Left ventricular longitudinal systolic dysfunction is associated with right atrial dyssynchrony in heart failure with preserved ejection fraction

OBJECTIVE

We aimed in this study to assess the role of longitudinal left ventricular (LV) systolic function in heart failure with preserved ejection fraction (HFpEF) in delayed intra- and interatrial conduction time.

METHODS

In 85 consecutive patients with HFpEF (age 60±11 years, ejection fraction [EF] ≥45%), a complete M-mode echocardiographic and tissue Doppler imaging (TDI) study was performed. The times from the onset of the P wave on the ECG to the beginning of the A' wave (PA) from the lateral and septal mitral and tricuspid annuli on TDI were recorded. The difference between these intervals gave the intra- and interatrial dyssynchrony. Based on mitral annular plane systolic excursion (MAPSE), patients were classified as having HFpEF with impaired (MAPSE ≤1.2 cm) or normal (MAPSE >1.2 cm) longitudinal systolic function.

RESULTS

Patients with impaired MAPSE were older (p<0.001), had higher LV mass index (p<0.001), greater left atrial (LA) minimum volume (p=0.007), reduced left atrial EF (p<0.001), higher E/e' ratio (p=0.002), reduced lateral and septal e' wave (p=0.005 and p=0.006, respectively), prolonged tricuspid PA' (p=0.03) and significantly increased right atrial (RA) dyssynchrony (p=0.001) compared with normal MAPSE. MAPSE correlated with RA dyssynchrony (r=-0.40, p<0.001) but not with interatrial and LA dyssynchrony.

CONCLUSION

In patients with HFpEF and impaired MAPSE, RA dyssynchrony is increased, compared to those with normal MAPSE. As patients with RA dyssynchrony are at higher risk for arrhythmia, assessment of this dyssynchrony may help to improve treatment, as well as to predict outcome in these patients.

Early and mid-term outcome in terms of functional and hemodynamic performance of the st. Jude regent 19-mm aortic mechanical prosthesis versus 19-mm carpentier edwards aortic biological prosthesis

BACKGROUND

The aim of the present study is to compare the early and mid-term clinical and hemodynamic results of the aortic valve replacement (AVR) with a St Jude Medical Regent 19-mm prosthesis (SJMR-19) versus Carpentied-Edwars bovine pericardial 19-mm valve (CE-19).

METHODS

Between January 2002 and January 2012, 265 patients (Group I) and 58 patients (Group II) with underwent AVR with a SJMR-19 and CE-19 respectively. There were no significant differences between groups regarding the demographic and preoperative echocardiographic data. Thirty-six patients in Group I and 4 in Group II required annulus enlargement in association or not with septal myectomy. The mean follow-up was 34 ± 18.5 months (range 5-60 months).

RESULTS

There were 14 (5.3 %) hospital deaths in Group I versus 4 (6.8 %) in Group II (p = 0.86). The multivariate logistic regression analysis identified the LVEF ≤ 35 % (p = 0.001), combined operation (p = 0.0005), CPB (p = 0.033), age (p = 0.011), annulus enlargement (p = 0.0009), reoperation (p = 0.039) and chronic renal failure (p = 0.011) as strong predictors for early postoperative death. Within 1 year after surgery peak pulmonary artery pressure, interventricular septal and left ventricular posterior wall thickness decreased significantly in both groups. The M-TPG was 15.7 ± 6.5 mmHg in Group I versus 17 ± 7 mmHg in Group II (p = 0.19). The multivariate regression analysis revealed the annulus enlargement (p = 0.018), small EOAi (p = 0.00004), postoperative LVMi (p = 0.0001) and BSA (p = 0.019) as strong predictors for higher M-TPG. The postoperative LVMi was 119 ± 22.5 gm/m(2) in Group I and 122 ± 22 gm/m(2) in Group II (p = 0.37), significantly lower than the respective preoperative values 162.5 ± 34 gm/m(2) (Group I) and 168 ± 30 gm/m(2) (Group II). The actuarial survival and cumulative free-reoperation actuarial survival at 5 years follow-up were 96.7 and 94.5 % respectively in Group I and 97 and 91 % in Group II.. There were non significant differences between groups regarding the actuarial survival and cumulative free-reoperation survival. The Cox model identified the older age (p = 0.022), LVEF ≤ 35 % (p = 0.009), reoperation (p = 0.018), combined surgery (p = 0.00075) and annulus enlargement (p = 0.033) as strong predictors for poor actuarial free-reoperation survival.

