Pulse wave velocity correlates with aortic atherosclerosis assessed with transesophageal echocardiography.

Aortic pulse wave velocity (PWV) is a noninvasive vascular parameter that is related to cardiovascular risk. We studied the relationship between aortic PWV and aortic atherosclerosis assessed with transesophageal echocardiography (TEE). The patients referred for TEE before electrical cardioversion of atrial fibrillation were included in the study. Maximal intima-media thickness (IMT) including maximal atherosclerotic plaque thickness of the descending thoracic aorta was measured on TEE images. PWV was measured in those patients who had the sinus rhythm restored. Univariable linear regression was used to test associations between the parameters studied. Variables identified by linear regression, as significantly related to PWV, were further analyzed by multivariable linear regression models. We studied 99 patients (57 men, 42 women, mean age 70.4±11.5 years). With univariable regression, we found that PWV was significantly related to IMT (P<0.0001), age (P<0.0001) and pulse pressure (PP, P=0.005). There was no significant relationship between PWV and systolic, diastolic and mean blood pressures, as well as heart rate. The multivariable regression analysis, with all the variables significant in the univariable analysis in the model, showed that only IMT remained significantly related to PWV (P<0.0001, ß=0.31), whereas age (P=0.18) and PP (P=0.16) were not. In conclusion, PWV is related to aortic atherosclerosis assessed with TEE independent of age and blood pressure.

Significance of cytomegalovirus infection in the failure of native arteriovenous fistula.

High cytomegalovirus (CMV) IgG levels have been identified as a risk factor for arteriovenous fistula (AVF) failure. None of the 68 patents in our study were CMV IgM positive, although 96% were CMV IgG positive. CMV antigens were detected in the radial artery or cephalic vein of 46% of patients who received an AVF. The presence of CMV antigens or high serum CMV IgG levels had no prognostic value for AVF failure.

Abdominal aortic Doppler waveform in patients with aorto-iliac disease.

OBJECTIVES: The mid-systolic deceleration (notch) in the proximal descending aortic Doppler waveform was reported to be common in patients with aorto-iliac disease. However, evaluation of the descending aorta is limited to echocardiography and may be technically difficult. Therefore, we decided to check whether similar Doppler flow disturbance can be found in abdominal aorta, which is easily evaluated in wider range of patients undergoing general abdominal and vascular ultrasound, as well as echocardiography. METHODS: We evaluated 115 consecutive symptomatic patients with severe peripheral artery disease admitted for vascular surgery, and 60 controls. The presence or absence of the mid-systolic deceleration in the Doppler waveform was evaluated retrospectively, by the single echocardiographer blinded to the localisation of the arterial occlusion or stenosis. RESULTS: The mid-systolic notch in the proximal abdominal aorta was present in 58 of 71 patients (82%) with significant aorto-iliac disease, seven of 44 (16%) patients with occlusion or significant stenosis distally to the external iliac artery (P < 0.001) and in none of the patients from the control group. Sensitivity, specificity and positive predictive value of the mid-systolic notch in the abdominal aortic Doppler waveform in the detection of aorto-iliac disease in patients with peripheral artery disease were 82%, 84% and 89%, respectively. CONCLUSION: The mid-systolic deceleration (notch) in the proximal abdominal Doppler waveform is a simple ultrasonographic marker of significant aorto-iliac disease.

Gas exchange abnormalities in patients listed for liver transplantation.

Abnormalities of pulmonary gas exchange are common in patients with advanced liver disease. Since arterial blood hypoxemia is an important issue in the preoperative evaluation of liver transplant candidates, the study was undertaken to determine the incidence and severity of lung function impairment with a special emphasis on pulmonary gas exchange abnormalities in this group of patients. 104 consecutive patients (47 F and 57 M, mean age 46 +/-11 yr) listed for orthotopic liver transplantation participated in this prospective study. All patients underwent evaluation including: clinical assessment (Child-Pough and MELD classification), chest X-ray, chest sonography, lung function tests, arterial blood gases measurement, and transthoracic contrast enhanced echocardiography. There were 2 patients with acute hepatic failure, 6 patients with primary or metastatic liver carcinoma, and 96 patients with chronic liver disease. The mean PaO(2) and lung function parameters for the entire group were within normal limits. There were 29 hypoxemic patients (PaO(2)< 80 mmHg) and 40 patients with widened (>20 mmHg) P(A-a)O(2). DL(CO) was significantly lower in cirrhotic vs. non-cirrhotic patients (76.5 +/-19.3 vs. 92.4 +/-19.0% predicted; P<0.001). Hepatopulmonary syndrome (HPS) was recognized in 23 (24%) patients. 91% of patients with HPS showed mild to moderate stage of disease. There were significant difference between differences HPS patients and non-HPS patients in DL(CO) (69.0 +/-14.5 vs. 83.5 +/-20.7, P<0.01). In conclusion, all patients referred for OLT should be screened for gas exchange abnormalities. Such a workup should include not only PAO(2) but also DL(CO) and P(A-a)O(2) measurement together with contrast enhanced echocardiography.

Echocardiographic assessment of left ventricular morphology and function in patients with Emery-Dreifuss muscular dystrophy.

