Myocardial Tissue Doppler Imaging Detects Right Ventricular Dysfunction after Percutaneous Angioplasty of Dysfunctional Hemodialysis Access in Uremic Patients.

BACKGROUND: Right ventricular dysfunction has been observed in uremic patients receiving percutaneous transluminal angioplasty (PTA). This prospective study focuses on the impact of tissue Doppler imaging echocardiographic parameters on assessing right ventricle function in uremic patients post PTA of dysfunctional hemodialysis access. METHODS: Sixty uremic patients were divided into two groups by angiographic findings: an occlusive group (26 patients) and a stenotic group (34 patients). All uremic patients underwent routine echocardiography with tissue Doppler imaging both before and immediately following PTA to assess the right ventricular (RV) function and pulmonary artery systolic pressure (PASP). The right ventricular (RV) myocardial performance index (MPI) was obtained during tissue Doppler imaging over the lateral tricuspid annulus. The M index was measured and defined as the peak early diastolic mitral inflow velocity divided by the RV MPI. The RV MPI, RV isovolumic relaxation time (IVRT) and M-index were used to evaluate RV function post-PTA. RESULTS: Immediately following PTA, PASP (31.6 ± 11.3 mmHg versus 42.6 ± 12.0 mmHg, p = 0.001), RV MPI (0.46 ± 0.08 versus 0.62 ± 0.13, p < 0.001) and IVRT (75.1 ± 12.9 versus 98.4 ± 27.7 ms, p < 0.001) increased significantly in the occlusive group. However, PASP and RV function did not change significantly in the stenotic group. In 42.3% patients from the occlusive group, the M-index fell below 112 and RV MPI rose above 0.55 post-PTA; this occurred in only 8.8% of the stenotic group. CONCLUSIONS: This prospective study demonstrated that there was a higher incidence of RV dysfunction in uremic patients with elevated PASP with totally occluded hemodialysis access than those with stenotic access post-PTA. KEY WORDS: Myocardial performance index; Percutaneous transluminal angioplasty; Pulmonary hypertension; Tissue Doppler image; Uremic.

Five-Year Outcomes after Acute Myocardial Infarction in Patients with and without Diabetes Mellitus in Taiwan, 1996-2005.

BACKGROUND: Diabetes mellitus (DM) is a strong risk factor of cardiovascular disease. To date, the impact of DM on outcomes after acute myocardial infarction (AMI) in Taiwan is undetermined. The aim of this study was to compare five-year outcomes after AMI in patients with and without diabetes in Taiwan. METHODS: A nationwide cohort of 25,028 diabetic and 56,028 non-diabetic patients who were first hospitalized with AMI between 1996 and 2005 was enrolled through linkage with the Taiwan National Health Insurance research database. Patient mortality rates within 30 days after AMI, and 1, 3, and 5 years thereafter were compared. RESULTS: Length of hospital stay (8.9 ± 8.7 vs. 8.2 ± 8.0 days, p < 0.01) and medical cost during admission (in Taiwan dollars: $129,123 ± $158,073 vs. $121,631 ± $157,018, p < 0.01) were significantly higher in diabetic patients. The difference in mortality rate within 30 days was insignificant between diabetic and non-diabetic patients (18.1% vs. 17.6%, p = 0.06). Mortalities within 1 year (31.0% vs. 26.8%, p < 0.01), 3 years (42.4% vs. 34.7%, p < 0.01), and 5 years (50.6% vs. 41.1%, p < 0.01) were significantly higher in diabetic patients. In patients with AMI who underwent percutaneous coronary intervention (PCI) during index admission, the mortality rate within 30 days was insignificant (6.3% vs. 6.4%, p = 0.70) but mortalities within 1 year (15.2% vs. 11.6%, p < 0.01), 3 years (24.1% vs. 17.2%, p < 0.01), and 5 years (32.2% vs. 22.6%, p < 0.01) were significantly higher in diabetic patients. CONCLUSIONS: The average patient length of hospital stay and medical cost during admission were significantly higher in diabetic patients. Additionally, the difference in mortality rate within 30 days after AMI was insignificant between diabetic and non-diabetic patients. Also, long-term mortality after AMI was significantly higher in diabetic patients. KEY WORDS: Acute myocardial infarction; Diabetes mellitus; Length of hospital stay; Medical cost; Mortality; National health insurance.

