Steep left ventricle to aortic root angle and hypertrophic obstructive cardiomyopathy: study of a novel association using three-dimensional multimodality imaging.

BACKGROUND: Patients with hypertrophic cardiomyopathy (HCM) exhibit a difference in left ventricular outflow tract (LVOT) obstruction, independently of basal septal thickness (BST). Some patients with HCM have a steeper left ventricle to aortic root angle than controls. OBJECTIVE: To test the predictors of the LV-aortic root angle and the association between LV-aortic root angle and LVOT obstruction using three-dimensional imaging. PATIENTS: 153 consecutive patients with HCM (mean (SD) age 46 (14) years, 68% men) and 62 patients with hypertensive heart disease of the elderly (all >65 years of age, 73 (6) years, 34% men) who underwent whole-heart three-dimensional cardiac magnetic resonance (CMR) angiography (1.5 T) and Doppler echocardiography. Forty-two controls (age 43 (11) years, 38% men) who underwent contrast-enhanced multidetector computed tomography and were free of cardiovascular pathology were also studied. MAIN OUTCOMES: LV-aortic root angle, BST and maximal non-exercise LVOT gradient were measured in patients with HCM and in hypertensive-elderly patients. Additionally, LV-aortic root angle and BST were measured in controls. RESULTS: The mean (SD) LV-aortic root angle was significantly different (p<0.001) in the three groups: HCM (134 (10) degrees ), hypertensive-elderly (128 (10) degrees ), control (140 (7) degrees ). There was an inverse correlation between age and LV-aortic root angle in the three groups (all p<0.001): HCM (r = -0.56), hypertensive-elderly (r = -0.35), control (r = -0.48). On univariate analysis, in the HCM group, LV-aortic root angle (beta = -0.34, p<0.001), age (beta = 0.23, p = 0.01) and end-systolic volume index (beta = -0.20, p = 0.02), but not BST (beta = 0.02, p = 0.8), were associated with LVOT gradient. On multivariate analysis, only LV-aortic root angle was associated with LVOT gradient. CONCLUSIONS: Patients with HCM have a steeper LV-aortic root angle than controls. In patients with HCM, a steeper LV-aortic root angle predicts dynamic LVOT obstruction, independently of BST.

Abnormal papillary muscle morphology is independently associated with increased left ventricular outflow tract obstruction in hypertrophic cardiomyopathy.

BACKGROUND: Abnormal papillary muscles (PM) are often found in hypertrophic cardiomyopathy (HCM). OBJECTIVE: To assess the relationship between morphological alterations of PM in patients with HCM and left ventricular outflow tract (LVOT) obstruction, using magnetic resonance imaging (MRI) and echocardiography. METHODS: Fifty-six patients with HCM (mean age 42 years (interquartile range 27, 51), 70% male) and 30 controls (mean age (42 (30, 53) years, 80% male) underwent MRI on a 1.5 T scanner (Siemens, Erlangen, Germany). Standard cine images were obtained in short-axis (base to apex), along with two-, three- and four-chamber views. The presence of bifid PM (none, one or both) and anteroapical displacement of anterolateral PM was recorded by MRI and correlated with resting LVOT gradients obtained by echocardiography. RESULTS: Double bifid PM (70% vs 17%) and anteroapical displacement of anterolateral PM (77% vs 17%) were more prevalent in patients with HCM than in controls (p<0.001). Subjects with anteroapically displaced PM and double bifid PM had higher resting LVOT gradients than controls (45 (6, 81) vs 12 (0, 12) mm Hg (p<0.01) and 42 (6, 64) vs 11 (0, 17) mm Hg (p = 0.02), respectively. In patients with HCM, the odds ratio of having significant (>or=30 mm Hg) peak resting gradient was 7.1 (95% CI 1.4 to 36.7) for anteroapically displaced anterolateral PM and 10.4 (95% CI 1.2 to 91.2) for double bifid PM (both p = 0.005), independent of septal thickness, use of beta-blockers and/or calcium blockers and resting heart rate. CONCLUSIONS: Patients with HCM with abnormal PM have a higher degree of resting LVOT gradient, which is independent of septal thickness.

Liposarcoma of the breast--a case report.

Sarcoma of the breast constitutes less than 1% of all malignant breast tumors and liposarcoma of the breast has an incidence of 0.3% of all the mammary sarcomas. A 90-year-old woman presented with a mass in the upper outer quadrant of the right breast measuring 25 x 15 x 7 cm. Mammography was performed and the mass was diagnosed as a liposarcoma. A wide excision was performed with a 2 cm margin of healthy tissue. The tumor was diagnosed histologically as a fibrous liposarcoma. The patient was discharged and her postoperative recovery was uneventful. We report a case of liposarcoma of the breast and discuss this rare malignant tumor together with the various diagnostic and therapeutic modalities used.

