Role of CMR-derived atrial deformation analysis in the prediction of atrial fibrillation recurrence rate after pulmonary vein isolation.

PURPOSE: Left atrial (LA) dimensions have been identified as anatomical predictors for atrial fibrillation (AF) recurrence after pulmonary vein isolation (PVI). The value of LA function compared to pure LA anatomical risk prediction for AF recurrence after PVI is not well investigated. Cardiovascular magnetic resonance (CMR) is able to simultaneously assess LA anatomical, tissue and functional markers within one examination. The hypothesis of this explorative study was that CMR-derived LA strain has incremental value for the prediction of AF recurrence after PVI. METHOD: Fifty-two patients with paroxysmal or persistent AF were retrospectively enrolled for CMR (1.5T) prior to PVI. Strain-analysis was derived from standard cine images in 4-, 3- and 2-chamber view. LA function was divided into LA reservoir strain and strain rate (εs and SRs), LA conduit (εe and SRe) and LA booster pump function (εa and SRa). The primary endpoint was recurrence of AF within one year after PVI. RESULTS: Twelve patients (23 %) presented with AF recurrence. There was no difference in age, LA size as well as LA sphericity index between the groups. Patients with AF recurrence (68.3 ± 5.5 years, 66 % male) showed significantly reduced LA booster pump function compared to the patients without AF recurrence (66.3 ± 10.5 years, 50 % male) (εa: p = 0.015; SRa: p = 0.036). In binomial logistic regression analyses, the only predictor for AF recurrence after PVI was εa (p = 0.033). CONCLUSIONS: In this descriptive study, impaired LA booster pump function predicted AF recurrence one year after PVI. Compared to further LA strain and anatomical parameters, LA booster pump might serve as additional predictor of AF recurrence.

Alterations of left ventricular function in women with insulin-dependent diabetes mellitus during pregnancy.

AIMS/HYPOTHESIS: During pregnancy, eminent cardiovascular changes occur. The aim of the following study was to investigate the course of haemodynamic parameters under the increased volume load during pregnancy and delivery in women with insulin-dependent diabetes mellitus. METHODS: We examined 51 pregnant diabetic women and 51 healthy pregnant women. The control group consisted of 51 healthy non-pregnant women. In all women, left ventricular mass and fractional shortening were calculated. To evaluate left ventricular diastolic function, mitral inflow and pulmonary venous flow profiles were analysed. RESULTS: During pregnancy left ventricular mass increased, fractional shortening decreased and diastolic dysfunction was found. While the healthy pregnant women developed signs of disturbed relaxation during pregnancy, pregnant diabetic women showed signs of a disturbed relaxation at the beginning of gestation. Of the pregnant diabetic women, 29 developed a restrictive filling pattern at the 24th week of gestation. The remaining 22 diabetic women had a comparable restrictive filling pattern only during vaginal delivery. In 10 of the 29 pregnant diabetic women dangerous complications were documented, while there were no complications in the healthy pregnant women and the other 22 diabetic pregnant women. CONCLUSION/INTERPRETATION: In healthy women pregnancy results in a reversible physiologic left ventricular hypertrophy, a disturbed relaxation pattern and a temporary decrease of left ventricular systolic function. In contrast, pregnant diabetic women showed a delayed relaxation at the beginning of pregnancy and developed a restrictive filling pattern. The early development of a restrictive filling pattern could indicate complications during delivery in pregnant diabetic women.

Left ventricular diastolic dysfunction as an early manifestation of diabetic cardiomyopathy.

