component of great physiologic interest, is very demanding in terms of ultrasound technology. The onset and end of its motion velocities should be unambiguously defined versus the QRS complex and ejection wall motion. This is a prerequisite for exploiting the new information as guidance toward new therapeutic strategies from a practical viewpoint. However, IC preload dependence should be kept in mind, because of its limited potential for contractility studies. Finally, when only duration measurements are made in the assessment of ventricular dyssynchrony, regional preejectional duration is the pertinent tool to single out the onset of ejection local wall motion.

Detection of prominent left anterior descending coronary artery stenosis for patients with stable angina using Doppler tissue echocardiography.

The midseptum has an elective left anterior descending coronary artery (LAD) supply. Septal peak velocity (PkV) and myocardial velocity gradient (MVG) were studied at rest with M-mode Doppler tissue echocardiography during the cardiac cycle including the septal active relaxation (SAR) outward wall motion preceding isovolumic relaxation. In all, 33 patients had significant multivessel coronary artery disease. Group A (15 patients) had prominent LAD stenosis. Group B (18 patients) had prominent circumflex (15) or right (3) coronary artery stenoses. The goal was to detect a prominent LAD stenosis. During SAR, sensitivity to detect a prominent LAD stenosis was 86% for PkV < 20 mm/s and 80% for MVG < 1.1 s(-1); specificity was 83% for both variables. During systole, sensitivity was 86% with a 55% specificity for MVG < 2.0 s(-1), whereas sensitivity was 73% and specificity 66% for PkV < 30 mm/s. Areas under receiver operating characteristic curves were over 0.90 during SAR and only 0.70 for PkV and 0.80 for MVG during systole. In multivessel coronary artery disease, SAR variables better identified a prominent LAD stenosis than systolic variables. Moreover, SAR PkVs were informative per se, whereas systole required MVG calculation.

Tissue Doppler echocardiographic and color M-mode estimation of left atrial pressure in infants.

OBJECTIVES: Using recorded flow and tissue Doppler, we evaluated the relation of peak velocity of early transmitral Doppler filling (E)/early diastolic velocity of the lateral mitral annulus (Ea) ratio and of E/flow propagation velocity (Vp) ratio to mean left atrial pressure in infants after surgery for congenital heart disease. DESIGN: Experimental design. SETTING: Pediatric intensive care unit. PATIENTS: Thirty-seven infants aged 4 (3-8) months. INTERVENTIONS: Patients underwent postoperative invasive hemodynamic monitoring with simultaneously obtained Doppler measurements. MEASUREMENTS AND MAIN RESULTS: Values are expressed as median (25th-75th percentiles). Heart rate was 145 (135-157) beats/min. Left atrial pressure was 10 (8-12) mm Hg with E/Ea 16 (12-19) and E/Vp 1.9 (1.3-2.4). E/Ea and E/Vp ratios were higher in patients with left atrial pressure >10 mm Hg (n = 18), than in patients with left atrial pressure < or =10 mm Hg (n = 19) (E/Ea, 16 [15-25] vs. 12 [9-17], p = .01; E/Vp, 2.3 [1.9-2.8] vs. 1.4 [1-1.9]. respectively, p = .001). At a cutoff point of 15, E/Ea sensitivity for left atrial pressure >10 mm Hg was 17 of 18 (94%) with specificity 13 of 18 (72%). At a cutoff point of 2, E/Vp sensitivity for left atrial pressure >10 mm Hg was 15 of 18 (83%) with specificity 16 of 18 (89%). Areas under the receiver operating characteristic curves were 0.76 (E/Ea) and 0.83 (E/Vp). CONCLUSIONS: Doppler ratios might be considered as promising noninvasive tools for left atrial pressure evaluation in infants after cardiac surgery.

A new Doppler tissue ratio to revisit systole: the pre-ejectional isovolumic to ejectional velocity ratio-application to aging.

