Can the hemodynamic model in heart failure be restored based on analysis of ventricular-arterial coupling?

The hemodynamic model was inappropriate to explain the disappointing effect of vasodilation and the beneficial effect of beta-blockade in chronic heart failure. A more nuanced hemodynamic analysis, taking both steady and pulsatile hemodynamics into consideration, improves insight into these apparently enigmatic effects. Of particular interest is the velocity of early systolic flow as a determinant of left ventricular afterload. Several drugs, in particular beta-blockers, directly or indirectly, influence the velocity of early systolic flow. Thus, the hemodynamic model in heart failure may deserve reconsideration.

A 50-year-old man with eosinophilia and cardiomyopathy: need for endomyocardial biopsy?

A 50-year-old man was admitted with a suspected acute coronary syndrome. The coronary angiogram, however, was normal. He was found to have a cardiomyopathy and eosinophilia. The diagnosis was established as a perimyocarditis secondary to the Churg-Strauss syndrome. An important question is whether an endomyocardial biopsy should have been performed.

Heart failure with preserved left ventricular ejection fraction: concepts, misconceptions and future directions.

Heart failure with preserved left ventricular ejection fraction (HFPEF) represents a huge medical problem, especially in light of an increasing elderly population. Dysfunction of both left ventricular filling and ejection, combined with adverse loading conditions related to advanced age, arterial hypertension, diabetes mellitus, obesity and atrial fibrillation are fundamental pathophysiological mechanisms. Hypertension is probably the most important modifiable risk factor. The diagnosis has largely been based on signs of increased left ventricular filling pressure. Additional matters of debate are the interpretation of left ventricular ejection fraction in concentric remodelling and the cut-off used for the definition of HFPEF, as well as inconsistencies related to prevalence and prognosis, and lack of benefit of drugs in randomized trials.

Left ventricular apical rotation is related to ambulatory blood pressure and body mass in healthy elderly females.

OBJECTIVE: The interaction between left ventricular (LV) apical rotation, blood pressure (BP) and body mass in elderly females may reveal mechanisms involved in the syndrome of diastolic heart failure. METHODS: Thirty-one healthy females, age 69-84 years, were studied with echocardiography, ambulatory BP and an exercise capacity (VO2peak) test. RESULTS: LV apical short-axis loops were eligible for speckle tracking analysis in 27 subjects. Peak apical rotation (PAR) correlated inversely with diastolic BP (r = -0.47, p = 0.01). PAR correlated positively with stroke volume and body weight (p<0.05), but not with VO2peak (n = 19, p = ns). PAR also correlated with peak rotation velocity in systole (r = 0.76, p<0.0001) and in diastole (r = 0.58, p = 0.001). Diastolic peak rotation velocity correlated with mitral E wave peak velocity (r = 0.48, p = 0.01). There was a significant reduction in LV volumes during the 4 years of follow-up. CONCLUSIONS: In healthy elderly females, there seems to be an interaction between LV apical rotation, BP and body mass. Peak apical rotation and peak diastolic rotation velocity correlate with indices of LV filling and ejection, indicating that suction, a crucial element for effective early LV filling, may be preserved in healthy elderly subjects. Suction deteriorates with elevations of the arterial BP. An age- and BP-related reduction in LV end-diastolic volume may represent an additional impediment to LV filling. Both features may contribute to the development of LV diastolic dysfunction and to episodes of diastolic heart failure.

[A 50-year old woman with cor triatriatum]. / 50 år gammel kvinne med rask hjerteaksjon.

BACKGROUND: Cor triatriatum is a rare congenital malformation in the heart. A recently published report has indicated that real time transthoracic 3-dimensional echocardiography (3DE) may replace transoesophageal echocardiography (TEE) in the diagnosis of this entity. MATERIAL AND METHODS: A patient with cor triatriatum was examined with 3DE. The results were compared to established echocardiographic methods, inclusive TEE, and to magnetic resonance imaging (MR). RESULTS AND INTERPRETATION: Due to excellent resolution, TEE is still unrivalled in the assessment of some congenital heart diseases such as cor triatriatum. Real time 3DE may have the potential to replace TEE in the future, but refinement of the method is necessary.

Tissue Doppler imaging of the left ventricle in healthy elderly females does not support the concept of "isolated" diastolic dysfunction.

The concept of "isolated" left ventricular diastolic dysfunction has recently been challenged, since left ventricular contraction abnormalities can be demonstrated in subjects with normal left ventricular ejection fraction (EF). In this study of 35 healthy females (aged 65--80 years) with EF>50%, the ratio of peak early transmitral flow velocity to peak early diastolic myocardial velocity (E/Em) correlated significantly with peak systolic myocardial longitudinal velocity (Sm) (r=-0.57, p<0.0001), assessed as an average in six basal left ventricular segments. E/Em correlated also with age (r=0.51, p<0.002), but not significantly with ambulatory daytime systolic blood pressure (r=0.32, p=0.06), nor with left ventricular mass. In conclusion, there is a significant correlation between left ventricular diastolic and systolic function also in an apparently healthy population when adequately sensitive methods are used, in terms of tissue Doppler assessment of the left ventricular longitudinal motion. Although age may influence left ventricular longitudinal motion, an influence of arterial blood pressures is unclear.

Escherichia coli endocarditis of the aortic valve with formation of a paravalvular abscess cavity.

A 42-year-old male with a history of chronic aortic valve disease and urethra stenosis, was admitted with fever, dysuria, and vomiting. Escherichia coli (E. coli) was cultured from blood and urine. Repeated transesophageal echocardiographic studies performed during the early phase of the hospitalization did not exclude the possibility of infective endocarditis. A definite diagnosis was, however, not established until 6 weeks after admission. At that time a large paravalvular aortic abscess cavity had developed and urgent surgery was necessary. A possible explanation for the delayed diagnostic evaluation was the low level of suspicion, as the septicemia was believed to originate from the urinary tract, without involvement of other organs. The possibility of endocarditis due to E. coli should be considered, especially in subjects with underlying cardiac valve disease, despite an alternative source of septicemia and despite the rarity of this condition. Frequent echocardiographic studies are recommended since extensive tissue destruction may occur without any striking symptoms.

[A 34-year-old male presented with fatigue, weight loss, double vision and extra heart sounds]. / 34-årig mann med slapphet, vekttap, dobbeltsyn og bilyd fra hjertet.

BACKGROUND: The diagnosis of culture-negative endocarditis, defined as an active infection of the endocardium in the absence of positive blood cultures, is challenging. MATERIAL AND METHODS: A 34-year-old male presented with persistent fever and negative blood cultures. The echocardiogram showed a bicuspid aortic valve, severe aortic regurgitation, an abscess cavity in the aortic root, and a mass on the anterior leaflet of the mitral valve. The abscess cavity could be visualised only with transoesophageal echocardiography. RESULTS: The diagnosis of infective endocarditis could be established clinically with the Duke criteria. The echocardiographic findings were confirmed at surgery. Cultures of the excised tissue were negative, but histology showed strong evidence of infection. INTERPRETATION: The Duke criteria can be useful in the assessment of a clinical diagnosis in subjects with endocarditis and negative blood cultures. Transoesophageal echocardiography is especially important in this setting.