AIMS/HYPOTHESIS: Early determination of myocardial manifestations of diabetes mellitus is of major importance, since myocardial involvement considerably influences the prognosis of diabetic patients. The aim of this study was to investigate whether young patients with insulin-dependent diabetes mellitus and normal systolic left ventricular (LV) function already show a diastolic LV dysfunction and an increased risk of arrhythmias. METHODS: Echocardiography was performed in 87 patients suffering from type I diabetes mellitus, without known cardiac disease and in 87 controls. Patients with a known manifest cardiac disease or a long-term diabetic syndrome were excluded. Morphological parameters were determined using M-mode echocardiography. Doppler echocardiography was used to evaluate parameters of LV diastolic function. The risk of arrhythmia was assessed by means of electrocardiography, heart rate variability, and late potential analysis. RESULTS: The left atrial and ventricular dimensions and systolic functional parameters of all patients were normal. A diastolic dysfunction with a reduction in early diastolic filling, an increase in atrial filling, an extension of isovolumetric relaxation and deceleration time was documented in diabetic patients, as well as an increased number of supraventricular and ventricular premature beats. CONCLUSION: Even young patients with diabetes mellitus suffer from a diastolic dysfunction while systolic ventricular function is normal. Therefore, echocardiography with measurements of diastolic functional parameters appears to be a sensitive method for evaluating the manifestation and course of early diabetic cardiomyopathy.

Successful thrombolysis of st. Jude medical aortic prosthesis with tissue-type plasminogen activator in a pregnant woman: a case report.

Mechanical valve thrombosis is a life-threatening event. Pregnancy is associated with a hypercoagulable state that further emphasizes the importance of adequate anticoagulation. This is associated with a therapeutic dilemma. Continued anticoagulation with warfarin throughout the first trimester can result in fetopathic effects, while replacement of warfarin by heparin between 6 and 12 weeks of gestation does not completely prevent the risk of valve thrombosis. There are a small number of reported cases of pregnant women with prosthetic heart valve thrombosis under low molecular weight heparin and consecutive lytic therapy. The authors report a 33-year-old pregnant woman with a St. Jude Medical aortic prosthesis, anticoagulated with a therapeutic dosage of low molecular weight heparin from 6 weeks of gestation, who developed prosthetic heart valve thrombosis at 17 weeks of gestation. A thrombolysis with recombinant tissue-type plasminogen activator (50 mg for 2 hours) was performed. Under thrombolysis, ST-segment elevation in leads II, III, aVF, V5, and V6 developed electrocardiographically with a maximal creatine kinase (CK) of 349 U/L (CK-MB isoenzyme of 48 U/L). Echocardiography revealed normal function of the St. Jude Medical aortic prosthesis 2 hours after thrombolysis and normal wall motions. Short-course thrombolytic therapy appears to be an effective alternative to surgical intervention for the treatment of thrombotic dysfunction of valve prostheses in pregnancy.

[Duplex ultrasound determination of shunt volume in iatrogenic arteriovenous fistulas after heart catheterization]. / Duplexsonographische Bestimmung des Shuntvolumens iatrogener arteriovenöser Fisteln nach Herzkatheteruntersuchung.

AIM: To determine the shunt volume of iatrogenic arteriovenous fistula (AVF) following arterial puncture of the groin and to evaluate its impact on natural history and clinical outcome. METHOD: Over a period of 12 months, 22 patients (p) with a newly acquired AVF were followed up. The arteriovenous shunt volume was determined by means of colored duplex- and doppler sonography immediately after diagnosis of AVF. RESULTS: Spontaneous closure of AVF was seen in 10 p (46%) during follow-up examination, whereas 12 p (54%) showed a persistence of their AVF. The median (I50) shunt volume of closed AVF was 310 (250-350) ml/min and 350 (160-510) ml/min for persistent fistulae (p = ns). A shunt volume of > or = 400 ml/min was determined as a significant (p < or = 0.05) cut-off point for prolonged persistence of AVF. CONCLUSION: Because spontaneous closure of AVF was 46% in the course of the first year, conservative management with regular duplex control seems to be justified at least for this duration. Patients with a shunt volume of > or = 400 ml/min have an increased risk of prolonged AVF persistence and therefore should be included in long-term follow-up with special attention to development of hemodynamic relevance.

Comparative evaluation of thermodilution and gated blood pool method for determination of right ventricular ejection fraction at rest and during exercise.