Begin with the real-world patients of non-goal-achieved hypercholesterolemia in taiwan through the ezetimibe/simvastatin tablet - The BRAVO Study.

OBJECTIVE: To assess the efficacy, safety, and tolerability of a combination of 10 mg ezetimibe and 20 mg simvastatin in Taiwanese patients with hypercholesterolemia. RESEARCH DESIGN AND METHODS: A prospective, open-label, multi-center, hospital-based cohort study was conducted to evaluate the efficacy, safety, and tolerability of a single tablet combination of ezetimibe/simvastatin for the treatment of hypercholesterolemia. Taiwanese adults without low-density lipoprotein cholesterol (LDL-C) goal achievement, based on the National Cholesterol Education Program Adult Treatment Panel III guidelines, were treated with ezetimibe/simvastatin once daily for 6 weeks. The primary endpoint was the percentage of patients achieving LDL-C treatment goals after 6 weeks of treatment. Secondary endpoints included percentage change from baseline of LDL-C, total cholesterol, high-density lipoprotein cholesterol, and triglyceride. Safety and tolerability were assessed via clinical and laboratory examinations. The clinicaltrial.gov identifier of this study was NCT00654628. RESULTS: In total, 173 patients with a mean age of 57.9 ± 10.4 years were included. Of these, 57.8% were female and the average body mass index was 25.5 ± 3.4 kg/m(2). After 6 weeks of treatment, the great majority of the patients had reached their treatment goals (90.4% for LDL-C; 87% for TC; and 59% for TG). LDL-C levels were significantly reduced from 156.8 ± 30.8 mg/dL at baseline to 75.9 ± 25.4 mg/dL (51.4%, P < 0.0001) after only 6 weeks of therapy. Forty-nine adverse events (AEs), including one non-drug related serious AE, were reported. For non-serious AEs, the most common reported AEs during the entire study period were myalgia and upper respiratory infection (both n = 7). Nine patients dropped out of the study, reportedly due to AEs. CONCLUSIONS: A single tablet combination of 10 mg ezetimibe and 20 mg simvastatin in Taiwanese patients with hypercholesterolemia provided high LDL-C goal attainment rates and resulted in significant reductions in LDL-C.

Tissue Doppler velocity is not totally preload-independent: a study in a uremic population after hemodialysis.