CONCLUSIONS

Both the SJMR-19 and CE-19 offers excellent postoperative clinical and hemodynamic outcome in patients with small aortic annulus. The LV hypertrophy and transvalvular gradients are reduced significantly indenpendently of the employed SJMR-19 or CE-19 prosthesis. Our data support recent suggestions that small valve size does not influence intermediate free-reoperation survival. The CE-19 is an excellent alternative to SJMR-19 in old patients.

Common carotid intima-media features determine distal disease phenotype and vulnerability in asymptomatic patients

OBJECTIVES

There is a growing awareness of the importance of carotid plaque features evaluation in stroke prediction. Carotid intima-media thickness (IMT) and recently its echogenicity were used for stroke prediction, although their clinical relevance was not well determined. The aim of this study was to assess the relationship between common carotid artery (CCA) ultrasound markers of atherosclerosis and distal, bifurcation and internal carotid artery (ICA), plaque features.

METHODS

We analyzed 137 carotid arteries in 87 asymptomatic patients with known carotid disease (mean age 69 ± 6 year, 34.5% females). Intima media thickness (IMT) and its gray scale median (IM-GSM) were measured at the CCA. Plaque textural features including gray scale median (GSM), juxtaluminal black area (JBA-mm(2)) without a visible cap, and plaque coarseness, at bifurcation and ICA were also determined. CCA measurements were correlated with those of the distal plaques.

RESULTS

An increased IMT in CCA correlated with plaque irregularities in the bifurcation and ICA (r=0.53, p<0.001), while IM-GSM was closely related to plaque echogenicity (GSM) (r=0.76, p<0.001), and other textural plaque features. Both, IMT and IM-GSM correlated weakly with stenosis severity (r=0.27, p=0.001 and r=-0.18, p=0.026) respectively.

CONCLUSION

In asymptomatic patients, measurements of CCA reflect distal, bifurcation and ICA disease, with IMT reflecting plaque irregularities and IM-GSM as markers of textural plaque abnormalities. Integrating measurements of both IMT and IM-GSM in a model could be used as a better marker of disease vulnerability over and above each measure individually.

Normal ranges of left ventricular strain in children: a meta-analysis

AIMS

The definition of normal values of two-dimensional speckle-tracking echocardiography derived left ventricular (LV) deformation parameters, is of critical importance for the routine application of this modality in children. The objectives of this study were to perform a meta-analysis of normal ranges for longitudinal, circumferential and radial strain/strain rate values and to identify confounders that may contribute to differences in reported measures.

METHODS AND RESULTS

A systematic search was conducted. Studies describing normal healthy subjects and observational studies that used control groups as a comparison were included. Data were combined using a random-effect model. Effects of demographic, clinical and equipment variables were assessed through meta-regression. The search identified 1,192 subjects form 28 articles. Longitudinal strain (LS) normal mean values varied from -12.9 to -26.5 (mean, -20.5; 95% CI, -20.0 to -21.0). Normal mean values of circumferential strain (CS) varied from -10.5 to -27.0 (mean, -22.06; 95% CI, -21.5 to -22.5). Radial strain (RS) normal mean values varied from 24.9 to 62.1 (mean, 45.4; 95% CI, 43.0 to 47.8). Meta-regression showed LV end diastolic diameter as a significant determinant of variation for LS. Longitudinal systolic strain rate (LSRs) was significantly determined by the age and RS by the type of vendor used.

CONCLUSION

Variations among different normal ranges were dependent on the vendor used, LV end-diastolic diameter and age. Vendor-independent software for analyzing myocardial deformation in children, using images from different vendors would be the ideal solution for strain measurements or else using the same system for patient's follow up.

