Time-dependence of appropriate implantable defibrillator therapy in patients with ischemic cardiomyopathy.

INTRODUCTION: Little is known about the risk of appropriate implantable cardioverter-defibrillator (ICD) therapy outside the context of controlled clinical trials where routine practice patients are followed for longer durations and questions of device replacement frequently arise. We assessed the incidence and time-dependence of appropriate ICD therapy in a routine clinical practice primary prevention population with prior myocardial infarction (MI) and reduced left ventricular ejection fraction (LVEF). METHODS AND RESULTS: Patients with prior MI and LVEF

Effect of the magnitude of lipid lowering on risk of elevated liver enzymes, rhabdomyolysis, and cancer: insights from large randomized statin trials.

OBJECTIVES: We sought to assess the relationship between the magnitude of low-density lipoprotein cholesterol (LDL-C) lowering and rates of elevated liver enzymes, rhabdomyolysis, and cancer. BACKGROUND: Although it is often assumed that statin-associated adverse events are proportional to LDL-C reduction, that assumption has not been validated. METHODS: Adverse events reported in large prospective randomized statin trials were evaluated. The relationship between LDL-C reduction and rates of elevated liver enzymes, rhabdomyolysis, and cancer per 100,000 person-years was assessed using weighted univariate regression. RESULTS: In 23 statin treatment arms with 309,506 person-years of follow-up, there was no significant relationship between percent LDL-C lowering and rates of elevated liver enzymes (R2 <0.001, p = 0.91) or rhabdomyolysis (R2 = 0.05, p = 0.16). Similar results were obtained when absolute LDL-C reduction or achieved LDL-C levels were considered. In contrast, for any 10% LDL-C reduction, rates of elevated liver enzymes increased significantly with higher statin doses. Additional analyses demonstrated a significant inverse association between cancer incidence and achieved LDL-C levels (R2 = 0.43, p = 0.009), whereas no such association was demonstrated with percent LDL-C reduction (R2 = 0.09, p = 0.92) or absolute LDL-C reduction (R2 = 0.05, p = 0.23). CONCLUSIONS: Risk of statin-associated elevated liver enzymes or rhabdomyolysis is not related to the magnitude of LDL-C lowering. However, the risk of cancer is significantly associated with lower achieved LDL-C levels. These findings suggest that drug- and dose-specific effects are more important determinants of liver and muscle toxicity than magnitude of LDL-C lowering. Furthermore, the cardiovascular benefits of low achieved levels of LDL-C may in part be offset by an increased risk of cancer.

Left ventricular remodelling index (LVRI) in various pathophysiological conditions: a real-time three-dimensional echocardiographic study.

BACKGROUND: Various studies have reported a close correlation between real-time three-dimensional echocardiography (RT3DE) and cine magnetic resonance imaging studies for the assessment of cardiac volumes and mass. OBJECTIVE: The aim of our study was to evaluate changes in left ventricular volumes and mass in subjects with different pathophysiological conditions. A ratio between left ventricular mass and end-diastolic volume (LVRI), detected by RT3DE, was used to describe various patterns of left ventricular remodelling. METHODS: RT3DE was performed to calculate left ventricular end-diastolic (LVEDV) and end-systolic volume (LVESV), ejection fraction (LVEF) and mass in 220 selected subjects. Of these, 152 were healthy volunteers, 19 top-level rowers, 23 patients with dilated cardiomyopathy and 26 patients with hypertrophic cardiomyopathy. Off-line analysis was performed by two independent operators by tracing manual endocardial and epicardial borders of the left ventricle through eight cutting planes. Inter- and intra-observer variability were calculated. RESULTS: Despite the increase in LV volume and mass in the rowers, LVRI remained unchanged compared with control subjects (p = 0.455), while significantly lower values were found patients with dilated cardiomyopathy (p<0.001) and significantly higher values in patients with hypertrophic cardiomyopathy (p<0.001). There was inter- and intra-observer variability. CONCLUSION: The LVRI may serve as a simple and useful indicator of left ventricular adaptation to physiological and pathological conditions.

