Differentiation of tricuspid regurgitation from constrictive pericarditis: novel criteria for diagnosis in the cardiac catheterisation laboratory.

BACKGROUND: Severe tricuspid regurgitation, constrictive pericarditis and restrictive cardiomyopathy can all present with signs and symptoms of right heart failure and similar haemodynamic findings of elevation and equalisation of diastolic pressures at catheterisation. Although catheterisation findings of enhancement of ventricular interaction are a reliable parameter to distinguish constrictive pericarditis from restrictive cardiomyopathy, this also may be present in severe tricuspid regurgitation. OBJECTIVE: To identify unique haemodynamic parameters that differentiate severe tricuspid regurgitation from constrictive pericarditis. METHODS: Haemodynamic findings from simultaneous right and left heart catheterisation of 14 patients (age 59 years; men 71%) with documented severe tricuspid regurgitation (group I) were compared with those of 14 patients with surgically proven constrictive pericarditis (group II). RESULTS: Findings of elevated right atrial pressure, early rapid ventricular filling and expiratory equalisation of ventricular diastolic pressures were similar in both groups. Ventricular interdependence, assessed by interaction of left ventricular (LV) and right ventricular (RV) systolic pressures, was also present in both groups. Relative changes in LV and RV diastolic pressures during respiration reliably distinguished group I from group II. During inspiration, the difference between the LV and RV diastolic pressures widened in group I but narrowed in group II. The height and slope of the early rapid filling wave in RV pressure trace was accentuated during inspiration in group I but did not change in group II. CONCLUSIONS: The haemodynamic findings at cardiac catheterisation in patients with severe, symptomatic tricuspid regurgitation are similar to those of constrictive pericarditis. Careful analysis of the relationship of the LV and RV diastolic pressures during respiration can help differentiate the two entities.

Device complications and inappropriate implantable cardioverter defibrillator shocks in patients with hypertrophic cardiomyopathy.

BACKGROUND: Although the benefit of implantable cardioverter defibrillator (ICD) therapy in patients with hypertrophic cardiomyopathy (HCM) at risk for sudden cardiac arrest is well established, there may be a higher risk for device complications and inappropriate shocks. OBJECTIVES: To determine the incidence of inappropriate ICD shocks and device complications in HCM patients and the impact of young age at ICD implant and atrial fibrillation. METHODS: HCM patients who underwent ICD implantation between January 1988 and December 2005 were included. The frequency of device complications, including pneumothorax, pericardial effusion, haematoma, lead revisions, infection and rate of inappropriate shocks, was determined. ICD shocks were characterised as inappropriate if triggered by sinus tachycardia, atrial fibrillation or device malfunction. RESULTS: A total of 181 patients were included (mean age 44 (SD 17) years; 62% males). During a mean follow-up of 59 (42) months (4.92 years; 830.75 patient-years), 65 patients (36%) had a total of 88 device complications, including 42 (23%) patients with inappropriate shocks. The rate of inappropriate shocks was 5.3% per year (vs 4% risk of appropriate shocks), and the likelihood of inappropriate ICD shocks per 100 patient-years was 5.1. Younger age and atrial fibrillation were associated with an increased risk of inappropriate ICD discharges. CONCLUSIONS: The rate of inappropriate ICD shocks and frequency of device complications in HCM patients are not insignificant and are most common in younger patients and those with atrial fibrillation. Inappropriate ICD shocks are the most common device complication and should be accounted for when counselling high-risk HCM patients for ICD implantation.

Immediate improvement in coronary flow reserve after alcohol septal ablation in patients with hypertrophic obstructive cardiomyopathy.

OBJECTIVES: To examine whether percutaneous alcohol septal ablation affects coronary flow reserve (CFR) in patients with hypertrophic cardiomyopathy (HCM). METHODS: CFR was measured immediately before and after septal ablation in patients with symptomatic obstructive HCM. CFR was also obtained in normal subjects (NL) for comparison. RESULTS: Patients with HCM (n = 11), compared with NL (n = 22), had a lower mean (SD) baseline CFR (1.96 (0.5) vs 3.0 (0.7), p<0.001), a lower coronary resistance (1.04 (0.45) vs 3.0 (2.6), p = 0.002), a higher coronary diastolic/systolic velocity ratio (DSVR; 5.1 (3.0) vs 1.8 (0.5), p = 0.04) and a lower hyperaemic coronary flow per left ventricular (LV) mass (0.73 (0.4) vs 1.1 (0.6) ml/min/g, p = 0.007). Septal ablation in the HCM group (n = 7) reduced the outflow tract gradient but not the left atrial or LV diastolic pressures. Ablation resulted in immediate normalisation of CFR (to 3.1 (1), p = 0.01) and DSVR (to 1.9 (0.8), p = 0.09) and an increase in coronary resistance (to 1.91 (0.6), p = 0.02). This was probably related to an improvement in the systolic coronary flow. CONCLUSIONS: This study demonstrates that successful septal ablation in patients with symptomatic HCM results in immediate improvement in CFR, which is reduced in HCM partly because of the increased systolic contraction load.

