Chronic mitral regurgitation and Doppler estimation of left ventricular filling pressures in patients with heart failure.

Previous studies relating Doppler parameters and pulmonary capillary wedge pressures (PCWP) typically exclude patients with severe mitral regurgitation (MR). We evaluated the effects of varying degrees of chronic MR on the Doppler estimation of PCWP. PCWP and mitral Doppler profiles were obtained in 88 patients (mean age 55 +/- 8 years) with severe left ventricular (LV) dysfunction (mean ejection fraction 23% +/- 5%). Patients were classified by severity of MR. Patients with severe MR had greater left atrial areas, LV end-diastolic volumes, and mean PCWPs and lower ejection fractions (each P <.01). In patients with mild MR, multiple echocardiographic parameters correlated with PCWP; however, with worsening MR, only deceleration time strongly related to PCWP. From stepwise multivariate analysis, deceleration time was the best independent predictor of PCWP overall, and it was the only predictor in patients with moderate or severe MR. Doppler-derived early mitral deceleration time reliably predicts PCWP in patients with severe LV dysfunction irrespective of degree of MR.

Restrictive left ventricular filling pattern as a strong predictor of depressed baroreflex sensitivity in heart failure.

BACKGROUND: The aim of this study was to test the hypothesis that a restrictive left ventricular diastolic filling pattern, as an index of elevated pulmonary wedge pressure, would predict a depressed baroreflex sensitivity (BRS) in patients with chronic heart failure. METHODS: A total of 189 consecutive patients with an ejection fraction < or = 40% at echocardiography, in sinus rhythm and clinically stable for at least 1 month in oral therapy, underwent clinical examination, echo-Doppler study and the phenylephrine test. RESULTS: The correlations between the NYHA functional class, echo-Doppler variables and BRS were weak, although significant (r ranging from -0.15 to 0.40). However, patients with a deceleration time < 140 ms as an expression of restrictive filling, compared to those with a deceleration time > or = 140 ms, had a lower BRS (3 +/- 4 vs 6 +/- 4 ms/mmHg, p < 0.00001), a lower ejection fraction (20 +/- 6 vs 28 +/- 7%, p < 0.00001), greater left ventricular (end-diastolic volume index 137 +/- 43 vs 113 +/- 45 ml/m2, p < 0.00001) and left atrial dimensions (25 +/- 6 vs 20 +/- 5 cm2, p < 0.00001), more severe mitral regurgitation (3 +/- 1 vs 2.3 +/- 1, p < 0.00001) and were in a higher NYHA class (2.3 +/- 0.6 vs 1.8 +/- 0.5, p < 0.00001). Medications at the time of the study were similar in the two groups. At stepwise regression analysis, the deceleration time emerged as the most powerful independent predictor of a depressed BRS (< 3 ms/mmHg), followed by mitral regurgitation, age, and NYHA class (all data p = 0.0001). CONCLUSIONS: In patients with chronic heart failure, the presence of a restrictive left ventricular filling pattern is highly predictive of autonomic derangement as expressed by low values of BRS.

Accurate noninvasive estimation of pulmonary vascular resistance by Doppler echocardiography in patients with chronic failure heart failure.

OBJECTIVES: This study was undertaken to explore further the relationship between Doppler-derived parameters of pulmonary flow and pulmonary vascular resistance (PVR) and to determine whether PVR could be accurately estimated noninvasively from Doppler flow velocity measurements in patients with chronic heart failure. BACKGROUND: The assessment of PVR is of great importance in the management of patients with heart failure. However, because of the inconclusive and conflicting data available, Doppler estimation of PVR is still considered unreliable. METHODS: Simultaneous Doppler echocardiographic examination and right heart catheterization were performed in 63 consecutive sinus rhythm heart failure patients with severe left ventricular systolic dysfunction. Hemodynamic PVR was calculated with the standard formula. The following Doppler variables on pulmonary flow and tricuspid regurgitation velocity curve were correlated with PVR: maximal systolic flow velocity, pre-ejection period (PEP), acceleration time (AcT), ejection time, total systolic time (TT), velocity time integral, and right atrium-ventricular gradient. RESULTS: At univariate analysis, all variables except maximal systolic flow velocity and velocity time integral showed a significant, although weak, correlation with PVR. The best correlation found was between AcT and PVR (r = -0.68). By regression analysis, only PEP, AcT and TT entered into the final equation, with a cumulative r = 0.87. When the function (PEP/AcT)/TT was correlated with PVR, the correlation coefficient further improved to 0.96. Of note, this function prospectively predicted PVR (r = 0.94) after effective unloading manipulations. CONCLUSIONS: The analysis of Doppler-derived pulmonary systolic flow is a reliable and accurate tool for estimating and monitoring PVR in patients with chronic heart failure due to left ventricular systolic dysfunction.