BACKGROUND: Emery-Dreifuss muscular dystrophy (EDMD) characterized by musculoskeletal abnormalities is often associated with atrioventricular conduction disturbances. Although some EDMD patients were reported to develop dilated cardiomyopathy, there are limited data on their left ventricular (LV) performance. METHODS: Therefore, we echocardiographically assessed 27 men (23 cases aged 26.4+/-6.8 years with X-linked, and four cases aged 22.2+/-8.6 years with autosomal dominant (AD)) EDMD. Control group included 16 male healthy controls aged 24.8+/-6.0 (18-37) years. RESULTS: Although LV end diastolic dimension was similar in EDMD and controls (4.9+/-0.6 and 4.99+/-1.1 cm, ns), dilated left ventricle was found in three X-linked EDMD subjects. LV ejection fraction was significantly reduced in EDMD (62.3+/-1% vs. 71.2+/-2%, p=0.01) and was below 50% in six (22.2%) X-linked EDMD patients. Doppler analysis disclosed prolonged isovolumetric relaxation time of the left ventricle in the studied group. This finding may indicate impaired LV relaxation. CONCLUSION: A significant subgroup of X-linked EDMD patients shows pronounced abnormalities of left ventricular function. This warrants cardiologic follow up of EDMD patients.

N-terminal pro-brain natriuretic peptide in patients with acute pulmonary embolism.

Plasma brain natriuretic peptide (BNP), released from myocytes of ventricles upon stretch, has been reported to differentiate pulmonary from cardiac dyspnoea. Limited data have shown elevated plasma BNP levels in acute pulmonary embolism (APE), frequently accompanied by dyspnoea and right ventricular (RV) dysfunction. The aim of this study was to assess plasma N-terminal proBNP (NT-proBNP) in APE, and to establish whether it reflects the severity of RV overload and if it can be used to predict adverse clinical outcome. On admission, NT-proBNP and echocardiography for RV overload were performed in 79 APE patients (29 males), aged 63 +/- 16 yrs. Plasma NT-proBNP was elevated in 66 patients (83.5%) and was higher in patients with (median 4,650 pg x mL(-1) (range 61-60,958)) than without RV strain (363 pg x mL(-1) (16-16,329)). RV-to-left ventricular ratio and inferior vena cava dimension correlated with NT-proBNP. All 15 in-hospital deaths and 24 serious adverse events occurred in the group with elevated NT-proBNP, while all 13 (16.5%) patients with normal values had an uncomplicated clinical course. Plasma NT-proBNP predicted in-hospital mortality. Plasma N-terminal pro-brain natriuretic peptide is elevated in the majority of cases of pulmonary embolism resulting in right ventricular overload. Plasma levels reflect the degree of right ventricular overload and may help to predict short-term outcome. Acute pulmonary embolism should be considered in the differential diagnosis of patients with dyspnoea and abnormal levels of brain natriuretic peptide.

Visualization of the central pulmonary arteries by biplane transesophageal echocardiography.

It is suggested that transesophageal echocardiography (TEE), by detecting thromboemboli in the proximal parts of the pulmonary arteries, is useful in the diagnosis of pulmonary embolism. However, the data on visualization of the pulmonary arteries are limited. The extent of the pulmonary arteries that can be precisely visualized during biplane TEE was assessed in 51 consecutive patients (23 female, 28 male, aged 56.6+/-12.5 years) without structural heart disease. The main pulmonary artery and the right pulmonary artery were detected in 96.1% and 94.1% of patients, respectively. Although the proximal part of the left pulmonary artery was found in only 47.0% of patients, its distal part was visualized in 92.2%. During TEE, proximal parts of the lobar arteries on both sides were visualized in 88.2% of patients. Thus, the central pulmonary arteries including proximal parts of the lobar branches can be precisely visualized by biplane TEE in the majority of patients. Only the proximal part of the left pulmonary artery is difficult to assess.

[Transesophageal echocardiography--a method for prompt diagnosis of acute hemodynamically significant pulmonary embolism]. / Echokardiografia przezprzelykowa--metoda szybkiego rozpoznania istotnej hemodynamicznie ostrej zatorowosci plucnej.

UNLABELLED: Patients with acute pulmonary embolism (PE) may require prompt confirmation of PE before aggressive therapy such as embolectomy or thrombolysis. However, emergency availability of routine diagnostic tests often remains a problem. Therefore, we assessed prospectively the diagnostic value of transesophageal echocardiography (TEE), recently reported to be useful in the diagnosis of PE. TEE was performed in 76 consecutive patients (42 F, 34 M) aged 66.7 +/- 15.8 yrs with suspected acute PE with echocardiographic signs of right ventricular pressure overload, but without known coexisting cardiorespiratory diseases. Pulmonary artery thrombi (TH) were visualized at TEE in 69.7% (53) pts. PE was confirmed by high probability lung scintigraphy and/or spiral CT in all these cases. Additionally, PE was diagnosed in 11 others without TEE-reported TH. In the 12 remaining patients PE was eventually excluded (specificity 100%, sensitivity 82.8%). Therefore, TEE in the diagnosis of hemodynamically significant PE reached 100%. No clinically important adverse events were observed during TEE. CONCLUSION: Transesophageal echocardiography is reliable and safe method of prompt confirmation of hemodynamically significant acute pulmonary embolism with relatively high sensitivity in adequately preselected patients. However, due to topographic limitations negative result of TEE does not exclude PE.

Secondary hypertension in the elderly.

This paper discusses the most significant aspects of secondary hypertension in older patients against the background of a rising proportion of elderly in the hypertensive population. Renal artery stenosis and pheochromocytoma are singled out as those causes of secondary hypertension which appear to be related to older age. The available data relevant to epidemiology of these conditions and age-dependent clinical characteristics are reviewed. Preservation of renal function in the elderly with renal artery stenosis is underlined as an important goal of therapy with revascularising techniques. It is proposed that screening for renal artery stenosis and pheochromocytoma may be equally important in the elderly as in the younger hypertensive patient.