Noninvasive assessment of exercise tolerance using mitral annular velocities.

PURPOSE: To investigate the feasibility of evaluating exercise tolerance using lateral and septal mitral annular velocities in patients with preserved left ventricular ejection fraction (LVEF) and those with reduced LVEF. METHOD: We studied 36 patients with LVEF ≥50% and 36 with LVEF <50%. We measured peak early diastolic velocity of transmitral flow (E) and peak early diastolic velocities of the lateral (LEa) and septal (SEa) mitral annulus. The ratios of E to LEa (E/LEa) and E to SEa (E/SEa) were calculated. We measured peak oxygen consumption [Formula: see text] and anaerobic threshold (AT) by cardiopulmonary exercise testing. RESULTS: In patients with LVEF ≥50%, E/LEa correlated well with [Formula: see text] and AT (r = -0.69 and r = -0.74, respectively; p < 0.001); E/SEa correlated modestly (r = -0.59 and r = -0.60, respectively; p < 0.001). In patients with LVEF <50%, E/LEa correlated well with [Formula: see text] and AT (r = -0.72 and r = -0.76; respectively, p < 0.001); E/SEa correlated modestly (r = -0.63 and r = -0.63, respectively; p < 0.001). CONCLUSION: E/LEa may be more useful than E/SEa for the noninvasive estimation of exercise tolerance, throughout a wide range of LVEF.

Impact of milrinone on mitral annular velocity in patients with congestive heart failure.

PURPOSE: The purpose of this study is to assess the impact of milrinone on mitral annular velocity in patients with congestive heart failure. METHOD: We studied 27 patients with congestive heart failure. All patients underwent transthoracic echocardiography both before and after administration of milrinone. We measured the early transmitral velocity (E) and the mitral annular early diastolic velocity (Ea). The ratio of E to Ea (E/Ea) was calculated. After the baseline echocardiography, milrinone was administered as a continuous infusion at a rate of 0.25 µg/kg/min. Echocardiographic measurements were repeated 4 h after milrinone was begun. RESULTS: After administration of milrinone, Ea was significantly increased, while E/Ea was significantly decreased. The population of 27 patients was divided into 20 (74 %) with left ventricular ejection fraction (LVEF) <50 % and seven (26 %) with LVEF ≥50 %. Ea was significantly increased in both groups, while E/Ea was significantly decreased. CONCLUSION: Even low-dose milrinone produced an improvement in left ventricular (LV) diastolic function, as evidenced by an increase in Ea, and falls in LV filling pressures, as determined by a decrease in E/Ea, in patients with congestive heart failure throughout a wide range of LV systolic function.

Nonbacterial thrombotic endocarditis demonstrated by repeat echocardiography.

We report a case of nonbacterial thrombotic endocarditis (NBTE) in a patient with bladder cancer presenting with multiple cerebral infarctions. Initial transthoracic and transesophageal echocardiography did not show any abnormalities. However, repeat transthoracic and transesophageal echocardiography demonstrated a vegetation on the anterior leaflet of the mitral valve with mild mitral regurgitation and no evidence of leaflet destruction. Persistent high-grade fevers and leukocytosis were observed. The patient was suspected to have infective endocarditis. However, abdominal ultrasound and computed tomography scan revealed multiple metastatic masses, and serial blood cultures were negative. The patient was ultimately diagnosed with NBTE associated with multiple metastases of bladder cancer. This case suggests that even if echocardiography does not initially demonstrate any abnormalities in patients with embolism, it must be repeated at the recurrence of embolism, and that even if clinical signs of infection are documented, NBTE should be suspected in any cancer patient with thromboembolic events.

Donepezil-induced torsades de pointes without QT prolongation.

We report a case of torsades de pointes (TdP) induced by donepezil without QT prolongation. An 86-year-old woman was admitted to our hospital because of a syncopal attack. She had been treated for Alzheimer's disease with donepezil. Initial 12-lead electrocardiogram showed atrial fibrillation and normal corrected QT interval. After admission, atrial fibrillation spontaneously recovered to normal sinus rhythm on electrocardiographic monitoring. On the second day, electrocardiographic monitoring documented TdP. We discontinued donepezil immediately. After washout of donepezil, TdP was not observed again. Corrected QT interval was normal throughout hospitalization. This case suggests that donepezil may cause life-threatening ventricular arrhythmias without QT prolongation. Even if corrected QT interval is normal in patients taking donepezil and experiencing symptoms associated with TdP, electrocardiographic monitoring is recommended. .

Effects of mineralocorticoid receptor antagonist spironolactone on atrial conduction and remodeling in patients with heart failure.