OBJECTIVES: The aim of this study was to investigate the changes of regional tissue Doppler velocity after volume removal following regular hemodialysis (HD) in uremic patients. Is tissue Doppler velocity really preload-independent? BACKGROUND: Diastolic dysfunction was divided into four stages: normal pattern, abnormal relaxation pattern, pseudonormalization pattern, and restrictive pattern. Pulse wave Doppler and color Doppler echocardiography were important diagnostic tools for these forms of diastolic dysfunction. However, they were preload-dependent and sometimes there was confusion between the normal pattern and the pseudonormalization pattern. Tissue Doppler echocardiography was promising for problems in diastolic dysfunction and appeared to be preload-independent. However, there are still some disputes over this point. METHODS: Ninety-three uremic patients receiving regular HD were included in the study. There were 45 males and 48 females aged 59 +/- 14 years. The mean volume removed after HD was 2.3 +/- 0.9 kg. The mean heart rates before and after HD were 77 +/- 11 and 76 +/- 12 beats per minute, respectively (p = 0.73). All patients received complete transthoracic echocardiography examinations before and after HD. The studies included cardiac chamber size, left ventricular systolic performance, pulse wave Doppler echocardiographic data of mitral inflow and the right upper pulmonary vein including peak velocity of early diastolic E wave, E wave time velocity integral (TVI-E), peak velocity of late diastolic A wave, A wave TVI, systolic phase of pulmonary vein (S wave TVI), early diastolic phase of pulmonary vein (D wave TVI) and atrial contraction phase of pulmonary vein (Ar wave TVI). Pulsed tissue Doppler echocardiography (TDE) was performed and a 4-mm sample volume was placed at the 6 corners of the mitral annulus including septal, lateral, anterior, inferior, anteroseptal and posterior corners. Five to ten cardiac cycles were recorded and the data were averaged. Measurements performed included peak velocity of systolic phase (Sa), early diastolic phase (Ea), late diastolic phase (Aa), Ea/Aa ratio and time from the beginning of electrocardiogram Q wave to the beginning of Sa (Q-Sa time). The same measurements were repeated after HD. RESULTS: After HD, left atrium diameter and left ventricular internal dimensions at end diastole became smaller. There were significant reductions for mitral peak E wave velocity, TVI-E, peak A wave velocity and E/A ratio. As for the pulmonary vein, systolic phase of pulmonary vein and early diastolic phase of pulmonary vein decreased significantly. Peak Ar wave did not change significantly. For TDE, Sa and Aa did not change but Ea did decrease. CONCLUSION: After HD, there is a significant reduction of intravascular effective volume. No significant change is found for myocardial peak systolic velocity and peak late diastolic velocity. However, there is a significant reduction of myocardial early diastolic phase peak velocity. This suggests that TDE is not completely preload-independent; at least, it is phase-dependent within each cardiac cycle.

Stroke volume and mitral annular velocities: insights from uremic patients with significant valvular regurgitation.

OBJECTIVE: This study investigates the change in new diastolic indices in uremic patients who undergo regular hemodialysis (H/D). MATERIALS AND METHODS: We studied uremic patients receiving regular H/D. All patients were sinus rhythm before H/D. They had normal left ventricular systolic performance without regional wall motion abnormality. Patients were separated into two groups according to whether they had significant aortic or mitral regurgitation (AR or MR) or not. They received complete transthoracic echocardiographic examinations. Stroke volume (SV) was calculated as the product of the time-velocity integral (TVI) and cross-sectional area of aortic annulus. Flow propagation velocity (FPV) was measured by color M-mode echocardiography in apical four-chamber view. Mitral annulus tissue Doppler velocities--peak systolic (Sa), early diastolic, and late diastolic--were measured from septal and lateral wall. All these parameters were obtained immediately before and after H/D. Paired data were compared. RESULT: H/D amount was strongly correlated with the change of SV. After H/D, the reduction of SV in patients without AR or MR (control group) was obvious but it was not significant in patients with significant AR or MR (study group). There were significant differences in mitral inflow velocities, FPV, and mitral annular velocities (except septal Sa) in the control group. In the study group, predialytic and postdialytic parameters of new diastolic indexes had no statistical difference. CONCLUSION: New echocardiographic indexes of uremic patients with significant AR or MR were relatively preload-independent. The phenomenon was possibly related to insignificant change of SV after H/D.

Preload and flow propagation velocity: insight into patients with uremia and different left ventricular systolic function.

OBJECTIVES: The aim of this study was to investigate the changes of flow propagation velocity (FPV) after regular hemodialysis (H/D) in patient who were uremic with different baseline left ventricular (LV) functions. METHODS: In all, 24 patients with uremia and abnormal LV systolic function were enrolled in this study and 30 patients with uremia and normal LV systolic performance served as the control group. All patients had in sinus rhythm and underwent a comprehensive transthoracic echocardiographic examination and mitral FPV by color M-mode echocardiography before and after H/D. RESULTS: The decline in FPV before H/D was proportional to the decline in the baseline LV function, whereas FPV after H/D varied according to the LV ejection fraction. An obvious decrement of FPV for patients with normal LV systolic function was noted, but no obvious difference was seen for patients with abnormal LV systolic function. CONCLUSION: FPV was strongly preload dependent for patients with normal LV systolic function. It was not significantly influenced by preload for patients with abnormal LV systolic function. FPV is a relatively good diastolic parameter for investigating patients with LV systolic dysfunction.