Anatomy of the first septal perforating artery: a study with implications for ablation therapy for hypertrophic cardiomyopathy.

OBJECTIVE: To determine the variability in the size and distribution of the first septal perforating artery (FSPA). MATERIAL AND METHODS: In this pilot study, 10 fresh autopsy hearts from patients who did not have hypertrophic cardiomyopathy (HCM) or clinical evidence of coronary artery disease were evaluated for the variability in the size of the FSPA. The size of the FSPA was also measured during coronary angiography in 8 patients with HCM who were undergoing alcohol septal ablation. RESULTS: Of the 10 autopsy hearts, 2 had a large FSPA (> or = 1.0 mm in maximal diameter) with prominent septal myocardial distribution, 2 had a medium-sized FSPA (0.5-0.9 mm), 2 had a small FSPA (0.1-0.4 mm), 3 had a tiny FSPA (< 0.1 mm), and 1 had an indiscernible ostium. In 2 patients the FSPA supplied the right ventricular free wall. In 4 patients the basal ventricular septum was incompletely supplied by the FSPA. Of the 8 patients with HCM, the FSPA was larger than 2 mm in diameter in 2 patients, 1 to 2 mm in 4, and smaller than 1 mm in 2. The distance between the left anterior descending coronary artery ostium and the origin of the FSPA ranged between 13.1 and 37.4 mm, indicating a large variation in the size and distribution of the FSPA. CONCLUSIONS: Variability in the size and distribution of the FSPA in patients without HCM was substantial. Areas of the heart other than the basal septum were supplied in some patients by the FSPA. In other patients the FSPA did not supply the entire basal septum. Similar findings were noted in patients with HCM. A detailed evaluation of the distribution of the FSPA may be necessary in all patients with HCM who are undergoing alcohol septal ablation.

Left ventricular and biventricular pacing in congestive heart failure.

Dual-chamber pacing improved hemodynamics acutely in a subset of patients with left ventricular (LV) dysfunction but conveyed no long-term symptomatic benefit in most. More recently, LV pacing and biventricular (multisite) pacing have been used to improve systolic contractility by altering the electrical and mechanical ventricular activation sequence in patients with severe congestive heart failure (CHF) and intraventricular conduction delay or left bundle branch block (LBBB). Intraventricular conduction delay and LBBB cause dyssynchronous right ventricular and LV contraction and worsen LV dysfunction in cardiomyopathies. Both LV and biventricular cardiac pacing are thought to improve cardiac function in this situation by effecting a more coordinated and efficient ventricular contraction. Short-term hemodynamic studies have shown improvement in LV systolic function, which seems more pronounced with monoventricular LV pacing than with biventricular pacing. Recent clinical studies in limited numbers of patients suggest long-term clinical benefit of biventricular pacing in patients with severe CHF symptoms. Continuing and future studies will demonstrate whether and in which patients LV and biventricular pacing are permanently effective and equivalent and which pacing site within the LV produces the most beneficial hemodynamic results.

Annulus paradoxus: transmitral flow velocity to mitral annular velocity ratio is inversely proportional to pulmonary capillary wedge pressure in patients with constrictive pericarditis.

BACKGROUND: The early diastolic velocity of the mitral annulus (E') is reduced in patients with diastolic dysfunction and increased filling pressures. Because transmitral inflow early velocity (E) increases progressively with higher filling pressures, E/E' has been shown to have a strong positive relationship with pulmonary capillary wedge pressure (PCWP) and left ventricular end-diastolic pressure. However, previous studies have primarily involved patients without a pericardial abnormality. In constrictive pericarditis (CP), E' is not reduced, despite increased filling pressures. This study evaluated the relationship between E/E' and PCWP in patients with CP. METHODS AND RESULTS: We studied 10 patients (8 men; mean age, 64+/-7 years) with surgically confirmed CP. Doppler echocardiography was performed to measure early and late diastolic transmitral flow velocities. Tissue Doppler echocardiography was performed to measure E'. PCWP was measured with right heart catheterization. All patients were in sinus rhythm. Mean E and E' were 91+/-15 cm/s and 11+/-4 cm/s, respectively. Mean PCWP was 25+/-6 mm Hg. E' was positively correlated with PCWP (r=0.69, P=0.027). There was a significant inverse correlation between E/E' and PCWP (r=-0.74, P=0.014). Despite high left ventricular filling pressures, E/E' (mean, 9+/-4) was <15 in all but 1 patient. CONCLUSIONS: Paradoxical to the positive correlation between E/E' and PCWP in patients with myocardial disease, an inverse relationship was found in patients with CP.

Calcium embolism of the coronary arteries after percutaneous mitral balloon valvuloplasty.

Two cases of rare, catastrophic calcium emboli to the coronary arteries immediately after percutaneous mitral balloon valvuloplasty are presented. Preoperative echocardiographic findings may identify patients at risk for this complication. These cases should increase the awareness of calcium emboli and lead to consideration of urgent coronary angiography for patients with signs or symptoms of acute coronary occlusion after valvuloplasty.