Quantification of right ventricular volumes and function by real time three-dimensional echocardiographic longitudinal axial plane method: validation in the clinical setting.

BACKGROUND: Measurement of right ventricular (RV) volumes and right ventricular ejection fraction (RVEF) by three-dimensional echocardiographic (3DE) short-axis disc summation method has been validated in multiple studies. However, in some patients, short-axis images are of insufficient quality for accurate tracing of the RV endocardial border. This study examined the accuracy of long-axis analysis in multiple planes (longitudinal axial plane method) for assessment of RV volumes and RVEF. METHODS: 3DE images were analyzed in 40 subjects with a broad range of RV function. RV end-diastolic (RVEDV) and end-systolic volumes (RVESV) and RVEF were calculated by both short-axis disc summation method and longitudinal axial plane method. RESULTS: Excellent correlation was obtained between the two methods for RVEDV, RVESV, and RVEF (r = 0.99, 0.99, 0.94, respectively; P < 0.0001 for all comparisons). CONCLUSION: 3DE longitudinal-axis analysis is a promising technique for the evaluation of RV function, and may provide an alternative method of assessment in patients with suboptimal short-axis images.

Avaliação do tamanho do átrio esquerdo pelo ecocardiografia tridimensional em indivíduos com anatomia cardíaca normal, em pacientes com cardiopatia dilatada ou cardiomiopatia hipertrófica: comparação com medidas do ecocardiograma bidimensional / Evaluation of the left atrium by tridimensional echocardiography in normal volunteers, in patients with dilated and hypertrophic cardiomyopathy: comparison with bidimensional echocardiography

Introdução: A análise do átrio esquerdo (AE) é importante para o entendimento da fisiopatologia de diferentes doenças cardíacas. Objetivo: Comparar as medidas do AE pelo ecocardiografia bidimensional (eco 2D) com as realizadas ao ecocardiograma tridimensional (eco 3D). Método: estudo prospectivo de medidas do AE ao eco 2D e 3D em 110 indivíduos: 47 com anatomia cardíaca normal (N),44 com cardiomiopatia dilatada (CMD), 19 com cardiomiopatia hipertrofica (HOCM), 62 eram homens, e a média de idade de 42 mais ou menos 16 anos). As medidas do AE pelo eco 2D foram: diâmetro ântero-posterior (AP), diâmetro inferior-superior(IS), médio-lateral (ML), área (2DAr), volume (2DV). Pelo eco 3D foi medido o volume do AE (3DV).Para a análise estatística foram aplicados: coeficiente de correlação de Spearman(r), 95 por cento IC, teste de Bland & Altman e regressão linear. Resultados: Os valores do volume do AE (ml) ao eco 3D e eco 2D, foram, respectivamente, no grupo N de 38 mais ou menos e 32,2 mais ou menos 78, no grupo CMD de 81,2 mais ou menos 30 e 63,6 mais ou menos 24 e no grupo HOCM de 75 mais ou menos 26 e 62,8 mais ou menos 21. No grupo N o coeficiente de correlação entre o 3DV com o...

What is the best approach for the assessment of left atrial size? Comparison of various unidimensional and two-dimensional parameters with three-dimensional echocardiographically determined left atrial volume.

BACKGROUND: Left atrial (LA) size has prognostic importance in a variety of cardiac conditions. Diameters, area, or volume derived from 2-dimensional (2D) echocardiography (2DE) are commonly used to measure LA size, but involve numerous assumptions. This study examined the accuracy of these 2DE parameters compared to 3-dimensional echocardiographic LA volume (3DV). METHODS: LA diameters, area, and volume measured from 2DE were correlated with 3DV in 118 patients with dilated cardiomyopathy, hypertrophic cardiomyopathy, or without structural heart disease. RESULTS: Diameter (anterior-posterior, superior-inferior, and medial-lateral) and 2DE area measurements had statistically significant, but modest, correlations with 3DV, and exhibited a large degree of scatter in comparison with 3DV. The 2DE-derived volume had an excellent correlation with 3DV, but consistently underestimated LA volume. CONCLUSION: The 2DE LA volume correlates better than other parameters with 3DV, but often results in underestimation. Thus, caution should be exercised when using unidimensional and 2D measurements of LA size.