BACKGROUND: Spironolactone was shown to reduce mortality in patients with heart failure (HF). However, the effect of spironolactone on the incidence of atrial fibrillation remains unknown. Therefore, we examined the effects of spironolactone on atrial conduction and remodeling in patients with HF. METHODS AND RESULTS: A total of 21 patients with HF were divided into either spironolactone group (n=11) or control group (n=10). The patients were followed up for 12 months. Blood examination, echocardiogram, and signal-averaged electrocardiogram were performed at study enrollment and after 3 and 12 months of treatment. In the spironolactone group, atrial natriuretic peptide tended to reduce, left atrium dimension was significantly smaller, the ratio of E wave to A wave tended to improve, and P-duration was significantly shortened. CONCLUSIONS: Spironolactone improves atrial conduction and remodeling in patients with HF.

Defibrillation efficacy of a subcutaneous array lead: A case report.

We report a case of Brugada syndrome with a high defibrillation threshold (DFT) in whom a subcutaneous array lead was used to lower the DFT in combination with a transvenous right ventricular defibrillation lead. The patient had previously received pacemaker implantation due to sick sinus syndrome. An implantable cardioverter defibrillator (ICD) with a transvenous right ventricular defibrillation lead alone required a high DFT. A subcutaneous array lead improved defibrillation efficacy in combination with a right ventricular lead. These data suggest that a subcutaneous array lead facilitates implantation of an effective ICD lead system in patients requiring a high DFT.

Impact of intraoperative transesophageal echocardiography in cardiac and thoracic aortic surgery: experience in 1011 cases.

BACKGROUND: Although intraoperative transesophageal echocardiography (IOTEE) has been widely used in cardiovascular surgery, the exact incidence of abnormalities detected by IOTEE in each type of surgical procedure is still unclear. The aim of this study was to review our experiences of IOTEE, in patients who underwent different types of cardiovascular surgery and to evaluate the clinical usefulness of IOTEE. METHODS AND RESULTS: Our database of 1011 consecutive patients, who underwent cardiovascular surgery and IOTEE monitoring was reviewed. The incidence of abnormal findings was 115 of 1011 patients (11.4%), and the highest incidence was the appearance of new wall motion abnormalities after cardiopulmonary bypass. These findings influenced surgical decision-making in 59 of the evaluated 1011 patients (5.8%). CONCLUSIONS: IOTEE provides important intraoperative and postoperative information that may influence surgical decision-making in various cardiovascular surgeries.

Cardio-ankle vascular index is superior to brachial-ankle pulse wave velocity as an index of arterial stiffness.

Both cardio-ankle vascular index (CAVI) and brachial-ankle pulse wave velocity (baPWV) are noninvasive methods to estimate arterial stiffness. The purpose of this study is to determine whether CAVI or baPWV is superior as an index of arterial stiffness. One hundred and thirty patients with chest pain syndrome who underwent coronary angiography (CAG) were included in this study. We obtained intima-media-thickness (IMT) and the stiffness parameter beta of the carotid artery by carotid ultrasounds (CU). The peak early diastolic velocity (E), deceleration time of E (EDCT), peak atrial systolic velocity (A) of transmitral flow and left ventricular mass index (LVMI) were obtained by echocardiography. CAVI, baPWV, total cholesterol (T-C), low density lipoprotein cholesterol (LDL-C), high density lipoprotein cholesterol (HDL-C) and triglycerides (TG) were measured before CAG. There was a significant correlation between CAVI and baPWV (r = 0.64, p < 0.01). Both CAVI and baPWV were significantly correlated with age, IMT and beta (age: r = 0.64, p < 0.01 for CAVI, and r = 0.48, p < 0.01 for baPWV; IMT: r = 0.40, p < 0.01, and r = 0.31, p < 0.01; beta: r = 0.36, p < 0.01 and r = 0.25, p < 0.01). However, only CAVI was correlated with the parameters of left ventricular diastolic indices from echocardiography (E/A: r = 0.44, p < 0.01; EDCT: r = 0.36, p < 0.01). Additionally, LDL-C and T-C/HDL-C were also associated with only CAVI (LDL-C: r = 0.26, p < 0.02; T-C/HDL-C: r = 0.30, p < 0.01), not baPWV. Finally, only CAVI was significantly higher in the group with angina pectoris than in the normal group (9.708 +/- 1.423 vs. 9.102 +/- 1.412; p = 0.0178). All parameters associated with atherosclerosis suggested that CAVI was superior to baPWV as a parameter of arterial stiffness.

Cardio-ankle vascular index is a new noninvasive parameter of arterial stiffness.