BACKGROUND: Since the development of a Swan-Ganz thermodilution ejection fraction catheter several studies have been published which compare this technique for obtaining right ventricular ejection fraction (RVEF(TD)) with alternative methods. However, the reliability of RVEF(TD) measurements under exercise conditions remains undetermined. Therefore, the aim of the present study was a comparative evaluation of RVEF(TD) with the established gated blood pool method (RVEF(GBP)) under exercise conditions. METHODS AND RESULTS: Twenty-two patients with different cardiac diseases underwent right heart catheterization, including RVEF(TD) and simultaneous RVEF(GBP) determination at rest and during supine bicycle exercise. Linear regression analysis showed a significant correlation between RVEF(TD) and RVEF(GBP) at rest (r = 0.73, p < or = 0.0005) and during exercise (r = 0.74, p < or = 0.0005). A Wilcoxon analysis showed a high probability of agreement of RVEF(TD) and RVEF(GBP) at rest and exercise (level of significance for error of the 0 hypothesis of 95.9/73.3%). CONCLUSION: The thermodilution ejection fraction catheter provides a useful device for reliable, repetitive and safe RVEF measurements, not only at rest but also under exercise conditions. This seems to be clinically important, because by it means RVEF, as a sensitive parameter of primary or secondary right ventricular dysfunction, can be determined in the course of standard right heart catheterization.

[Determination of right ventricular ejection fraction by thermodilution catheter technique during exercise: a comparison with radionuclide ventriculography]. / Bestimmung der rechtsventrikulären Ejektionsfraktion mittels Thermodilutionskatheter unter Belastungsbedingungen. Eine Vergleichstudie zur Radionuklidventrikulographie.

Since the development of a Swan-Ganz Thermodilution Ejection Fraction Catheter, several studies have been published which compare this technique for obtaining right ventricular ejection fraction (RVEFTD) with alternative methods. However, the reliability of RVEFTD measurements under exercise conditions remains undetermined. Therefore, the aim of the present study was to evaluate RVEFTD with the Gated Blood Pool method (RVEFGBP) under exercise conditions. Twenty patients with different cardiac diseases (coronary artery disease, valvular incompetence, cardiomyopathy) underwent right heart catheterization, including RVEFTD and simultaneous RVEFGBP determination at rest and during supine bicycle exercise. Cardiac index at rest-/exercise was 2.9 +/- 0.8/5.7 +/- 2.2 l/min/m2, mean pulmonary artery pressure was 15 +/- 5/25 +/- 8 mmHg, RVEFTD was 38 +/- 6/41 +/- 11% and RVEFRNV was 39 +/- 6/43 +/- 8%. Linear regression analysis showed a significant correlation between RVEFTD and RVEFGBP at rest (r = 0.72, p < or = 0.0005) and during exercise (r = 0.72, p < or = 0.0005). It is concluded that the Thermodilution Ejection Fraction Catheter is a useful device for reliable, repetitive and safe RVEF measurements, not only at rest but also under exercise conditions. This is clinically important, because RVEF, as a sensitive parameter of primary or secondary right ventricular dysfunction, can be determined in the course of standard right heart catheterization.

[Lipoid pneumonia following attempted suicide by intravenous injection of lamp oil]. / Entwicklung einer lipoiden Pneumonie als Folge einer intravenösen Injektion von Lampenöl in suizidaler Absicht.

BACKGROUND: Pneumonic complications after intoxication with mineral oils have been described before in the contents of accidental aspiration and oral ingestion. However, intoxication following an intravenous injection leading to a lipoid pneumonia after an attempted suicide is a rare finding. CASE REPORT: A case report is presented of an attempted suicide by intravenously self-injection of 20 ml lamp oil (liquid paraffin). Immediately after injection the patient suffered from dry coughing which changed in the course of the next hours into a productive cough with white thick mucous sputum accompanied by hemoptysis. Additionally, he developed a mild disseminated intravascular coagulation with a fall of thrombocytes, an INR of 1.6 and a rise of D-dimeres. Under a therapy with hydrocortisone, ascorbic acid, ambroxol, acetylcysteine, heparin, antibiotics and oxygen, the patient improved without the need of mechanical ventilation. Initially seen signs of right heart dilatation diminished 3 days after onset of therapy. Apart from pulmonal manifestation no relevant organ damage was observed. The patient was discharged from the intensive care unit 9 days after intoxication and was submitted to psychiatric therapy. CONCLUSION: Lipoid pneumonia caused by intoxication with a mineral oil is a severe disease, whereas in the presented case a relative bland course of the disease has been seen. The employed therapy in this patient might be encouraging for a comparable treatment of pneumological complications resulting from similar clinical pictures.