Most diagnostic applications of Doppler tissue echocardiography rely on peak (Pk) velocity (V) values of single variables or myocardial V gradient. Whereas age-related changes in diastolic V are well-known, previous Doppler tissue echocardiography studies of systolic function showed no age effect for pre-ejectional (Ej) isovolumic (PEI) and Ej inward wall motion Pk V. In addition to myocardial V gradient, ratios were calculated between PEI and Ej Pk V, and mean V averaged over systole (PEI/Ej V ratios) at each layer of the posterior wall using M-mode color on two control groups: A (27 +/- 5 years) and B (54 +/- 10 years). The only changes were for PEI/Ej V ratios (mean V endocardial 21 +/- 7% vs 34 +/- 20%, P = .01; mean V epicardial 27 +/- 8% vs 40 +/- 18%, P = .006; Pk epicardial V 21 +/- 10% vs 30 +/- 16%, P = .04 for groups A and B, respectively). Correlation versus age were r = 0.52 and P = .005 (mean V endocardial), r = 0.50 and P = .007 (mean V epicardial), and r = 0.32 and P = .03 (Pk epicardial V). PEI/Ej V ratios and mean V studied in separate layers showed that the new systolic approach had advantages over single variable or Pk V to study age-related changes.

Evolution of the postoperative pericardial effusion after day 15: the problem of the late tamponade.

STUDY OBJECTIVES: To evaluate, through clinical and transthoracic echocardiography (TTE) follow-up, the natural history of persistent pericardial effusion (PE) after postoperative day 15 in patients who were given and were not given anticoagulant therapy. DESIGN AND PATIENTS: We retrospectively studied a cohort of 1,277 patients who were hospitalized between May 1997 and May 1999 in our center a mean (+/- SD) time period of 15 +/- 3 days after undergoing coronary artery bypass graft (CABG) surgery (856 patients) or valve replacement (VR) surgery (421 patients). MEASUREMENTS: TTE was performed on mean (+/- SD) postoperative day 20 +/- 1 (TTE(1)) and postoperative day 30 +/- 2 (TTE(2)). PE severity was classified on a scale from grade 1 to grade 4. RESULTS: On postoperative day 20 +/- 1, PE was present in 22% of the 1,277 patients and was more frequent after patients underwent CABG surgery than after undergoing VR surgery (25% vs 17%, respectively; p < 0.01). On postoperative day 30 +/- 2, the overall incidence of late tamponade in patients with PE was 4%. The incidence increased with the severity grade of PE at TTE(1) (p < 0.001). The negative predictive value of a severity grade < 2 at TTE(1) for late tamponade was 100%. Late tamponade incidence was higher after VR surgery than after CABG surgery (11% vs 2%, respectively; p < 0.01), and was higher in patients who had received anticoagulation therapy than in those who had not (8% vs 2%, respectively; p < 0.05). CONCLUSION: Persisting PE is common after postoperative day 15 and is more frequent after undergoing CABG surgery than after undergoing VR surgery. The incidence of late tamponade is usually underestimated, and it increases with the presence of VR, anticoagulation therapy, and/or higher postoperative TTE severity grade. Our data suggest that only patients with a PE severity grade of >/= 2 (< 10% of patients) require TTE follow-up after postoperative day 20.

Comparison of transradial vs. transfemoral approach in the treatment of acute myocardial infarction with primary angioplasty and abciximab.