Doppler tissue imaging and color M-mode flow propagation velocity: are they really preload independent?

OBJECTIVE: This study investigated the change in new diastolic indexes in patients with uremia who undergo regular hemodialysis (H/D). METHODS: We studied 81 patients with uremia (41 men and 40 women) receiving regular H/D. All patients were in sinus rhythm before H/D. They had normal left ventricular systolic performance without regional wall-motion abnormality. Three patients were excluded because of atrial fibrillation after H/D. Patients were separated by the amount of body fluid removed during H/D procedure: 30 patients with H/D amount less than 2 kg (group 1), 33 patients with H/D amount between 2 and 3 kg (group 2), and 18 patients with H/D amount larger than 3 kg (group 3). They received complete transthoracic echocardiographic examinations. Flow propagation velocity (FPV) was measured by color M-mode echocardiography in apical 4-chamber view. Mitral annulus Doppler tissue velocities (peak systolic [Sa], early diastolic [Ea], and late diastolic [Aa]) were measured from septal, lateral, inferior, and posterior walls. All these parameters were obtained immediately before and after H/D. Paired data were compared. RESULTS: In patients with removed fluid amount less than 2 kg (group 1), the change of all diastolic parameters showed insignificant change except FPV (peak mitral E, P = .14; peak mitral A, P = .916; FPV, P = .009; septal Sa, P = .173; septal Ea, P = .295; septal Aa, P = .649). In patients with H/D amount between 2 and 3 kg, the change of all diastolic parameters showed statistically significant difference except Sa (peak mitral E, P = .001; peak mitral A, P = .001; FPV, P = .001; Sa, P = .589; Ea, P = .001; Aa, P = .015). In patients with H/D amount larger than 3 kg, Sa still showed insignificant change. Ea, Aa, and FPV showed significant difference after H/D (peak mitral E, P = .001; peak mitral A, P = .035; FPV, P = .008; septal Sa, P = .777; septal Ea, P = .014; septal Aa, P = .048). CONCLUSION: In patients with normal left ventricular systolic function, FPV was preload dependent. Diastolic phase mitral annulus Doppler tissue velocities (Ea and Aa) behaved differently according to the amount removed during H/D. They were preload independent when the amount removed during H/D was less than 2 kg. When the amount removed during H/D was larger than 2 kg, diastolic phase mitral annulus Doppler tissue velocities changed significantly. That is to say, diastolic phase mitral annulus Doppler tissue velocities were not totally preload independent. For systolic phase mitral annulus Doppler tissue velocity index (Sa), it was preload independent.

Color M-mode flow propagation velocity: is it really preload independent?

OBJECTIVE: This study investigates the change in flow propagation velocity (FPV) in uremic patients who undergo regular hemodialysis (H/D). MATERIALS AND METHODS: We studied 93 uremic patients (44 men and 49 women; 59 +/- 14-years-old) receiving regular hemodialysis. Patients were separated by baseline left ventricular ejection fraction (LVEF): 71 patients with LVEF > 50% (group 1), 13 patients with LVEF 35-50% (group 2), 7 patients with LVEF < 35% (group 3). All patients were in sinus rhythm before H/D. They received complete transthoracic echocardiographic examinations. Flow propagation velocity was measured by color M-mode echocardiography in apical four chambers view. All these parameters were obtained before and after H/D. Paired data were compared. According to different H/D amounts, we viewed the FPV response after H/D in variant baseline LVEF groups. RESULT: The baseline FPV became lower in patients with low LVEF. After H/D, obvious decrement of FPV occurred in group 1, but there were no obvious changes in groups 2 and 3. In fact, a slight increment of FPV was found in group 3. In patients with baseline LVEF > 50%, FPV after H/D was almost always lower, regardless of H/D amount. But there was different response in patients with baseline LVEF < 50%. CONCLUSION: Flow propagation velocity is preload independent in patients with LVEF < 50%, but it is preload-dependent in patients with LVEF > 50%.