Abnormal heart rate recovery after exercise: a comparison with known indicators of increased mortality.

BACKGROUND: Abnormal heart rate (HR) recovery at 1 min after exercise (< or =12 beats) was recently suggested to be a predictor of all cause and cardiac mortality. AIM: This study aimed to (1) correlate HR recovery at 1 min after exercise with known exercise and myocardial perfusion markers of increased cardiac mortality, and (2) compare the known exercise and myocardial perfusion markers of increased cardiac mortality between patients with a normal and abnormal HR recovery at 1 min after exercise. METHODS: One hundred patients with known or suspected coronary artery disease referred for exercise stress testing (ETT) were prospectively enrolled. Percent, ETT time peak HR, HR reserve, summed stress score (SSS), extent of stress (SE%) and reversible perfusion abnormalities (RE%) were recorded in every patient. RESULTS: There was poor correlation with markers of myocardial ischemia or infarction [SSS (r = 0.15), SE% (r = 0.05), RE% (r = 0.12), all p = n.s.] but highly significant correlation between HR recovery at 1 min after exercise and chronotropic variables [ETT time (r = 0.56), peak HR (r = 0.65), HR reserve % (r = 0.64), all p < 0.001]. Patients on beta-blockers had significantly more incidence of an abnormal HR recovery at 1 min after exercise, compared to patients not on beta-blockers (88 vs. 56%, p < 0.01). CONCLUSION: Abnormal HR recovery at 1 min after exercise has no correlation with known myocardial perfusion markers of increased cardiac mortality. Patients with an abnormal HR recovery do not appear to have an increased incidence or more severe myocardial infarction or ischemia. However, there is a strong correlation between HR recovery at 1 min after exercise and the chronotropic variables during exercise.

Can pre-treatment with beta-agonists reduce stress test time and the use of atropine in dobutamine stress testing?

AIM: To determine whether the use of inhaled beta-agonists decreases the duration of dobutamine stress testing (DAS), reduces the amount of dobutamine infused and decreases the use of atropine. METHODS: 34 patients on beta-agonists (group A) (mean age 65 +/- 8 years) and 32 patients not on beta-agonists or beta-blockers (group B) (mean age 65 +/- 10 years) undergoing DAS with SPECT were enrolled. RESULTS: The time of infusion of dobutamine in group A was 6.41 +/- 1.58 min and in group B was 9.77 +/- 3.60 min (p < 0.001). The amount of dobutamine infused was 10.64 +/- 5 mg in group A and 19.20 +/- 8 mg in group B (p < 0.001). In group A, 2 of 34 patients and 18 of 32 patients in group B needed atropine to reach peak HR (p < 0.001). CONCLUSION: Patients on short acting beta-agonists require smaller amounts of dobutamine with a shorter infusion time during DAS, and lesser use of side-effect prone atropine.

Abnormal heart rate recovery after exercise as a reflection of an abnormal chronotropic response.

Abnormal decline in heart rate (HR) after exercise has been linked to increased cardiac mortality. This study compares the decrease in HR in different patient types, elucidates the relation between the increase and decrease of HR with exercise, and studies the role of beta blockers on the recovery of HR after exercise. One hundred patients with coronary artery disease (CAD), 50 subjects with a very low likelihood of CAD (normals), and 21 postcardiac transplant (Tx) patients underwent Bruce protocols. Peak HR, percent of peak HR achieved, HR reserve percent, and decline in HR at 1, 3, 5, and 8 minutes were obtained for all groups and also for subgroups based on the use of beta blockers. HR recovery at 1, 3, 5, and 8 minutes differed significantly between patients with CAD, normals, and Tx patients. HR recovery at 1, 3, 5, and 8 minutes also differed significantly within the groups (normal and CAD) based on the use of beta blockers. There was highly significant correlation between decrease in HR and peak HR, percent peak HR and HR reserve percent in normal and CAD groups. After correction of the HR recovery for dependence on peak HR and HR reserve percent, the difference in HR recovery between normal and CAD groups was markedly reduced. The difference in the decrease of HR within each group (normal and CAD), based on the use of beta blockers or not, was also markedly reduced. beta blockers have a significant impact on the decrease in HR due to its effect on chronotropism. HR recovery rate is highly dependent on the chronotropic response. Hence, the main portion of the abnormality in HR recovery after exercise can be explained by chronotropic incompetence.