[Non-invasive evaluation of the hemodynamic profile in patients with heart failure: estimation of right atrial pressure]. / Valutazione non invasiva del profilo emodinamico nel paziente con scompenso cardiaco: stima della pressione atriale destra.

The estimation of right atrial pressure is often needed for the diagnosis, management and monitoring of various pathologic hemodynamic conditions and plays a significant role in patients with chronic heart failure. In the past decade several attempts have been made to non-invasively estimate right atrial pressure, and echocardiography has always been considered the most reliable tool. Morphologic parameters such as respiratory motion of the inferior vena cava, its respiratory diameters and percent collapse (caval index), left hepatic vein diameter or right atrial dimension (areas, volumes) were initially studied. More recently, functional data such as left hepatic or tricuspid flow variables have been considered. Some of these indexes, however, offer only semiquantitative measures of right atrial pressure, and have failed to demonstrate any prognostic value. Others, although highly sensitive and specific, are useful only in selected groups of patients because of technical or clinical limitations. In recent years, attention has focused on Doppler diastolic tricuspid flow as a means of predicting mean right atrial pressure. Analyzing the Doppler tricuspid velocity profile and mean right atrial pressure (Swan-Ganz catheter) simultaneously recorded in patients with severe left ventricular systolic dysfunction and chronic heart failure, acceleration rate of early filling emerged as the strongest independent predictor of right atrial pressure both in patients in sinus rhythm and in those with atrial fibrillation (r = 0.98), irrespective of whether the recordings are at baseline or after acute loading manipulations.

Doppler-derived acceleration rate of right ventricular early filling reliably predicts mean right atrial pressure at baseline and after loading manipulations in patients with chronic heart failure.

BACKGROUND: We investigated whether Doppler-derived variables of tricuspid flow could estimate mean right atrial pressure and monitor its changes after loading manipulations in patients with chronic heart failure. METHODS: Simultaneous mean right atrial pressure (Swan-Ganz catheterization) and tricuspid Doppler recordings were initially evaluated in 136 patients (23 with atrial fibrillation) with chronic heart failure and severe left ventricular systolic dysfunction, and then were repeated in 18 patients after unloading (sodium nitroprusside infusion) and in 13 patients after overloading (active leg elevation) manipulations. RESULTS: A significant correlation was observed between mean right atrial pressure and peak E velocity (r = 0.70), early deceleration time (r = -0.72) and acceleration time (r = -0.75). However, the best correlation found was between the acceleration rate of early flow and mean right atrial pressure, and it was identical in patients in sinus rhythm or with atrial fibrillation (r = 0.98). Moreover, after acute effective unloading or overloading manipulations, although all Doppler tricuspid variables changed significantly, the acceleration rate of early flow still emerged as the strongest independent predictor of mean right atrial pressure (r = 0.95 and 0.99, respectively). CONCLUSIONS: Doppler-derived acceleration rate of early diastolic tricuspid flow is a powerful tool to predict mean right atrial pressure and to monitor its changes after loading manipulations.

Estimation of pulmonary wedge pressure by transmitral Doppler in patients with chronic heart failure and atrial fibrillation.

Previous studies have demonstrated that left ventricular (LV) filling pressures can be estimated from transmitral Doppler recording in patients in sinus rhythm who have a broad spectrum of cardiac diseases. However, the correlation between pulmonary wedge pressure (PWP) and mitral Doppler profile has not yet been clearly defined in patients with atrial fibrillation, particularly in the presence of severe LV systolic dysfunction. The aim of this study was to evaluate the correlations between PWP and transmitral Doppler variables in patients with atrial fibrillation and chronic heart failure due to dilated cardiomyopathy. PWP and the mitral Doppler profile were simultaneously recorded in 35 consecutive heart failure patients (28 men, 7 women; mean age, 69 +/- 9 years) with severe LV dysfunction (mean ejection fraction 22% +/- 5%). Doppler measurements were averaged over 10 cardiac cycles. In addition, left atrial areas were derived from the apical 4-chamber view. Significant relations were observed between PWP and several parameters derived from the mitral flow: isovolumic relaxation time (r = -70), acceleration rate (r = 0.78), deceleration rate (r = 0.82), and deceleration time (r = -0.95). However, by stepwise multivariate analysis, deceleration time emerged as the sole independent predictor of PWP (r2 = 0.95, F = 590). The analysis led to the following equation: PWP = 51 - 0.26 (deceleration time). Our data suggest that mitral Doppler echocardiography is a useful tool for predicting PWP in heart failure patients with severe LV dysfunction even in the presence of atrial fibrillation.

Reversible restrictive left ventricular diastolic filling with optimized oral therapy predicts a more favorable prognosis in patients with chronic heart failure.

