[Prognostic value of ventricular longitudinal systolic velocities and maximal oxygen consumption in patients with dilated cardiomyopathy].

OBJECTIVE: To compare the prognostic value of regional longitudinal ventricular systolic velocities with that of maximal oxygen consumption (VO(2max)) in patients with dilated cardiomyopathy (DCM). METHODS: VO(2max) derived from cardiopulmonary exercise tests and regional longitudinal ventricular systolic velocities obtained from tissue Doppler imaging were compared in 18 DCM patients with cardiac events (death, cardiac transplantation, hospitalization, group A) and 24 patients without cardiac events (group B). Peak velocities during isovolumic contraction (is) and ejection (ez) were interrogated at the mitral or tricuspid annulus (site 1), at the mid parts of the walls (site 3, at the level of papillary muscle), and at the midpoints (site 2) between sites 1 and 3 of interventricular septum (S), lateral wall of LV (L) and of RV (R) in apical 4 chambers view. RESULTS: R1is, R2is, R2ez, R3is, S1is, S1ez, S2ez, L1is, L1ez and L2ez of group A were significantly lower than those in group B (all P < 0.05). Independent of VO(2max), high sensitivity and specificity were shown for R3ez, S1ez, L1ez, L1is, L2is and L3is in predicting cardiac events of DCM patients. CONCLUSION: LV and RV systolic velocities could independently predict cardiac events in DCM patients.

Prediction of restenosis after coronary angioplasty by use of a new index: TIMI frame count/minimal luminal diameter ratio.

BACKGROUND: It has been shown recently that postangioplasty coronary flow reserve and the degree of residual stenosis have a modest predictive value for short- and long-term clinical outcomes after coronary angioplasty. Corrected TIMI frame count (CTFC) is a simple quantitative index of coronary blood flow. Its relationship with Doppler coronary flow velocity and clinical outcome after coronary angioplasty has not been fully clarified. The aim of this study was to identify clinical, angiographic, and functional predictors of clinical and angiographic restenosis after conventional coronary angioplasty. METHODS AND RESULTS: We studied 70 consecutive patients in whom intracoronary Doppler flow-velocity measurements were performed before and after angioplasty. Patients were evaluated for restenosis by clinical follow-up, exercise stress test/(201)Tl scintigraphy, and follow-up angiography, which was performed at 10. 5+/-10.3 months in 63 patients. According to the results of univariate analysis, a new index, postangioplasty CTFC/minimal luminal diameter (MLD) ratio, was created. Multivariate analysis revealed that CTFC/MLD ratio was the only independent predictor of angiographic (OR 2.02; 95% CI 1.37 to 2.97; P<0.0004) and clinical (OR 1.60; 95% CI 1.15 to 2.21; P<0.005) restenosis. The receiver operating characteristic curve area of this index was 79% for angiographic and 73% for clinical restenosis. The optimal CTFC/MLD ratio cutoff values were 7.88 for angiographic and 7.94 for clinical restenosis, respectively. CONCLUSIONS: Our data indicate that postangioplasty CTFC/MLD ratio, which incorporates both the angiographic and functional features of coronary lesions, is a reliable, objective, and inexpensive index for prediction of angiographic and clinical restenosis after conventional coronary angioplasty.

Dispersion of ventricular repolarization is determined by the presence of myocardial viability in patients with old myocardial infarction. A dobutamine stress echocardiography study.