Utility of stress Doppler echocardiography in patients undergoing percutaneous mitral balloon valvotomy.

A subset of patients with mitral stenosis have symptoms out of proportion to the resting hemodynamics. Exercise Doppler echocardiography is a useful diagnostic modality to determine which patients are limited by their valve obstruction and would therefore benefit from percutaneous mitral balloon valvotomy. We analyzed 11 patients who showed a peak exercise mean mitral gradient that doubled from baseline or a final gradient of > 15 mm Hg. The mean mitral gradient increased from 7 +/- 2 mm Hg at rest to 19 +/- 6 mm Hg (P < .001) with exercise. All patients reported improvement in symptoms of at least 1 functional class after valvotomy.

Clinical utility of Doppler echocardiography and tissue Doppler imaging in the estimation of left ventricular filling pressures: A comparative simultaneous Doppler-catheterization study.

BACKGROUND: Noninvasive assessment of diastolic filling by Doppler echocardiography provides important information about left ventricular (LV) status in selected subsets of patients. This study was designed to assess whether mitral annular velocities as assessed by tissue Doppler imaging are associated with invasive measures of diastolic LV performance and whether additional information is gained over traditional Doppler variables. METHODS AND RESULTS: One hundred consecutive patients referred for cardiac catheterization underwent simultaneous Doppler interrogation. Invasive measurements of LV pressures were obtained with micromanometer-tipped catheters, and the mean LV diastolic pressure (M-LVDP) was used as a surrogate for mean left atrial pressure. Doppler signals from the mitral inflow, pulmonary venous inflow, and TDI of the mitral annulus were obtained. Isolated parameters of transmitral flow correlated with M-LVDP only when ejection fraction <50%. The ratio of mitral velocity to early diastolic velocity of the mitral annulus (E/E') showed a better correlation with M-LVDP than did other Doppler variables for all levels of systolic function. E/E' <8 accurately predicted normal M-LVDP, and E/E' >15 identified increased M-LVDP. Wide variability was present in those with E/E' of 8 to 15. A subset of those patients with E/E' 8 to 15 could be further defined by use of other Doppler data. CONCLUSIONS: The combination of tissue Doppler imaging of the mitral annulus and mitral inflow velocity curves provides better estimates of LV filling pressures than other methods (pulmonary vein, preload reduction). However, accurate prediction of filling pressures for an individual patient requires a stepwise approach incorporating all available data.

Right ventricular infarction associated with anteroseptal myocardial infarction: a clinicopathologic study of nine cases.

The association of right ventricular (RV) infarction with inferoseptal myocardial infarction is well established. However, a question remains about the occurrence of RV infarction in association with anteroseptal myocardial infarction. To determine the frequency and clinical correlates of this entity, we studied autopsied hearts from patients with isolated anteroseptal left ventricular (LV) infarcts. Among 3,249 autopsy specimens, 88 cases were identified. From each, sections were taken from the RV anterior, lateral, and inferior regions at basal, middle, and apical levels. All 1,584 slides were reviewed by blinded assessment. RV and LV infarcts were compared to confirm similarity in age. Patient records and cardiac investigations were reviewed for evidence of RV involvement. Of the 88 hearts with anteroseptal LV infarcts, 9 (10%) had coexistent RV infarction (6, old; 3, new). For these 9, the RV infarction involved 11% to 33% of the RV area, and the left anterior descending coronary artery was the infarct-related artery in each. All 3 patients who had an echocardiographic examination within 4 weeks of anteroseptal LV infarction had RV dysfunction. One patient, studied 15 years after infarction, had a normal right ventricle by echocardiography. In 3 patients with acute myocardial infarction, right heart catheterization during the acute phase revealed increased right-sided diastolic pressures out of proportion to left-sided diastolic pressures (right atrial pressure to pulmonary capillary wedge pressure, 60% to 95%). In conclusion, 10% of patients with an isolated anteroseptal LV infarct had evidence of RV free wall infarction. The RV infarction was associated with identifiable hemodynamic and echocardiographic features.

Idiopathic annular dilation: a rare cause of isolated severe tricuspid regurgitation.

The management of patients with severe tricuspid regurgitation (TR) requires the clinician to clarify the mechanism of regurgitation. Primary disorders of the tricuspid valve, either congenital or acquired, may be readily identified by echocardiography. Severe TR most often results from left-sided heart disease and secondary pulmonary hypertension. Cardiomyopathic processes may also cause right ventricular failure and functional TR. We report three patients with severe TR due to idiopathic annular dilation. The tricuspid valves were otherwise normal on surgical inspection, and the pulmonary pressures were not significantly elevated. Each patient was aged over 65 years and had chronic atrial fibrillation with preserved left ventricular systolic function. Surgical treatment was associated with marked clinical improvement. Clinicians should recognize this unusual but treatable cause of right-sided congestive heart failure.