Compared to the femoral approach, the use of radial arterial access has been demonstrated to reduce the incidence of access site bleeding complications in staged procedures. The purpose of this study was to evaluate clinical outcomes comparing radial and femoral approaches in the treatment of acute myocardial infarction with primary angioplasty and the GP IIb/IIIa inhibitor abciximab. Between 15 September 1999 and 15 September 2002, we prospectively enrolled 119 consecutive patients undergoing primary angioplasty with abciximab comparing radial (n = 64) and femoral (n = 55) access. In this nonrandomized study, freedom from major cardiac events at 1-month follow-up occurred in 62 (97%) and 52 (94.5%) patients in the radial and the femoral groups, respectively (P = 0.19). There were no major access site bleeding complications in the radial group, as opposed to three (5.5%) in the femoral group (P = 0.03), all requiring transfusions, with surgical repair necessary in two. Uncomplicated clinical course occurred in 62 (97%) of patients in the radial group and 49 (89%) in the femoral group (P = 0.04). Total hospital length of stay was significantly higher in the femoral group (5.9 +/- 2.1 vs. 4.5 +/- 1.2 days; P = 0.05). Cannulation time (from patient arrival at the catheterization laboratory to the effective placement of arterial sheath) and procedural time were not significantly different in the radial and the femoral group (respectively 8.5 +/- 5.2 vs. 9.0 +/- 5.8 min, P = 0.81, and 42 +/- 28 vs. 44 +/- 27 min, P = 0.74). Nevertheless, time of radiation (23.1 +/- 11 vs. 16.5 +/- 10.9 min; P = 0.01) and dose-area product (28,616 +/- 16,571 vs. 18,819 +/- 10,739 R. cm2; P = 0.01) were significantly higher in the radial group. In patients with acute myocardial infarction treated with primary angioplasty and abciximab, the transradial access is efficacious with fewer major access site complications than transfemoral access. Transradial approach produces a shorter length of stay, as compared to the transfemoral approach, although with longer times of radiation and higher dose-area product.

Clinical relevancy of the myocardial velocity gradient: limitations of a binary response.

BACKGROUND: Doppler tissue echocardiographic myocardial velocity gradient (MVG) overcomes translational or tethered motion effects. Diagnostic applications rely on MVG numeric value, an instantaneous value calculated at peak endocardial velocity. Our aim was to test the clinical relevancy of MVG for patients with dilated cardiomyopathy (CM) at rest. Efficiency of MVG, as a marker of the underlying mechanism, ischemic or nonischemic, was compared with that of mean velocities averaged over a cycle. METHODS: Peak and mean velocities were measured and MVG calculated during ejection, and early and late diastole, in the endocardium and epicardium on color M-mode Doppler tissue echocardiographic parasternal recordings of the posterior wall, simultaneously imaged with the septum. The population consisted of 34 patients with similar clinical presentation (left ventricular ejection fraction < 40%, left ventricular end-diastolic diameter > 6 cm, and proven ischemic [14] or nonischemic [20] dilated CM) and 16 control subjects. RESULTS: Doppler tissue echocardiography data significantly differed between control subjects and all patients with CM. Between patients, the only significant differences were found at the posterior wall for mean velocities at the epicardium in systole (9 +/- 4 mm/s for ischemic vs 14 +/- 5 mm/s for nonischemic, P =.002), and at both layers in early diastole (endocardium, 14 +/- 9 vs 29 +/- 12 mm/s, P =.0004; epicardium, 12 +/- 4 vs 22 +/- 11 mm/s, P =.002; ischemic vs nonischemic CM, respectively). CONCLUSION: Specific features of CM were characterized by myocardial velocity changes studied layer by layer throughout a phase. The binary response of transient peak MVG could not reach this goal.

Dynamic myocardial velocity changes between phases of the cardiac cycle.