AIMS: The study sought to investigate the relationship of myocardial viability detected by dobutamine stress echocardiography to changes of QT dispersion and to the presence of arrhythmias during dobutamine infusion in patients with old myocardial infarction. We also examined whether patency of the infarct-related artery is associated with the presence of myocardial viability and QT dispersion. BACKGROUND: QT dispersion and myocardial variability have been associated with the presence of arrhythmias during late post infarction but not during dobutamine stress. Restoration of anterograde coronary flow has beneficial effects on ventricular systolic function and repolarization, suggesting that the extent of viable myocardium may determine ventricular repolarization. METHODS: Seventy five patients with previous myocardial infarction were studied in a low dose (up to 20 microg(-1) x kg(-1) x min(-1)) dobutamine stress echocardiography study. ECGs were obtained at rest and peak stress for measurement of QT intervals. The presence of ventricular arrhythmias (Lown grade >lb) during stress was noted. A reduction in the total wall motion score of the left ventricle at peak stress confirmed the presence of myocardial viability. RESULTS: Dobutamine infusion increased QT dispersion in all patients (P<0.01). Patients with myocardial viability had a lower resting QT dispersion (P<0.05) and a greater increase in QT dispersion% (P<0.01) than patients without. The combination of a resting QT dispersion <65 ms or an increase in QT dispersion >30% predicted viability with a sensitivity of 67%, a specificity of 96%, and an accuracy of 78%. A patent infarct-related artery, as well as ventricular arrhythmias, were more commonly observed in patients with evidence of viable myocardium (P<0.05). Patients with arrhythmias had a higher QT dispersion than patients without (P<0.05). CONCLUSION: The combination of a resting QT dispersion +/-65 ms or an increase in QT dispersion >30% predicts the presence of viable myocardium and thus, may represent a simple index for the assessment of viability in everyday clinical practice. Myocardial viability is related to a patent coronary artery and to a high incidence of arrhythmias accompanied by a greater increase in QT dispersion at peak dobutamine infusion.

Usefulness of flow reserve in the left internal mammary artery to determine graft patency to the left anterior descending coronary artery.

Two-dimensional Doppler echocardiography (DE) and intravascular Doppler-tipped guidewire (flowire) have been used to measure flow in aortocoronary conduits at rest and during hyperemia, but they have not been compared. We investigated which flow velocity parameters obtained with these 2 different techniques can predict left internal mammary artery (LIMA) graft patency. Twenty-nine patients with previous coronary artery bypass grafting referred for evaluation of symptoms of coronary artery disease were studied after cardiac catheterization using the flowire and DE. Proximal LIMA graft flow velocity was measured at rest and during hyperemia produced by 140 microg/kg/min of intravenous adenosine infusion over 6 minutes with both methods. Normal LIMA grafts and left anterior descending artery (LAD) distal to the anastomosis were present in 16 patients, whereas 13 had >70% graft or native vessel stenosis. The coronary flow velocity reserve (r = 0.79) and the diastolic-to-systolic velocity ratio during hyperemia (r = 0.73) correlated very well between the 2 techniques. Among the variables obtained with the 2 techniques, the intragraft coronary flow velocity reserve measured by both methods was the only independent predictor of graft/recipient LAD patency. This variable had a sensitivity and specificity of 86% at a cutoff point of 2.07 with the flowire method and 83% at a cutoff point of 1.54 with DE. The areas below the receiver-operating characteristic curves were 0.91 and 0.93, respectively. Coronary flow velocity reserve measurements obtained with DE appears a reliable noninvasive method for assessing LIMA graft and/or LAD distal to the anastomosis patency in patients after bypass surgery and correlate very well with those directly obtained by intravascular Doppler.

Prognostic significance of echocardiographically estimated right ventricular shortening in advanced heart failure.

Little is known about the association of echocardiographic estimates of right ventricular (RV) function with survival, in relation to hemodynamic and exercise-derived predictors of outcome in congestive heart failure. We prospectively studied 40 patients (age 55+/-10 years, in New York Heart Association functional class III [70%] and IV [30%]), with left ventricular (LV) ejection fraction <30%. At enrollment, all patients underwent echocardiographic evaluation of LV dimensions and function. RV shortening was measured as the difference of the end-diastolic distance - the end-systolic distance between the tricuspid annulus and the RV apex. Thirty-five patients (88%) were able to perform a maximal symptom-limited exercise test. Peak oxygen consumption (peak VO2) and percent peak age- and gender-adjusted predicted oxygen consumption (%peak VO2) were calculated. Of 40 patients, 10 died during a mean follow-up period of 14+/-10 months. On univariate analysis, nonsurvivors had lower RV shortening (p=0.0001), higher pulmonary artery wedge pressure (p=0.009), higher pulmonary vascular resistance (p=0.02), and lower mean aortic pressure (p=0.05). Cox proportional-hazards model revealed that the only independent associate of survival was RV shortening (p=0.0005), with a trend toward significance for mean aortic pressure (p=0.08). The best cutoff point of RV shortening identified by the receiver-operating curve was 1.25 cm. This value had a sensitivity of 90%, specificity of 80%, and overall predictive accuracy of 83% to distinguish survivors from nonsurvivors. In patients with advanced heart failure, preserved RV function as indicated by an echocardiographically derived RV shortening > 1.25 cm is a strong predictor of survival.

