[Heart failure with preserved ejection fraction: a systemic disorder?]. / L'insuffisance cardiaque à fraction d'éjection préservée : une maladie de système ?

When the syndrome of heart failure (HF) is due to left ventricular (LV) systolic dysfunction the clinical manifestations and natural history of the syndrome depend primarily on the severity of LV systolic dysfunction. In contrast, when the syndrome is attributed to LV diastolic dysfunction multiple comorbidities are responsible for the clinical manifestations and the natural history of the syndrome. The present review underscores the multifactorial pathogenesis of the syndrome of HF associated with LV diastolic dysfunction that nowadays is more properly referred to as HF with preserved LV ejection fraction (HFpEF) than to diastolic HF. The prognosis is similarly poor whether HF is due to systolic dysfunction or associated with diastolic dysfunction. The cause of death that is commonly non-cardiovascular in HFpEF supports the pathogenic importance of comorbidities in this condition. Hypertension, chronic kidney disease (CKD), diabetes, obesity and sleep disorder breathing are among the most frequent comorbidities in HFpEF. These comorbidities account for the multiple clinical presentations of the syndrome of HFpEF. Limited functional capacity is in HFpEF largely related to the downward spiral between CKD mediated fluid accumulation and LV stiffness as well as altered ventricular-vascular coupling. The diagnosis of HFpEF currently relies on 2D-Doppler echocardiography findings of impaired LV relaxation and increased LV stiffness and to a lesser extent on biomarkers. Owing to both lack of stringent inclusion and exclusion enrollment criteria and mistaken therapeutic target, placebo-controlled randomized therapeutic trials have been so far negative in HFpEF.

Elevated left atrial pressure estimated by Doppler echocardiography is a key determinant of mitral valve tenting in functional mitral regurgitation.

BACKGROUND: Functional mitral regurgitation (FMR) may occur in patients with reduced or preserved left ventricular ejection fraction (LVEF) and has been associated with excess valvular tenting only in patients with reduced LVEF. This study aimed at identifying the predictors of FMR and to determine whether or not they are different in patients with reduced versus preserved LVEF. METHODS: 190 consecutive patients free of congenital or primary valvular disease had a comprehensive echocardiographic assessment of LV remodelling and function, diastolic function and FMR severity. RESULTS: 112 patients had depressed LVEF (<50%) and 78 had preserved LVEF. FMR was present in 30 patients with preserved LVEF and in 65 with reduced LVEF. Higher E/Ea, E/A and larger mitral tenting were independent predictors of FMR regardless of LVEF. The mitral tenting area was an independent predictor of FMR severity in patients with reduced or preserved LVEF (p = 0.04 and p = 0.0045) in addition to E/A (p = 0.0007), E/Ea (p = 0.004) in patients with reduced and preserved LVEF, respectively. Higher E/Ea was independently associated with larger mitral tenting in patients with reduced and preserved LVEF. Mitral tenting area was linearly related to E/Ea (r = 0.30, p<0.0001) and E/A (r = 0.43, p<0.0001) and LA enlargement (r = 0.54, p<0.0001) after having paired 96 patients with and without FMR on indices of LV remodelling. CONCLUSIONS: In both patients with preserved and reduced LVEF, mitral tenting that leads to FMR is mainly determined by both mitral tethering forces-that is, displacement of papillary muscles and by pushing forces-that is, increased left atrial pressure. This study underscores that LV preload is a key determinant of FMR.

Exercise testing and exercise stress echocardiography in asymptomatic aortic valve stenosis.

Management of asymptomatic patients with severe aortic valve stenosis (AVS) remains a source of debate. Exercise testing is no longer contraindicated and needs now to be considered when evaluating asymptomatic patients with AVS. Several studies have clearly demonstrated that exercise-elicited symptoms during conventional upright exercise portends clinical events. Semi-supine exercise with continuous Doppler echocardiography monitoring elicits cardiovascular abnormalities that are not detected at rest. Abnormal left ventricular response to exercise and/or major increase in mean transvalvular gradient add to the prognostic value of elicited symptoms in asymptomatic patients with severe AVS. However, preliminary experience needs to be confirmed to warrant routine use of exercise Doppler echocardiography in the evaluation of patients with asymptomatic AVS.