The purpose of this study was 1. to define relationships between myocardial velocities according to phases and the range of dynamic phasic changes in controls using tissue Doppler echocardiography (TDE); 2. to compare the usefulness of dynamic changes vs. peak velocities alone on controls and patients. Peak velocity changes between phases were studied by colour M-mode TDE in the posterior wall from pre-ejection to systole (ejectional wall velocity increase) and from ejection to early diastole (early diastolic wall velocity increase) in 17 age-matched controls and a group of 30 patients with dilated cardiomyopathies (CMy) consisting of ischaemic (14) and nonischaemic (16) CMy with similar clinical and echocardiographic presentations. Systolic were correlated with early diastolic peak velocities (r = 0.79 p < 0.0001). Velocity values were significantly lower in patients than in controls (p < 0.001) as well as dynamic ejectional (p = 0.02) and early diastolic (0.03) increases. Dynamic changes were closely similar to controls (74 +/- 7%, 46 +/- 14%) in nonischaemic CMy (66 +/- 18%, 39 +/- 10% NS, respectively), but markedly reduced in ischaemic CMy (28 +/- 59%, and 26 +/- 31%, p = 0.005 and p = 0.06 vs. nonischaemic CMy, respectively). Of patients with ischaemic CMy, 78% had an ejectional increase < 40% and/or an early diastolic increase < 25%. Thus, correlation exists between systolic and early diastolic velocities. Normal range of dynamic changes was defined in an elderly population. Results suggest that velocity dynamics might be more informative than peak velocities alone to show left ventricular dysfunction.

Myocardial time intervals preceding left ventricular filling in chronic coronary artery disease: value of a decreased septal ejection time.

The aim was to assess the capabilities of a two-segment myocardial recording to recognize patients with an underlying chronic ischemic process as a fast screening from controls, prior to the usual segment-to-segment tissue Doppler echocardiographic assessment of ischemia. Ischemia generates systolic and relaxation abnormalities. A flow Doppler index of global systolic and diastolic myocardial performance was recently drawn from time durations studied by coupling isovolumic relaxation (IR) to preejection (PEP)/ejection (ET) ratio (PEP/ET). We derived a similar tissue Doppler approach to the period preceding the left ventricular filling: PEP', the ejectional inward wall motion representing ET' and the prefilling (PreFg) period ranging from the end of ET' to the onset of the outward wall motion approximating IR, were measured and ratios calculated between variables. Spectral tissue Doppler was applied to septal and posterior walls of 28 patients with proven chronic coronary artery disease and preserved left ventricular function and of 12 age-matched controls. Data were compared with global flow data. Global information did not differentiate both groups, save for IR (sensitivity 32%, specificity 57%). In patients, tissue Doppler mean values of single variables (P=0.004-0.0006) and ratios (P=0.03-0.002) significantly differed from controls. Moreover, septal ET' differentiated 13 patients with one-vessel (219+/-34 ms) from 10 with two-vessel disease (158+/-70 ms, P=0.01). Sensitivity and specificity of a septal ET'<190 ms for a two-vessel disease were 80%. The two-segment tissue Doppler echocardiographic study provided a rapid screening of patients versus controls and helped to predict the number of diseased vessels.

Aortic pulse pressure and extent of coronary artery disease in percutaneous transluminal coronary angioplasty candidates.

BACKGROUND: Pulse pressure and aortic stiffness are both predictors of coronary artery disease. Whether these parameters are directly related to coronary structural alterations has never been studied. METHODS: From September 1999 to September 2000, the following data were collected from 99 eligible patients: invasive intra-aortic systolic and diastolic blood pressures (BP), extent of coronary artery disease, cardiovascular risk factors, and the incidence of angiographically documented restenosis after coronary angioplasty. RESULTS: In the study population, independent determinants of aortic pulse pressure were age, gender, aortic mean BP, heart rate, and extent of coronary artery disease (r2 = 0.57, P < .0001). In univariate analysis, invasive aortic, but not noninvasive brachial, mean pressure (P = .017) and pulse pressure (P = .027) were significantly associated to the extent of coronary artery disease. In a multiple regression analysis, only male gender (P = .013) and the level of aortic pulse pressure (P = .023) were independently associated with the extent of coronary heart disease. Restenosis was angiographically documented in 11 patients (11%). There was a borderline significant association of restenosis to aortic mean BP (P = .05) and to a past history of multiple previous angioplasties (P = .03). CONCLUSIONS: In this study, aortic pulse pressure was a significant risk factor for the extent of coronary artery disease. There was only a borderline significant association of restenosis to the steady, but not pulsatile, component of aortic BP in the stent era.