Double-inlet and double-outlet left ventricle in situs inversus.

Double-outlet left ventricle is a rare congenital cardiac malformation that has been traditionally difficult to diagnose accurately. We report a unique case of situs inversus totalis, L-loop, double-inlet left ventricle and double-outlet left ventricle with pulmonary stenosis, diagnosed mainly by transesophageal echocardiography and magnetic resonance imaging.

Effect of plaque burden on coronary vasoreactivity in early atherosclerosis.

Coronary atherosclerosis, during its initial stages of development, may result in abnormal endothelium-dependent vasomotor responses. The relation between the degree of vasoreactivity and the amount of atheromatous plaque load has not been decisively determined. The aim of the present study was to investigate the effects of segmental plaque burden on endothelium-dependent and independent coronary stimulation. We studied 37 individual coronary segments along the course of coronary arteries that had angiographically either nonvisible or nonobstructive atheromatous lesions. Endothelium-dependent and independent stimulation of each segment from 10 patients with known significant coronary artery disease was examined with intracoronary administrations of normal saline, acetylcholine 10(-6) M and 10(-5) M, and nitroglycerin, respectively, using quantitative coronary angiography. Simultaneous vasomotor effects on the microcirculation were evaluated by a Doppler guidewire (Flowire). Subsequently, intracoronary ultrasound was used at each segment for detailed morphometric and composition analysis. By quantitative coronary angiography, when compared with normal saline, acetylcholine produced a reduction in minimal lumen diameter of 15.2 +/- 25.6%, and nitroglycerin produced an increase of 18.0 +/- 22.5%. The degree of vasoconstriction induced by acetylcholine correlated inversely (r = 0.51, p = 0.001) to the amount of segmental maximal plaque thickness. No relation between the response to nitroglycerin and the parameters obtained by intracoronary ultrasound was documented. Fibrous coronary plaques showed less vasomotor changes than plaques with mixed echogenicity, probably due to a significantly larger plaque burden. Acetylcholine produced overall a differential vasomotor response in the epicardial segments (vasoconstriction) compared with the microcirculation (vasodilation). These results indicate that in early atheromatous coronary lesions, the degree of endothelium-dependent vasoconstrictive response is inversely related to the amount of segmental plaque burden.

Magnitude of myocardial dysfunction is greater in painful than in painless myocardial ischemia: an exercise echocardiographic study.

OBJECTIVES: This study sought to assess the presence and extent of inducible myocardial dysfunction during painful and painless (silent) myocardial ischemia in a homogeneous patient cohort with coronary artery disease and no previous myocardial infarction. BACKGROUND: The functional significance of painless versus painful demand-driven ischemia remains controversial, with conflicting results in published reports regarding the amount of myocardium in jeopardy. METHODS: Exercise echocardiography was performed in 89 patients (mean [+/- SD] age 59.3 +/- 8.2 years) with significant coronary artery disease and positive exercise stress test results. Patients were taking no antianginal medications and were classified into painless and painful cohorts after the outcome of a symptom-limited treadmill exercise test. No patients had previous coronary artery bypass surgery. Images were acquired in digital format before and immediately after treadmill exercise testing. RESULTS: Fifty-eight patients had painful and 31 painless myocardial ischemia. Clinical and demographic characteristics as well as coronary artery anatomy were similar in both groups. Patients with painless ischemia achieved better exercise performance with greater exercise duration (p < 0.001) and higher maximal rate-blood pressure product (p < 0.001) than those with painful ischemia. New wall motion abnormalities were seen in 54 patients (93%) with painful versus 17 (55%) with painless ischemia (p < 0.001). Total ischemic score was greater in patients with painful than in those with painless ischemia (15.9 +/- 3.7 vs. 12 +/- 1.4, p < 0.001, respectively), with a greater number of ischemic myocardial segments in painful than in painless ischemia (101 [16%] vs. 21 [6%], p < 0.001, respectively). CONCLUSIONS: Patients with painless ischemia frequently have regional myocardial dysfunction on exertion detected by echocardiography, but painful episodes are accompanied by a greater magnitude of myocardial dysfunction.