Age-related decline of PCr/ATP-ratio in progressively hypertrophied hearts of spontaneously hypertensive rats.

Although the ultimate cause for the myocardial dysfunction of hypertensive heart disease is still unclear, a crucial role of the myocardial energy metabolism has been suggested. Therefore, the aim of the present study was to investigate whether age-related myocardial dysfunction in hearts of spontaneously hypertensive rats (SHR) is associated with an impaired myocardial energy metabolism. Isolated hearts of SHR and Wistar Kyoto rats (WKY) aged about 40, 60, and 80 weeks, respectively (each n = 4-5), were perfused according to the working heart technique. Cardiac work and coronary flow were monitored online. Myocardial energy metabolism was evaluated by calculating the ratio of phosphocreatine (PCr) and adenosine triphosphate (ATP) which were measured by nuclear magnetic resonance (31P-NMR) spectroscopy. All hearts were subjected to work for 30min at baseline conditions (low afterload), followed by another 30min under a moderate pressure load (high afterload). Each SHR group showed a higher heart weight/body weight ratio than the age-matched WKY controls. The SHR showed a progressive age-dependent reduction of cardiac work (40 weeks = 5.1+/-0.3, 60 weeks = 4.0+/-0.3, 80 weeks = 3.8+/-0.2 (mW/g) at baseline conditions) and PCr/ATP-ratio (40 weeks = 1.82+/-0.06, 60 weeks = 1.69+/-0.05, 80 weeks = 1.59+/-0.09 (PCr/ATP) at baseline conditions). Similar results were found for hearts of SHR at high afterload. In WKY no significant decline in cardiac work or PCr/ATP-ratio was found under either low or under high afterload. The cardiac work capacity of hearts of SHR progressively decreases with increasing age and left ventricular hypertrophy. This myocardial dysfunction is closely associated with an impaired PCr/ATP-ratio, suggesting a decreased energy reserve.

Nitric oxide induced contractile dysfunction is related to a reduction in myocardial energy generation.

OBJECTIVE: It has been suggested that nitric oxide (NO) is involved in the regulation of myocardial function in a variety of diseases such as dilated cardiomyopathy, myocarditis, heart transplant rejection, and septic shock. However, the underlying mechanism of NO mediated reduction of cardiac contractility has not been clearly established so far. Therefore, we studied the effects of authentic NO on left ventricular function and myocardial energy status in the isolated heart. METHODS: In 43 isolated perfused guinea pig hearts quantitative and kinetic changes in coronary flow (CF), left ventricular developed pressure (LVDP), the cardiac release of adenosine, lactate, cyclic GMP, and norepinephrine were measured during infusion of authentic NO. In parallel, myocardial phosphocreatine (PCr), ATP and the free energy change of ATP-hydrolysis (delta GATP) were measured using 31P nuclear magnetic resonance spectroscopy. RESULTS: At low concentrations (0.01 to 1.0 mumol/L) NO increased CF only; at higher concentrations (1 to 100 mumols/L) CF remained elevated and LVDP was significantly reduced. Onset and offset of changes in LVDP occurred always within 2 to 5 s after start and cessation of NO infusion. Contractile dysfunction was significantly correlated to a pronounced increase in adenosine formation (> 70-fold), a significant decrease in myocardial PCr (-78%), ATP (-25%) and a decrease in delta G(ATP) from -61.76 kJ/mol to -50.75 kJ/mol. This was paralleled by a significant decrease in myocardial oxygen consumption (-65%) and a tenfold increase in lactate production. Coronary vasodilation (NO: 0.001 to 1.0 mumol/L) significantly correlated with the increase in cGMP release, whereas at negative inotropic concentrations (NO: 10 to 100 mumols/L) a clear quantitative and kinetic dissociation between NO-induced changes in cGMP and LVDP was observed. Contractile dysfunction was not related to cardiac release of norepinephrine. CONCLUSIONS: In the isolated heart NO can potently depress myocardial energy generation thus being an effective modulator of cardiac contractility. This effect of NO may be of pathophysiological significance in cardiac muscle disorders in vivo.