BACKGROUND: Beta is an index of arterial stiffness independent of blood pressure. Beta of the thoracic descending aorta (TDA) has been obtained by transesophageal echocardiography (TEE) and the cardio-ankle vascular index (CAVI) is a new noninvasive estimation of beta. METHODS AND RESULTS: The purpose of this study was to evaluate the accuracy and usefulness of CAVI and to compare it with other parameters of arteriosclerosis by carotid ultrasound (CU). The instantaneous dimensional change of the TDA on TEE was measured simultaneously with systemic pressure of the brachial artery in 70 patients in sinus rhythm. There were significant correlations between CAVI and age (r=0.65, p<0.01), and CAVI and the beta from TEE (Aobeta) (r=0.67, p<0.01). Next, 110 patients with chest pain syndrome underwent CU and measurement of CAVI, intima - media thickness (IMT), plaque score and beta. There were significant relationships between CAVI and IMT (r=0.42, p<0.01), and between CAVI and beta (r=0.39, p<0.01). CAVI of the group diagnosed with plaque was significant higher than that of the normal group (9.872+/-1.464 vs 9.038+/-1.377, p=0.0039). CONCLUSIONS: CAVI is measured easily and noninvasively and is a new index of arterial stiffness that is independent of blood pressure.

Ratio of early transmitral velocity to lateral mitral annular early diastolic velocity has the best correlation with wedge pressure following cardiac surgery.

BACKGROUND: Although previous investigators reported that mitral annular velocity predicts mean pulmonary capillary wedge pressure (PCWP), it is unknown whether the lateral or septal mitral annular velocity more faithfully predicts PCWP after cardiac surgery. METHODS AND RESULTS: To assess the effect of cardiac surgery on the predictive values for PCWP by measuring mitral annular velocity, 52 consecutive patients undergoing cardiac surgery were studied. All patients underwent transthoracic echocardiography and right-sided cardiac catheterization both before and after surgery. The peak early diastolic velocity of transmitral flow (E) was measured by pulsed-wave Doppler and the peak early diastolic velocities of the lateral (LEa) and septal (SEa) mitral annulus by pulsed-wave tissue Doppler imaging. The ratios of E to LEa (E/LEa) and SEa (E/SEa) were calculated. Immediately after echocardiography, PCWP was measured using a balloon-tipped pulmonary artery catheter. After surgery, LEa was significantly increased (6.4+/-2.7 vs 8.6+/-3.3 cm/s, p<0.001), but SEa was unchanged (6.0+/-2.5 vs 5.5+/-2.3 cm/s, p=0.09). E/LEa correlated well with PCWP both before and after surgery (r=0.79 and r=0.69, respectively, p<0.001). Although E/SEa correlated well before surgery (r=0.67, p<0.001), it correlated only weakly after surgery (r=0.44, p<0.01). CONCLUSIONS: E/LEa has the best correlation with PCWP both before and after cardiac surgery and may be more useful than E/SEa in the noninvasive estimation of PCWP.

Augmentation of left ventricular apical endocardial rotation with inotropic stimulation contributes to increased left ventricular torsion and radial strain in normal subjects: quantitative assessment utilizing a novel automated tissue tracking technique.

BACKGROUND: The difference in the left ventricular (LV) torsion of the endo- and epicardium (Endo, Epi) with inotropic stimulation and its relation to radial strain (RS) remain unclear. METHODS AND RESULTS: LV basal and apical short-axis images were recorded in 13 normal subjects at rest and during dobutamine infusion (5, 10 microg x kg (-1) x min(-1)). A total of 8 points (anterior, lateral, posterior and septum in both Endo and Epi) were manually placed by 2-dimensional tissue tracking technique and the movement of these points during a cardiac cycle was tracked, after which the rotation angles and RS were calculated. LV torsion was defined as the net difference between the basal and apical rotations. In the LV apex, Endo-rotation increased (7.8+/-2.7 to 14.1+/-4.6 degrees, p<0.01), whereas Epi-rotation was unchanged, with dobutamine. The apical Endo-rotation was significantly greater than the Epi-rotation, although no difference was seen between the Endo and Epi in the LV base throughout the study. During dobutamine infusion, the LV Endo-torsion increased (9.5+/-2.8 to 19.3+/-4.8 degrees, p<0.01) and these values were greater than those for Epi. The apical RS increased with the dobutamine dose (39.0+/-9.3 to 61.9+/-15.5%, p<0.01), whereas basal RS initially increased at 5 microg x kg(-1) x min(-1), but thereafter showed no further increase at 10 microg x kg(-1) x min(-1) of dobutamine. CONCLUSIONS: Augmentation of LV rotation with inotropism was clearly observed in the apical Endo, thus causing increased LV endo-torsion and apical RS.