Ultrasound assessment of carotid plaque echogenicity response to statin therapy: a systematic review and meta-analysis

OBJECTIVE

To evaluate in a systematic review and meta-analysis model the effect of statin therapy on carotid plaque echogenicity assessed by ultrasound.

METHODS

We have systematically searched electronic databases (PubMed, MEDLINE, EMBASE and Cochrane Center Register) up to April, 2015, for studies evaluating the effect of statins on plaque echogenicity. Two researchers independently determined the eligibility of studies evaluating the effect of statin therapy on carotid plaque echogenicity that used ultrasound and grey scale median (GSM) or integrated back scatter (IBS).

RESULTS

Nine out of 580 identified studies including 566 patients' carotid artery data were meta-analyzed for a mean follow up of 7.2 months. A consistent increase in the echogenicity of carotid artery plaques, after statin therapy, was reported. Pooled weighted mean difference % (WMD) on plaque echogenicity after statin therapy was 29% (95% CI 22%-36%), p<0.001, I2=92.1%. In a meta-regression analysis using % mean changes of LDL, HDL and hsCRP as moderators, it was shown that the effects of statins on plaque echogenicity were related to changes in hsCRP, but not to LDL and HDL changes from the baseline. The effect of statins on the plaque was progressive; it showed significance after the first month of treatment, and the echogenicity continued to increase in the following six and 12 months.

CONCLUSIONS

Statin therapy is associated with a favorable increase of carotid plaque echogenicity. This effect seems to be dependent on the period of treatment and hsCRP change from the baseline, independent of changes in LDL and HDL.

Left ventricular response to pressure afterload in children: aortic stenosis and coarctation: a systematic review of the current evidence

Congenital aortic stenosis (CAS) and Coarctation of Aorta (CoA) represent two forms of pressure afterload that affect the left ventricle (LV), hence require regular echocardiographic monitoring. Subclinical dysfunction of the LV exists even in asymptomatic patients with preserved left ventricular ejection fraction (EF), implying low sensitivity of EF in predicting optimum time for intervention. In this article we review patterns of LV myocardial deformation before and after correction of CAS and CoA in infants, children and adolescents, showing their important role in monitoring the course of LV dysfunction. A systematic search using PubMed was performed and suitable studies are presented on a narrative form. Normal EF and/or fractional shortening (FS), with subclinical myocardial dysfunction are reported in all studies before intervention. The short-term results, after intervention, were related to the type of procedure, with no improvement or further deterioration related to surgery but immediate improvement after balloon intervention. Long term follow-up showed further improvement but still subnormal function. Thus correction of CAS and CoA before irreversible LV dysfunction is vital, and requires longitudinal studies in order to identify the most accurate parameter for function prognostication. Until then, conventional echocardiographic parameters together with myocardial velocities and deformation parameters should continue to provide follow-up reproducible measures of ventricular function.

Mortality in heart failure patients

Heart failure (HF) is a clinical syndrome, which is becoming a major public health problem in recent decades, due to its increasing prevalence, especially in the developed countries, mostly due to prolonged lifespan of the general population as well as the increased of HF patients. The HF treatment, particularly, new pharmacological and non-pharmacological agents, has markedly improved clinical outcomes of patients with HF including increased life expectancy and improved quality of life. However, despite the facts that mortality in HF patients has decreased, it still remains unacceptably high. This review of summarizes the evidence to date about the mortality of HF patients. Despite the impressive achievements in the pharmacological and non-pharmacological treatment of HF patients which has undeniably improved the survival of these patients, the mortality still remains high particularly among elderly, male and African-American patients. Patients with HF and reduced ejection fraction have higher mortality rates, most commonly due to cardiovascular causes, compared with patients HF and preserved ejection fraction.

The clinical dilemma of quantifying mechanical left ventricular dyssynchrony for cardiac resynchronization therapy: segmental or global?