Clinical applicability for the assessment of the valvular mitral stenosis severity with Doppler echocardiography and the proximal isovelocity surface area (PISA) method.

Evaluation of the severity of valvular mitral stenosis and measurements of the effective rheumatic mitral valve area by noninvasive echocardiography has been well accepted. The area is measured by the two-dimensional planimetry (PLM) method and the Doppler pressure half-time (PHT) method. Recently, the proximal isovelocity surface area (PISA) by color Doppler technique has been used as a quantitative measurement for valvular heart disease. However, this method needs more validation. The aim of this study was therefore to investigate the clinical applicability of the PISA method in the measurements of effective mitral valve area in patients with rheumatic valvular heart disease. Forty-seven patients aged from 23 to 71 years, with a mean age of 53 +/- 13 (25 male and 22 female, 15 with sinus rhythm, mean heart rate of 83 +/- 14 beats per minute, with rheumatic valvular mitral stenosis without hemodynamically significant mitral regurgitation) were included in the study. Effective mitral valve area (MVA) derived by the PISA method was calculated as follows: 2 x Pi x (proximal aliasing color zone radius)2x aliasing velocity/peak velocity across mitral orifice. Effective mitral valve areas measured by three different methods (PLM, PHT, and PISA) were compared and correlated with those calculated by the "gold standard" invasive Gorlin's formula. The MVA derived from PHT, PLM, PISA and Gorlin's formula were 1.00 +/- 0.31cm2, 0.99 +/- 0.30 cm2, 0.95 +/- 0.30 cm2 and 0.91 +/- 0.29 cm2, respectively. The correlation coefficients (r value) between PHT, PLM, PISA, and Gorlin's formula, respectively, were 0.66 (P = 0.032, SEE = 0.64), 0.67 (P = 0.25, SEE = 0.72) and 0.80 (P = 0.002, SEE = 0.53). In conclusion, the PISA method is useful clinically in the measurement of effective mitral valve area in patients with rheumatic mitral valve stenosis. The technique is relatively simple, highly feasible and accurate when compared with the PHT, PLM, and Gorlin's formula. Therefore, this method could be a promising supplement to methods already in use.

Three-Dimensional Echocardiographic Assessment of Lambl's Excrescences on the Aortic Valve.

The present case reports demonstrate the incremental value of three-dimensional echocardiography over multiplane transesophageal two-dimensional imaging in the assessment of Lambl's excrescences (strands) involving the aortic valve.

Transesophageal Echocardiographic Diagnosis of Coronary Stenosis in a Stroke Patient.

This study represents another example of the usefulness of transesophageal echocardiography in the assessment of stenosis involving the proximal, mid, and distal coronary arteries in stroke patients referred for exclusion of a cardiac source of embolism.

Transpharyngeal Echocardiographic Diagnosis of Carotid Bulb and Left Internal Carotid Artery Stenosis.

We report a patient in whom we were able to make an accurate diagnosis of left carotid bulb and left internal carotid artery stenosis by carefully and slowly withdrawing the probe from the esophagus into the pharynx.

Transesophageal Three-Dimensional Echo Assessment of Sinus Venosus Atrial Septal Defect.

The incremental value of three-dimensional echocardiography over transesophageal multiplane two-dimensional imaging in the assessment of sinus venosus atrial septal defect is demonstrated in the present study.