Echocardiographic measures of left ventricular structure and their relation with rest and ambulatory blood pressure in blacks and whites in the United Kingdom.

OBJECTIVES: This study attempted to determine whether people of black African descent have more left ventricular hypertrophy than those of white European descent and whether this can be explained by rest or ambulatory blood pressure. BACKGROUND: Mortality associated with hypertension is higher in black populations than among whites, but differences in morbidity and their associations with blood pressure are inconsistent. METHODS: We examined 1,166 black and white men and women 40 to 64 years old in a community survey in London, United Kingdom. Echocardiograms were obtained for all subjects and ambulatory blood pressure recordings for 319. RESULTS: Adjusted for body size, ventricular septal thickness was greater in blacks than whites (p < 0.05), and cavity dimension was smaller (p < 0.05). In men, ventricular septal thickness was > 10 mm for 32% of whites and 53% of blacks; for women these figures were 14% and 38%, respectively. Relative wall thickness was greater in blacks (p < 0.01 for men and women), but left ventricular mass index was similar in the two ethnic groups. In men, hypertension resulted in an increase in wall thickness in both ethnic groups, but cavity dimension decreased in blacks and increased in whites. Wall thickness was higher in blacks than in whites for equivalent levels of either rest (p = 0.05) or ambulatory (p = 0.007) blood pressure. CONCLUSIONS: Left ventricular mass index may not be valid for comparison between ethnic groups because this derived measure does not take into account ethnic differences in ventricular structural response to hypertension. Interventricular wall thickness may be more valid. Using this measure, we demonstrate greater ventricular hypertrophy in blacks than in whites, unexplained by differences in either rest or ambulatory blood pressure. The pattern of ventricular hypertrophy observed in blacks is associated with an increased mortality risk. Conventional blood pressure thresholds for instituting antihypertensive treatment may be too conservative for people of black African descent.

Differential response of high-density lipoproteins to first-step lipid-lowering diet according to their initial level.

BACKGROUND: A lipid-lowering diet has been shown to lower total cholesterol but also high-density-lipoprotein (HDL) cholesterol. The effect of the first-step lipid-lowering diet (as suggested by the European Atherosclerosis Society) on HDL levels was studied in 129 Greek patients aged 52.7 +/- 9.8 years, of whom 78 were men and 51 women of similar ages. METHODS: Total, HDL, and low-density-lipoprotein (LDL) cholesterol, and the total: HDL cholesterol and triglyceride ratio were assessed before and 3 months after the diet. RESULTS: Overall, total cholesterol decreased by 12% (P < 0.001), LDL by 15% (P < 0.001), HDL by 3% (NS), triglycerides by 12% (P < 0.01), and total: HDL cholesterol ratio by 11% (P < 0.001). A difference was found in the response to diet according to baseline HDL levels: in patients with HDL of 39 mg/dl or higher (group A), HDL decreased by 10% and the total: HDL cholesterol ratio by 3%, whereas in those with HDL lower than 39 mg/dl (group B) HDL increased by 17% and the total: HDL cholesterol ratio decreased by 22%. The difference between the groups was statistically significant (P < 0.001) for these two values as well as for triglycerides, but not for total cholesterol and LDL. No difference in the responses between men and women was found. CONCLUSION: This differential response to diet should be taken into account when planning treatment. Patients with baseline HDL levels higher than 39 mg/dl should probably be considered for early treatment not only by diet but by lipid-lowering-HDL-raising drugs as well.

Beat-to-beat variability in stroke volume during VVI pacing as predictor of hemodynamic benefit from DDD pacing.