OBJECTIVES: We sought to assess whether in clinically stable patients with chronic heart failure (CHF) the prolongation (i.e., increase) of an initially short (< or = 125 ms) Doppler transmitral deceleration time (DT) of early filling obtained with long-term optimal oral therapy predicts a more favorable prognosis. BACKGROUND: It has been recently demonstrated that transmitral early DT is a powerful independent predictor of poor prognosis in patients with left ventricular dysfunction. However, DT may change over time according to loading conditions and medical treatment. METHOD: One hundred forty-four patients with CHF and a short DT (< or = 125 ms) underwent repeat Doppler echocardiographic study 6 months after the initial examination, while clinically stable with optimal oral therapy, and were then followed up for a mean period of 26 +/- 7 months. RESULTS: After 6 months, DT had not changed in 80 patients (group 1), whereas it was significantly prolonged (> 125 ms) in the remaining 64 patients (group 2). Baseline Doppler echocardiographic features were similar in the two groups. No changes were found after 6 months in group 1, whereas group 2 showed a slight but significant (p < 0.01) reduction in end-systolic volume, an improvement in left ventricular ejection fraction (p < 0.01) and a decrease (p < 0.01) in the degree of tricuspid regurgitation. During follow-up, 37% of patients in group 1 experienced cardiac death versus 11% in group 2 (p < 0.0005). By Cox model analysis, prolongation of a short DT emerged as the single best predictor of survival (chi-square 15.70). CONCLUSIONS: The prolongation of an initially short DT obtained with long-term optimal oral therapy predicts a more favorable outcome in clinically stable patients with CHF.

Doppler-derived acceleration rate of right ventricular early filling as a measurement of right atrial pressure in chronic heart failure secondary to ischemic or idiopathic dilated cardiomyopathy.

This study demonstrates that a Doppler-derived tricuspid flow velocity pattern provides an accurate, feasible, and noninvasive method of estimating and monitoring mean right atrial pressure in patients with heart failure due to left ventricular systolic dysfunction, and who are both in sinus rhythm and atrial fibrillation. In particular, the acceleration rate of early right ventricular filling is a powerful and independent predictor of mean right atrial pressure.

[A paradigmatic case of partial agenesis of the pericardium]. / Un caso paradigmatico di agenesia parziale del pericardio.

Complete or partial absence of the pericardium is an uncommon congenital abnormality. Since its first description, several cases have been reported. Although the clinical and instrumental features of this defect are well described, at present it is often overlooked. We report a case of a 19-year old boy referred to our Echocardiography laboratory because of a suspected interatrial septal defect. For this reason it has been recommended to undergo cardiac catheterization. The patient, completely asymptomatic, had a negative physical examination. The echocardiogram excluded the presence of an interatrial septal defect, but some abnormalities, regarding overall right-sided heart, were found (paradoxical interventricular septal movement, apparent right-sided heart enlargement, with unusual bulging of the apex of the right ventricle, an excessive basculant heart movement). In the absence of any other heart disease, we thought that these abnormalities reflected a congenital absence of the pericardium. Indeed, the chest X-ray showed some features, considered patognomonic for congenital absence of the pericardium (levoposition of the heart, lung interposition between the diaphragm and the base of the heart and between the aorta and pulmonary artery). Nuclear magnetic resonance study showed the absence of the pericardium in the posterior and posterolateral wall, confirming our suspicion. Furthermore, the posterior wall of the heart leaned to herniate through the pericardial defect. Since the partial absence of the pericardium can lead to severe complications, surgery was recommended. The correct diagnosis of this disease is very important because of its prognostic implications; this case represents a further contribution to the understanding of this defect.

[Estimate of lung capillary pressure and identification of the "pseudonormal" transmitral flow pattern in patients with severe systolic dysfunction of the left ventricle]. / Stima della pressione capillare polmonare ed identificazione del pattern di flusso transmitralico "pseudonormale" in pazienti con severa disfunzione sistolica del ventricolo sinistro.