Echocardiographic diagnosis of air embolism associated with central venous catheter placement: case report and review of the literature.

Transthoracic echocardiography (TTE) is a valuable tool in the evaluation of patients with suspected air embolism. This report describes the presentation and evaluation of a critically ill woman with spontaneous air embolism occurring during a central venous catheter replacement. Bedside TTE established the diagnosis of air embolism, allowing prompt initiation of appropriate therapy. This case report highlights this uncommon but potentially life-threatening complication of central line placement and the utility of echocardiography in its evaluation.

Echocardiographic detection of intrapulmonary shunting in a patient with hepatopulmonary syndrome: case report and review of the literature.

Transthoracic echocardiography is a useful tool in the evaluation of patients with intrapulmonary and intracardiac shunts. We describe a case of a 49-year-old female with severe hypoxemia in the setting of aortic stenosis and cirrhosis of the liver. The use of agitated saline contrast during an echocardiography study helped to establish the diagnosis of intrapulmonary arteriovenous shunting consistent with the hepatopulmonary syndrome, thereby confirming the etiology of her symptoms and laboratory findings. This case report highlights the utility of echocardiography in diagnosing intrapulmonary shunts and assists in the understanding of the pathophysiology of hypoxemia in such patients.

[Mechanism of cardiac resynchronization therapy by real-time three-dimensional echocardiography in patients with heart failure]. / Demonstração do mecanismo da terapia de ressincronização ventricular com ecocardiografia tridimensional em tempo real em paciente com insuficiência cardíaca.

We report the case of a 66-year-old man with heart failure NYHA class IV treated with biventricular pacing for cardiac resynchronization. The patient was evaluated by real-time three-dimensional transthoracic echocardiography before and 48 hours after pacemaker implantation. The use of three-dimensional echocardiography contributed to understanding the underlying mechanism involved in cardiac resynchronization therapy by demonstrating enhanced synchrony of myocardial segments, which resulted in the patient's clinical improvement.

Demonstracão do mecanismo da terapia de ressincronizacão ventricular com ecocardiografia tridimensional em tempo real em paciente com insuficiência cardíaca / Mechanism of cardiac resynchronization therapy by real-time three-dimensional echocardiography in patients with heart failure

Relatamos caso de homem de 66 anos de idade portador de insuficiência cardíaca classe funcional (NYHA) IV que foi submetido a terapia de ressincronizacão cardíaca por implante de marcapasso biventricular. O paciente foi avaliado antes e 48 horas após o implante do marcapasso com o emprego da ecocardiografia tridimensional transtorácica em tempo real. A utilizacão da ecocardiografia tridimensional contribuiu para o entendimento do mecanismo envolvido na ressincronizacão cardíaca através da demonstracão da melhor sincronizacão dos segmentos cardíacos, o que resultou em melhora clínica do paciente.

Thrombotic thrombocytopenic purpura/hemolytic uremic syndrome associated with high-dose interleukin-2 for the treatment of metastatic melanoma.

Various drugs have been associated with the development of thrombotic thrombocytopenic purpura (TTP) and hemolytic uremic syndrome (HUS). Among the biologic agents, alpha-interferon therapy, used for treatment of hepatitis B and chronic myelogenous leukemia, has been associated with TTP in a few recent reports. The authors report the first case of TTP/HUS occurring in a metastatic melanoma patient receiving treatment with high-dose interleukin-2 (IL-2). A 57-year-old patient with malignant melanoma presented with seizures 3 days after completing the first week of high-dose IL-2, and the characteristic hematologic picture revealed TTP/HUS. This occurrence is unlikely to be explained by the association with malignant melanoma, which was not presenting with widespread visceral disease at the time of the occurrence, or by the use of other medications. Similar cytokine release profiles are encountered in TTP, HUS caused by Shiga toxin-1, HUS caused by E. coli O157, after IL-2 or IL-2-containing biochemotherapy, as well as in TTP caused by interferon-alpha. This cytokine profile could reflect a common cause, or just the presence of similar pathways involved.