To determine whether the magnitude of Beat-to-Beat variability in stroke volume (SV) during VVI pacing can predict hemodynamic benefit from DDD pacing, we undertook Doppler recordings of systolic and diastolic LV flow during VVI and DDD pacing in 20 patients (age 54 +/- 9 years) with DDD pacemakers implanted due to AV block. SV increased by 19% +/- 10% from VVI to DDD (P < 0.01). This increase was greater (29% +/- 9%) in patients with a ratio of early (E)/late (A) filling < 1 compared to those with E/A > 1 (10% +/- 9%) (P < 0.001). Beat-to-Beat variability in SV was greater in VVI (13% +/- 8%) compared to DDD (4% +/- 1%) (P < 0.001). Patients with E/A < 1 showed greater Beat-to-Beat variability in SV during VVI pacing (19 +/- 6%) compared to those with E/A > 1 (8% +/- 4%) (P < 0.001). Beat-to-Beat variability in SV during VVI pacing correlated with both percent change in SV from VVI to DDD (r = 0.89, P < 0.001) and E/A (r = -0.71, P < 0.001). In conclusion, patients with E/A < 1 derive greater hemodynamic benefit at rest from DDD pacing compared with E/A > 1. In addition, patients with complete AV block who show large variations in SV during VVI pacing may obtain greater hemodynamic benefit at rest from DDD pacing than patients with small variations.

[Systemic lupus erythematosus: valvular regurgitation and its relation to anticardiolipin antibodies]. / Lupus eritematoso sistémico: insuficiencia valvular y su relación con anticuerpos anticardiolipinas.

The aim of this study was to assess the relationship between the incidence and severity of valvular regurgitation and the presence of high levels of anticardiolipin antibodies in a group of patients with systemic lupus erythematosus. Fifty patients aged 35.5 +/- 13.4 years and 84 healthy age and sex matched controls were studied with two dimensional echocardiography with color flow imaging. IgG and IgM anticardiolipin antibodies were measured in all patients within a week of the echocardiographic study. Patients had a similar incidence of aortic, tricuspid and pulmonic regurgitation than normals. However there was a greater incidence of mitral regurgitation among patients (56 vs 21% p < 0.001). The seven patients with moderate or severe mitral regurgitation had Libman Sacks vegetations of the valve. Twenty five of 28 patients with mitral regurgitation had increased anticardiolipin antibodies; moreover, these levels were significantly higher among patients with mitral regurgitation and thickened mitral valves than those with normal valves. Patients with increased anticardiolipin antibodies had a higher incidence of Libman Sacks vegetations. No association between the presence of these antibodies and the severity of aortic, pulmonic or tricuspid regurgitation was observed. It is concluded that the incidence of mitral valve regurgitation is increased in systemic lupus erythematosus and related to raised anticardiolipin antibodies.

Doppler haemodynamic profiles of clinically and echocardiographically normal mitral and aortic valve prostheses.

Doppler echocardiographic studies were performed in 380 consecutive patients with 415 normally functioning artificial valves to establish normal Doppler characteristics for each type of prostheses used in our institution, with particular reference to Starr-Edwards valves, and to serve as control studies for future assessment. None of the patients were in heart failure at the time of the study. Peak transaortic velocities (m.s-1) were higher and effective orifice areas (cm2) smaller in mechanical valves as a whole, when compared with bioprostheses (P less than 0.01); 2.7 +/- 0.7 and 1.4 +/- 0.55 for Starr-Edwards, 2.7 +/- 0.6 and 1.5 +/- 0.6 for Bjork-Shiley, 1.8 +/- 0.1 and 1.5 +/- 0.6 for Duromedics and 1.5 +/- 0.06 and 2 +/- 0.12 for bioprostheses, respectively. In the mitral position, the average peak diastolic velocities (m. s-1) and pressure half-times (ms) were higher in mechanical valves, but there was a large overlap between the various types and sizes of prostheses (P = NS); 1.6 +/- 0.3 and 98 +/- 25 for Starr-Edwards, 1.4 +/- 0.3 and 88 +/- 26 for Bjork-Shiley, 1.8 +/- 0.1 and 75 +/- 5 for Duromedics and 1.5 +/- 0.3 and 90 +/- 20 for bioprostheses, respectively. There was an inverse relation between valve size and pressure halftime for Starr-Edwards prostheses (P less than 0.01). Doppler flow characteristics in mechanical valves where similar in patients with normal and dysfunctioning prostheses. Valvular or myocardial dysfunction could best be ascertained when early postoperative studies were available for comparison.(ABSTRACT TRUNCATED AT 250 WORDS)