Usefulness of mitral annular velocity in predicting exercise tolerance in patients with impaired left ventricular systolic function.

Left ventricular (LV) diastolic function is 1 of the determinants of exercise tolerance. However, the relation between early diastolic velocity of the mitral annulus (Ea) obtained by tissue Doppler imaging and exercise tolerance is unknown in patients with impaired LV systolic function. To investigate the feasibility of evaluating exercise tolerance using tissue Doppler imaging, we studied 53 consecutive patients (mean age 58 +/- 14 years) with a LV ejection fraction of <50% (mean 37 +/- 9%). We measured the peak early diastolic velocity of transmitral flow (E) and Ea at the lateral border of the mitral annulus and then calculated the E/Ea ratio. After echocardiography, we measured the peak oxygen consumption and anaerobic threshold (AT) by cardiopulmonary exercise testing. Of all the echocardiographic parameters, the best correlation for AT was the E/Ea ratio (r = -0.74, p <0.001). Peak oxygen consumption correlated well with Ea and the E/Ea ratio (r = 0.64 and r = -0.68, respectively, p <0.001). The AT and peak oxygen consumption did not correlate with conventional Doppler indexes. Using an AT of 8 ml/min/kg as the cutoff to separate severe exercise intolerance from normal, mild, or moderate exercise intolerance, a receiver-operating characteristic curve showed that an E/Ea ratio of >11.3 had the best combination of sensitivity (88%) and specificity (86%). Exercise tolerance correlated with the E/Ea ratio in patients with impaired LV systolic function. In conclusion, the evaluation of LV diastolic function using tissue Doppler imaging is useful for predicting exercise tolerance in patients with heart failure.

[Cardioversion of amiodarone-insensitive atrial fibrillation by bepridil in heart failure: two case reports].

Two patients presented with atrial fibrillation which was refractory to amiodarone but successfully treated with bepridil. A 76-year-old man with ischemic cardiomyopathy, non-sustained ventricular tachycardia (NSVT) and atrial fibrillation received amiodarone for NSVT, which disappeared but atrial fibrillation was sustained. A month after receiving amiodarone, interstitial pneumonia occurred. Interstitial pneumonia was improved after amiodarone was discontinued, but NSVT occurred again. He received bepridil, when NSVT and atrial fibrillation disappeared. An 83-year-old man with dilated cardiomyopathy, NSVT, and atrial fibrillation received amiodarone for NSVT, which disappeared but atrial fibrillation was sustained. Five months after receiving amiodarone, interstitial pneumonia occurred. Interstitial pneumonia was improved after amiodarone was discontinued, but NSVT occurred again. He received bepridil, when NSVT and atrial fibrillation disappeared.

Aging and transmitral flow pattern in patients with systemic hypertension.

PURPOSE: Currently, the transmitral flow (TMF) pattern is routinely recorded as the first step in the assessment of left ventricular diastolic function. In young, healthy subjects, it is known that the early diastolic flow (E wave) of TMF is larger than the late diastolic flow (A wave). The E/A ratio then gradually decreases with age. This change in the pattern of TMF can be expected to occur earlier in patients with systemic hypertension than in healthy subjects. However, data pertaining to this matter are limited for Japanese patients. The purpose of this study was to investigate the changing pattern of TMF with age in Japanese patients with systemic hypertension. METHODS: A database of echocardiographic examination reports was surveyed. A total of 553 patients with systemic hypertension (HT group) and 394 patients without hypertension or organic heart disease (control group) were included in this study. The patients were subdivided according to age, after which the E/A ratio was compared for different patient categories and age groups. RESULTS: The E/A ratio gradually decreased with age in the control group, and the mean value of E/A was <1 in the sixth decade. On the other hand, the E/A ratio rapidly decreased and was <1 in the fifth decade in the HT group. CONCLUSION: In patients in the HT group, the E/A ratio decreased about a decade earlier compared with patients in the control group.

Can transthoracic Doppler echocardiography predict the discrepancy between left ventricular end-diastolic pressure and mean pulmonary capillary wedge pressure in patients with heart failure?