OBJECTIVES: Aim of this study was to investigate whether Doppler-derived transmitral flow velocity variables would allow a reliable estimate of pulmonary capillary wedge pressure in patients with left ventricular systolic dysfunction and normal mitral flow velocity pattern, and would then predict the presence of a "pseudonormal" transmitral flow velocity profile. BACKGROUND: Abnormal relaxation and increased chamber stiffness have opposing effects on the left ventricular filling pattern. When both abnormalities are present at the same time, as often occurs in patients with systolic dysfunction, the mitral pattern may appear to be normal: in this case the ability of Doppler recording to assess diastolic function and predict left ventricular filling pressure may be significantly compromised. METHOD: Pulmonary capillary wedge pressure (PWP) and Doppler transmitral flow velocity profile were simultaneously recorded in 70 postinfarction patients with ejection fraction < or = 35% and mitral flow velocity pattern apparently normal (E/A ratio between 1 and 2). Doppler traces were analyzed using a microcomputer-based digitizing system, and the following variables were measured: peak flow velocity in early diastole (E) and during atrial contraction (A), peak E/A wave velocity ratio and the deceleration time (Dec T) of early diastolic flow. RESULTS: Mean E/A ratio was 1.3 +/- 0.2 and mean PWP was 17 +/- 7 mm Hg. Forty-two patients had a PWP < 20 mm Hg and the remaining 28 patients (40%) had PWP > or = 20 mm Hg. Peak E, peak A and E/A ratio were similar in the two groups, whereas Dec T was significantly (p < 0.001) lower in patients with > or = 20 mm Hg PWP (93 +/- 15 vs 146 +/- 19 msec). A very weak correlation was found between PWP and both E and A velocity (r = 0.14 and r = 0.09, respectively). Furthermore, no correlation was found between E/A ratio and PWP (r = 0.08). Conversely, a very close negative correlation was observed between Dec T of early filling and PWP (r = -0.96). Sensitivity and specificity of < or = 120 ms in Dec T in predicting > or = 20 mm Hg in PWP were 100% and 99%, respectively. CONCLUSIONS: These data point out the relevant role of Doppler-derived deceleration time of early diastole in predicting left ventricular filling pressure. In patients with left ventricular systolic dysfunction an apparently normal diastolic filling pattern is often associated with elevated PWP. Through the estimate of increased PWP, early deceleration time seems to provide an important means of differentiating a real normal from a pseudonormal or masked abnormal filling pattern caused by increased left ventricular filling pressure.

Doppler-derived mitral deceleration time of early filling as a strong predictor of pulmonary capillary wedge pressure in postinfarction patients with left ventricular systolic dysfunction.

OBJECTIVES: The aim of this study was to investigate the correlations between Doppler-derived transmitral flow velocity variables and pulmonary capillary wedge pressure in patients with severe left ventricular systolic dysfunction. BACKGROUND: Abnormal relaxation and increased chamber stiffness have opposing effects on the left ventricular filling pattern. When both abnormalities are present at the same time, as often occurs in patients with systolic dysfunction, the ability of Doppler recording to assess diastolic function and predict left ventricular filling pressure may be significantly compromised. METHOD: Pulmonary capillary wedge pressure and Doppler transmitral flow velocity profile were simultaneously recorded in 140 postinfarction patients with ejection fraction < or = 35%. RESULTS: Correlation between the ratio of mitral peak flow velocity in early diastole to peak flow velocity in late diastole (E/A ratio) and pulmonary capillary wedge pressure was weak (r = 0.65). Although the specificity of E/A > or = 2 in predicting > or = 20 mm Hg in pulmonary capillary wedge pressure was high (99%), its sensitivity was low (43%). Conversely, a very close negative correlation was found between mitral deceleration time of early filling and pulmonary capillary wedge pressure (r = -0.90). Sensitivity and specificity of < or = 120 ms in deceleration time in predicting > or = 20 mm Hg in pulmonary capillary wedge pressure were 100% and 99%, respectively. CONCLUSIONS: Doppler-derived mitral deceleration time of early filling provides a simple and accurate means of estimating pulmonary capillary wedge pressure that is particularly useful in patients with a normal or normalized mitral flow velocity pattern.

[Correlation between the sites of mitral annular calcification and conduction disturbances: echocardiographic evaluation]. / Correlazione tra sede della calcificazione dell'anello mitralico e disturbi della conduzione: valutazione ecocardiografica.

A clinical, electrocardiographic and echocardiographic (M-Mode, 2D) study was performed to explain the causal relationship between mitral annular calcification and cardiac conduction disturbances. Forty-seven patients, 28 women and 19 men (mean age 69) with mitral annular calcification were studied. In 18 patients A-V and/or intraventricular conduction disturbances were present. In this study we have found: a greater incidence of posterior than anterior mitral annular calcification; the anterior mitral annular calcification is often associated with aortic valve calcification and ultimately the common association between anterior mitral annular calcification and conduction disturbances.

Histological characteristics of the human testis after long-term treatment with cyproterone acetate.

Cyproterone acetate, an antiandrogen drug, is used to reduce mammalian fertility. Effects on the human testis are controversial. Findings in this study reveal that long-term treatment-7 months with 200 mg/day-leads to disappearance of the germinal cells and to Sertoli cells with either a normal or undifferentiated aspect as well as involution of the Leydig cell. Some pathogenetic hypotheses on the action of cyproterone acetate upon human spermatogenesis are discussed.