Impaired elastic properties of ascending aorta in patients with giant cell arteritis.

OBJECTIVE: To investigate the elastic properties of the ascending aorta in untreated patients with giant cell arteritis compared with age and sex matched normal controls. METHODS: Distensibility of the ascending aorta and aortic strain were measured in 22 patients with a recent diagnosis of giant cell arteritis (documented by a positive temporal artery biopsy) before initiation corticosteroid treatment, and in 44 age and sex matched healthy subjects. Aortic distensibility was calculated as 2x[pulsatile change in aortic diameter]/[(diastolic aortic diameter)x(aortic pulse pressure)], and aortic strain as [pulsatile change in aortic diameter]/[diastolic aortic diameter]. Aortic diameters were measured by echocardiography. Aortic pressures were obtained by external sphygmomanometry. RESULTS: Distensibility of the ascending aorta and aortic strain were both lower in patients with giant cell arteritis than in the controls (p<0.01). In the patients with giant cell arteritis, aortic distensibility was inversely correlated with white blood cell count (p<0.05), but not with erythrocyte sedimentation rate or C reactive protein. CONCLUSIONS: Compared with healthy subjects, aortic distensibility and aortic strain are decreased in patients with giant cell arteritis before initiation of corticosteroid treatment. There was an association between the degree of reduction of aortic distensibility and the white blood cell count in the patient group.

Natural history of early aortic paraprosthetic regurgitation: a five-year follow-up.

OBJECTIVES: To assess the incidence and natural course of paravalvular leaks detected early after aortic valve replacement. BACKGROUND: Although the use of echocardiography has simplified the postoperative assessment of patients with aortic valve replacement, there are no data regarding the natural history of early detected paravalvular aortic leaks. METHODS: Eighty-four consecutive patients with aortic valve replacement were prospectively followed clinically every 6 months and by echocardiography early (11 +/- 7 days), at midterm (27 +/- 3 months), and late (63 +/- 4 months) after aortic valve replacement. The competence of artificial valves was assessed by Doppler color flow mapping. RESULTS: Paraprosthetic leaks were detected in 40 (47.6%) aortic prostheses during the early study; the majority (90%) were small. All leaks remained unchanged during the follow-up period. Left ventricular dimensions and function did not differ between patients with or without paravalvular leak during the follow-up. Left ventricular fractional shortening, however, increased during the intermediate study in both subgroups, indicating improved left ventricular function overall. Three patients had severe paravalvular regurgitation suddenly develop from late infective endocarditis, and 1 patient had a degenerative tissue valve failure 4 years after implantation. CONCLUSIONS: Paraprosthetic aortic leaks detected early after surgery, in the absence of valve infection, are common, are usually small, and have a benign course. However, the development of new, usually severe, regurgitation should raise the suspicion of prosthetic valve endocarditis or bioprosthetic valve failure.

Hypotensive response during dobutamine stress echocardiography in coronary patients: a common event of well-functioning left ventricle.

BACKGROUND: Hypotensive response during dobutamine stress echocardiography (DSE) is a common complication, lacking the prognostic significance of hypotension during exercise treadmill test. HYPOTHESIS: The present study aimed to assess the possible mechanisms of hypotensive response during DSE and to compare it with exercise treadmill test. METHODS: In all, 91 patients with known coronary artery disease (CAD) underwent both DSE and exercise treadmill test. Dobutamine-induced hypotension was defined as a systolic blood pressure drop > or = 20 mmHg from baseline or from the previous level of infusion. RESULTS: Twenty-one (23%) patients, 10 of whom also had bradycardia, developed hypotension during dobutamine infusion. Five (5.5%) patients were severely symptomatic and the infusion was stopped prematurely, while in the remaining 16 the addition of atropine allowed the continuation of the test. Patients prone to hypotension were predominantly female (p = 0.0004), had smaller (p = 0.01) and better functioning left ventricles (p = 0.0004), were unlikely to have rest wall motion abnormalities (p = 0.0008) or multivessel CAD (p = 0.02), and had less ischemia (wall motion score difference) (p = 0.03). Hypotension during exercise treadmill test was observed in only one (1%) patient with left main disease. CONCLUSION: Hypotension during DSE is unrelated to the anatomical or functional extent of CAD and is frequent in the setting of a well-functioning left ventricle. We suppose that vigorous contraction of a small chamber during dobutamine infusion results in an excessive stimulation of cardiac mechanoreceptors that mediate reflex hypotension and bradycardia.

Incidence and evolution of carcinoid syndrome in the heart.

BACKGROUND AND AIMS OF THE STUDY: Carcinoid syndrome originates from carcinoid tumors localized in the gastrointestinal system, pancreas, biliary vessels, bronchi, ovaries and testes. The condition is characterized by flushing, telangiectasias, diarrhea, bronchoconstriction and cardiac involvement, while cardiac lesions may occur in 50% of patients. This study aimed to investigate-non-invasively-the frequency, severity and evolution of carcinoid heart involvement. METHODS AND RESULTS: Among 87 patients with carcinoid syndrome undergoing routine echocardiography, 39 (45%) had cardiac involvement; 36 of these had thickened, shortened, immobile tricuspid leaflets. Tricuspid regurgitation was present in all 36, it was moderate or severe in 22. Pressure half-time rose to 117 +/- 35 ms, implying mild tricuspid stenosis. The pulmonary valve was also thickened, retracted and immobile with stenotic appearance in 19 patients; regurgitation was present in 16, and mild in 11. Nine patients had pericardial effusion. Of 39 patients with cardiac lesions, 18 had at least one follow up study within 16 +/- 7 months; in 15 cases the valve lesions deteriorated. Tricuspid regurgitation became more severe in six and pressure half-time rose from 107 +/- 46 to 132 +/- 50 ms. Pulmonary regurgitation deteriorated in two, while three patients had new pulmonary valve involvement. The peak gradient across the pulmonary valve increased from 18 +/- 7 to 25 +/- 9 mmHg. Twenty-two patients without heart involvement in the first examination had a follow up study (19 +/- 5 months) during which seven developed valvular lesions, with four moderate and three mild tricuspid regurgitation; mild stenosis was present in all cases. Two patients with mild tricuspid regurgitation had mild mixed pulmonary valve involvement, while of those with moderate tricuspid regurgitation, one also had moderate pulmonary stenosis with mild regurgitation. Five patients with both tricuspid and pulmonary valve diseases had interventional treatment: three underwent balloon valvuloplasty on both valves simultaneously due to stenotic lesions but later relapsed; the other two underwent double valve replacement with biological prostheses but in both cases the pulmonary valve developed severe destruction leading to one death. The other four patients survived for 36, 41, 25 and 16 months, respectively. CONCLUSIONS: Right valvular heart disease occurs frequently in patients with carcinoid syndrome. Evolution of lesions is rapid, leading to right heart failure, though death usually occurs from progressive systemic disease and rarely from pulmonary stenosis. Surgery is the most effective treatment and balloon valvulotomy is only palliative. However, therapy of the systemic condition is predominantly the treatment of choice.