Heart failure (HF) represents a serious clinical and public cause of mortality, morbidity, as well as healthcare expenditures. Guidelines for treatment of HF join in recommending multimedical regimen at targeted doses as the best medical strategy, despite that a significant percentage of patients remain symptomatic. Studies have shown that these patients might benefit from cardiac resynchronization therapy (CRT), particularly those presenting with broad QRS duration, >135 msec. Trials have already shown that CRT results in improved morbidity and survival of these patients particularly those in New York Heart Association class III-IV HF, but almost 30% do not show any symptomatic or survival benefit, hence are classified as nonresponders. Exhaustive efforts have been made in using noninvasive methods of assessing left ventricle (LV) dyssynchrony in predicting nonresponders to CRT, including Doppler echocardiography, magnetic resonance imaging, and even single photon emission computed tomography analysis, but only with modest success. In this report, we aimed to review the available evidence for assessing markers of mechanical LV dyssynchrony by various echocardiographic modalities and their respective strength in predicting favorable response to CRT treatment, comparing global with segmental ones. While the accuracy of segmental markers of dyssynchrony in predicting satisfactory response to CRT remains controversial because of various technical limitations, global markers seem easier to measure, reproducible, and potentially accurate in reflecting overall cavity response and its clinical implications. More studies are needed to qualify this proposal.

Combined electrical and global markers of dyssynchrony predict clinical response to cardiac resynchronization therapy

AIM

To assess potential additional value of global left ventricular (LV) dyssynchrony markers in predicting cardiac resynchronization therapy (CRT) response in heart failure (HF) patients.

METHODS

We included 103 HF patients (mean age 67 ± 12 years, 83% male) who fulfilled the guidelines criteria for CRT treatment. All patients had undergone full clinical assessment, NT-proBNP and echocardiographic examination. Global LV dyssynchrony was assessed using total isovolumic time (t-IVT) and Tei index. On the basis of reduction in the NYHA class after CRT, patients were divided into responders and non-responders.

RESULTS

Prolonged t-IVT [0.878 (range, 0.802-0.962), p = 0.005], long QRS duration [0.978 (range, 0.960-0.996), p = 0.02] and high tricuspid regurgitation pressure drop [1.047 (range, 1.001-1.096), p = 0.046] independently predicted response to CRT. A t-IVT ≥ 11.6 s/min was 67% sensitive and 62% specific (AUC 0.69, p = 0.001) in predicting CRT response. Respective values for a QRS ≥ 151 ms were 66% and 62% (AUC 0.65, p = 0.01). Combining the two variables had higher specificity (88%) in predicting CRT response. In atrial fibrillation (AF) patients, only prolonged t-IVT [0.690 (range, 0.509-0.937), p = 0.03] independently predicted CRT response.

CONCLUSION

Combining prolonged t-IVT and the conventionally used broad QRS duration has a significantly higher specificity in identifying patients likely to respond to CRT. Moreover, in AF patients, only prolonged t-IVT independently predicted CRT response.

Left atrial emptying fraction predicts limited exercise performance in heart failure patients

AIM

We aimed in this study to assess the role of left atrial (LA), in addition to left ventricular (LV) indices, in predicting exercise capacity in patients with heart failure (HF).

METHODS

This study included 88 consecutive patients (60 ± 10 years) with stable HF. LV end-diastolic and end-systolic dimensions, ejection fraction (EF), mitral and tricuspid annulus peak systolic excursion (MAPSE and TAPSE), myocardial velocities (s', e' and a'), LA dimensions, LA volume and LA emptying fraction were measured. A 6-min walking test (6-MWT) distance was performed on the same day of the echocardiographic examination.

RESULTS

Patients with limited exercise performance (≤ 300 m) were older (p = 0.01), had higher NYHA functional class (p = 0.004), higher LV mass index (p = 0.003), larger LA (p = 0.002), lower LV EF (p = 0.009), larger LV end-systolic dimension (p = 0.007), higher E/A ratio (p = 0.03), reduced septal MAPSE (p < 0.001), larger LA end-systolic volume (p = 0.03), larger LA end-diastolic volume (p = 0.005) and lower LA emptying fraction (p < 0.001) compared with good performance patients. In multivariate analysis, only the LA emptying fraction [0.944 (0.898-0.993), p = 0.025] independently predicted poor exercise performance. An LA emptying fraction < 60% was 68% sensitive and 73% specific (AUC 0.73, p < 0.001) in predicting poor exercise performance.