BACKGROUND: Left ventricular end-diastolic pressure (LVEDP) is difficult to measure continuously; therefore, pulmonary capillary wedge pressure (PCWP) is frequently used instead for hemodynamic monitoring in patients with heart failure. However, a discrepancy between LVEDP and mean PCWP is sometimes observed. METHODS AND RESULTS: To assess the feasibility of evaluating this discrepancy using echo-Doppler indexes, 140 consecutive patients with heart disease were studied. Transthoracic Doppler echocardiography (TTDE) was performed immediately before bilateral-sided cardiac catheterization. We measured peak velocities of early (E: cm/s) and late (A: cm/s) diastolic transmitral flow, and duration of A wave (MAd: ms). We also measured the duration of atrial reversal of pulmonary venous flow (PAd: ms). The difference between PAd and MAd (Deltad = PAd-MAd: ms) was calculated. The ratio of E to tissue Doppler-derived peak early diastolic velocity of mitral annulus (Ea: cm/s) was also calculated (E/Ea). There was a good positive correlation between LVEDP and Deltad (r = 0.77, p < 0.001). There was a modest correlation between mean PCWP and E/Ea (r = 0.56, p < 0.001). When patients were classified by Deltad > or = 10 ms and E/Ea < or = 14, elevated LVEDP (> or = 17 mmHg) and normal mean PCWP (< or = 12 mmHg) were predicted with 100% sensitivity and 85% specificity. CONCLUSIONS: Evaluation of the discrepancy between LVEDP and mean PCWP in patients with heart failure was feasible by separately estimating LVEDP by Deltad and mean PCWP by E/Ea using noninvasive TTDE. Early detection of patients with elevated LVEDP and normal mean PCWP may be useful for preventing acute exacerbation of chronic heart failure.

Significance of predischarge BNP on one-year outcome in decompensated heart failure--comparative study with echo-Doppler indexes.

BACKGROUND: Cardiac natriuretic peptides and echo-Doppler indexes are important as prognostic indicators of congestive heart failure (CHF). However, differences between etiologies have not been fully investigated. This study aimed to assess the prognostic value of transmitral flow (TMF) and B-type natriuretic peptide (BNP) on admission or predischarge in patients with acutely decompensated CHF of ischemic and nonischemic etiologies. METHODS AND RESULTS: We studied 52 patients with chronic CHF, 31 with old myocardial infarction (OMI), and 21 with idiopathic dilated cardiomyopathy (DCM), admitted for emergency acute decompensation. Patients underwent echo-Doppler study and measurement of plasma BNP on admission and predischarge. The combined index of BNP with echo-Doppler indexes were calculated. Pulmonary capillary wedge pressure (PCWP) and cardiac index were measured on admission. All were followed for 1 year, and those rehospitalized (R group) were compared with those with a stable clinical course (S group). TMF and BNP on admission were similar between DCM and OMI groups. During follow up, 9 with OMI and 10 with DCM were rehospitalized. There were no statistical differences in TMF or BNP levels on admission between the R and S groups. However, the predischarge BNP level was significantly higher in the R group than in the S. Kaplan-Meier curves revealed the influence of predischarge BNP on prognosis. CONCLUSION: Predischarge BNP, not BNP on admission, levels are considered predictive of rehospitalization for decompensation within a year. There were no differences between BNP and echo-Doppler indexes with regard to the CHF etiology.

Echocardiographic predictors of remote outcome in patients with angiographically successful reflow after acute myocardial infarction.

BACKGROUND: The angiographically no-reflow phenomenon after percutaneous coronary intervention (PCI) predicts poor left ventricular (LV) functional recovery and a high risk of cardiac events in patients with their first acute myocardial infarction (AMI). However, risk factors of long-term adverse outcome for patients with angiographically successful reflow (TIMI (Thrombolysis in Myocardial Infarction) flow grade 3) for the AMI remain unknown. METHODS AND RESULTS: Of 168 echocardiograms were performed before PCI and at discharge, 113 were suitable for analysis. Clinical, angiographic, and echocardiographic variables were submitted to statistical analysis to detect the risk factors of cardiac events. During the follow-up period of 46+/-20 months, 31 patients had cardiac events, though there were no cardiac deaths. The 2 most important risk factors for congestive heart failure (CHF) or total cardiac events were LV dilation (chi-square: 7.5 and 9.4; both p<0.01) and pseudonormal transmitral flow pattern (PN, chi-square: 4.9, p<0.05 and 6.7, p<0.01, respectively). However, only multivessel disease (chi-square: 9.4, p=0.05) became the predictor for revascularization after PCI. The incidence of CHF or total cardiac events in patients with PN and LV dilation at discharge determined by the Kaplan-Meier method were significantly higher than those with normal or abnormal relaxation transmitral flow pattern (log-rank: 41 and 27, both p<0.001) and no LV dilation (log-rank: 20 and 20, both p<0.001). CONCLUSION: Poor LV diastolic function and LV dilation at discharge are predictors of the cardiac events in patients in whom epicardial coronary flow was well-restored after PCI for the first AMI.