Functional mitral regurgitation and chronic heart failure.

Functional mitral regurgitation (MR) frequently develops during the progression of chronic heart failure and predicts poor outcome. Impaired left ventricular (LV) function, LV remodeling associated with papillary muscle apical displacement and annular enlargement result in decreased mitral closing forces and tenting of the mitral valve at closure. Reduced closing forces and tenting both promote MR. Active myocardial ischemia, myocardial asynchronism and excessive loading conditions worsen MR at rest and during exercise. The therapeutic target in functional MR is the left ventricle and not the valve.

A conservative method for the treatment of undermining resorption of a mandibular primary molar.

The authors describe a simple, conservative procedure to guide the first permanent molar into its normal position in the dental arch. The second primary molar is recontoured and covered with a stainless steel crown, thus providing a free path of eruption for the first permanent molar.

Hereditary dentinogenesis imperfecta: a treatment program using an overdenture.

The aim of treatment in cases of dentinogenesis imperfecta is to improve the esthetic appearance and maintain the oral masticatory apparatus in a healthy and functional state. In the growing child, it was decided to maintain the teeth for as long as possible under an overdenture, until such time when a permanent prosthetic solution can be decided upon.

Teenage luxation injury: report of case.

The endodontic, restorative, and orthodontic treatment sequence of the accidental injury of three maxillary incisors has been presented. The treatment objective was to achieve an esthetically acceptable result for a young adult, until a definitive fixed prosthetic restoration can be planned. The ankylosed maxillary right permanent central incisor (11) is being maintained for reasons of arch-length space and alveolar bone height.

A fourteen-year follow-up study of traumatic injuries to the permanent dentition.

The frequency of traumatic injuries to permanent teeth was studied in a Swiss population sample consisting of 262 children. The prevalence of injuries was 10.81 percent. The children (106 girls and 156 boys) ranged in age from 6-18 years; the boy/girl ratio was 1.47:1. The largest number of injuries for boys was found between the ages of 9 and 10 years. The teeth most commonly injured were the maxillary central incisors (80 percent), and the most frequent type of injury was an enamel-dentin fracture without pulp exposure (53 percent). After the emergency treatment, 42 percent of the patients were followed for study from as early as one month up to 9 years. The recall evaluations show that the prognosis was extremely favorable for enamel fractures only, while pulp necrosis developed in 11.8 percent of the enamel-dentin fractures. Fourteen percent of the traumatic injuries were luxation injuries and, of these, 46 percent required endodontic therapy.

Induced root apexification following traumatic injuries of the pulp in children: follow-up study.

Of twenty-five cases presented here, eighteen were boys and seven were girls who required apexification through December 1986. Nine teeth were considered treatment failures after a 9.5-year follow-up period. With these nine cases, however, five teeth to date have had successful endodontic treatment. Additional follow-up time (5-8 years) is required to evaluate the final outcome of pulp canal therapy applied in cases of traumatized maxillary permanent incisor teeth, with incomplete root formation.

The single maxillary central primary incisor: report of case.

The presented case is a single anomaly not associated with other conditions. In rare cases of the solitary maxillary incisor, the tooth is symmetrical and is always present in the midline, but the crown and root of the tooth are the size of a normal central incisor.

The problems of treatment of early ankylosis: report of case.

The case report described in this paper, a patient with an early ankylosed second primary mandibular molar, illustrates the importance of patient cooperation in treatment planning. Extraction too early can cause space loss requiring future orthodontic treatment.

Chin trauma as a cause of primary molar fracture: report of case.

Primary molars can fracture if a severe blow is received on the chin; the fracture can remain undiagnosed, with pain on mastication the only symptom. A case report is described in which an 81/2-year-old boy sustained chin trauma and fractures of primary molars.