CONCLUSION

In heart failure patients, the impaired LA emptying function is the best predictor of poor exercise capacity. This finding highlights the need for routine LA size and function monitoring for better optimization of medical therapy in HF.

Vulnerable plaques in the contralateral carotid arteries in symptomatic patients: a detailed ultrasound analysis

BACKGROUND AND AIM

Carotid plaques may represent a generalized atherosclerotic syndrome or a localized disease. The aim of this study was to assess the morphological and textural features of carotid plaques located contralateral to the symptomatic side and compare them with the symptomatic side and with plaques from asymptomatic patients.

METHODS

We studied 66 arteries in 39 patients (mean age 70 ± 7 year, 33% females). Arterial plaques were classified as either symptomatic (n = 30), contralateral to symptomatic (n = 25) or asymptomatic (n = 11). We compared several plaque features between these groups including the mean values of the grey scale median (GSM), entropy, juxtaluminal black area (JBA) without visible echogenic cap, GSM of the JBA and surface irregularity.

RESULTS

The plaques contralateral to symptomatic arteries had similar morphological and textural features to those in the symptomatic arteries. In contrast, they had more vulnerable morphological and textural features than those in asymptomatic arteries: less smooth plaques (12% vs. 55%) and instead more often mildly irregular (60% vs 36%) or markedly irregular (28% vs. 9%; p = 0.03), lower GSM (26.2 ± 8 vs. 49.4 ± 14, p < 0.001) and lower GSM of the JBA (5.0 ± 3.6 vs. 11.4 ± 2.1, p = 0.008). The frequency of entropy and plaque calcification was similar in all groups.

CONCLUSION

Symptomatic patients with carotid artery disease seem to have similar morphological and textural features of vulnerability in the symptomatic and the contralateral carotid arteries, which are profound compared with asymptomatic carotid arteries. These findings support the concept of generalized carotid atherosclerotic pathology rather than incidental unilateral disease, and also emphasize a need for aggressive measures for plaque stabilization, particularly in symptomatic patients.

Coronary and carotid atherosclerosis: how useful is the imaging?

The recent advancement of imaging modalities has made possible visualization of atherosclerosis disease in all phases of its development. Markers of subclinical atherosclerosis or even the most advanced plaque features are acquired by invasive (IVUS, OCT) and non-invasive imaging modalities (US, MRI, CTA). Determining plaques prone to rupture (vulnerable plaques) might help to identify patients at risk for myocardial infarction or stroke. The most accepted features of plaque vulnerability include: thin cap fibroatheroma, large lipid core, intimal spotty calcification, positive remodeling and intraplaque neovascularizations. Today, research is focusing on finding imaging techniques that are less invasive, less radiation and can detect most of the vulnerable plaque features. While, carotid atherosclerosis can be visualized using noninvasive imaging, such as US, MRI and CT, imaging plaque feature in coronary arteries needs invasive imaging modalities. However, atherosclerosis is a systemic disease with plaque development simultaneously in different arteries and data acquisition in carotid arteries can add useful information for prediction of coronary events.

Gender related predictors of limited exercise capacity in heart failure

AIM

The aim of this study was to investigate the impact of gender on the prediction of limited exercise capacity in heart failure (HF) patients assessed by 6 minute walk test (6-MWT).

METHODS

In 147 HF patients (mean age 61 ± 11 years, 50.3% male), a 6-MWT and a Doppler echocardiographic study were performed in the same day. Conventional cardiac measurements were obtained and global LV dyssynchrony was indirectly assessed using total isovolumic time - t-IVT [in s/min; calculated as: 60 - (total ejection time - total filling time)] and Tei index (t-IVT/ejection time). Patients were divided into two groups according to gender, which were again divided into two subgroups based on the 6-MWT distance (Group I: ≤ 300 m, and Group II: > 300 m).

RESULTS

Female patients were younger (p = 0.02), and had higher left ventricular (LV) ejection fraction - EF (p = 0.007) but with similar 6-MWT distance to male patients (p = 68). Group I male patients had lower hemoglobin level (p = 0.02) and lower EF (p = 0.03), compared with Group II, but none of the clinical or echocardiographic variables differed between groups in female patients. In multivariate analysis, only t-IVT [0.699 (0.552-0.886), p = 0.003], and LV EF [0.908 (0.835-0.987), p = 0.02] in males, and NYHA functional class [4.439 (2.213-16.24), p = 0.02] in females independently predicted poor 6-MWT distance (< 300 m).

CONCLUSION

Despite similar limited exercise capacity, gender determines the pattern of underlying cardiac disturbances; ventricular dysfunction in males and subjective NYHA class in female heart failure patients.

Abnormal systolic and diastolic myocardial function in obese asymptomatic adolescents

Structural and functional cardiac changes are known in obese adults. We aimed to assess the relationship between body mass index (BMI) and cardiac function in overweight and obese asymptomatic adolescents. Ninety three healthy adolescents, aged 12.6 ± 1.2 years, received weight, height, BMI, waist, hips, waist/hips ratio assessment, hematology and biochemistry tests and an echocardiogram. Based on BMI, subjects were divided into: lean (L, n=32), overweight (Ov, n=33) and obese (Ob, n=32). Interventricular septal and LV posterior wall thickness were increased parallel to the BMI (L: 0.84 ± 0.1cm, Ov: 0.88 ± 0.1cm, Ob: 0.96 ± 0.1cm, p<0.001, and L: 0.78 ± 0.1cm, Ov: 0.8 ± 0.1cm, Ob: 0.94 ± 0.1cm, p<0.001, respectively) as were relative wall thickness (RWT) and mass index (LVMI) (L: 0.34 ± 0.05, Ov: 0.34 ± 0.05, Ob: 0.40 ± 0.04, p<0.001, and L: 47.7 ± 8.4 g/m(2), Ov: 51.9 ± 8.3g/m(2), Ob: 65.2 ± 13.3g/m(2), p=0<001, respectively). LV early diastolic (E') lateral and septal velocities (L: 15.3 ± 3.9 cm/s, Ov: 13.6 ± 4 cm/s, Ob: 10.5 ± 3.4 cm/s, p<0.001, and L: 12.2 ± 2.3 cm/s, Ov: 11.1 ± 2.4 cm/s, Ob: 9.8 ± 3.1cm/s, p=0.003, respectively), and systolic (S') velocities (L: 9.2 ± 1.4 cm/s, Ov: 9.3 ± 2.3 cm/s, Ob: 8.04 ± 1.5 cm/s, p=0.018, and L: 9.05 ± 2.3 cm/s, Ov: 9 ± 2.4 cm/s, Ob: 7.6 ± 1.1cm/s, p=0.014, respectively) were all reduced, only in obese adolescents. LV lateral E' (r=-0.44, p<0.001) and S' (r=-0.29, p=0.005) correlated with BMI. In asymptomatic adolescents, LV wall is thicker and diastolic function impaired and correlate with BMI. These findings demonstrate early cardiac functional disturbances which might explain the known obesity risk for cardiac disease.

Coronary and carotid atherosclerosis: similarities and differences

Although a relationship is commonly accepted between coronary and carotid arterial disease, suggesting that atherosclerosis is a systemic condition, the extent of this association and correspondence has not been fully elucidated. This review discusses recent research in this field and highlights areas for future study. The prevalence of severe carotid stenosis increases with prevalence of coronary stenosis, with the latter being found in a significant number of stroke patients, while those with carotid stenosis may be at higher risk of myocardial infarction than stroke. There also appear to be common risk factors (age, diabetes, hypertension, smoking and dyslipidemia), although the effects in both vascular systems may not be identical. Furthermore, while the degree of stenosis in the coronary artery has little ability to predict acute coronary syndrome, which is caused by local thrombosis from a ruptured or eroded plaque, severe carotid stenosis causing hypoperfusion is highly predictive of stroke, although this effect may be time-limited. This apparent difference in event mechanism in the two arteries is interesting as is the difference in the rate of development of collaterals. Overall, the evidence shows that a clear relationship exists between disease in the coronary and carotid arteries, since conventional risk factors and the extent of stenosis and/or previous events emanating from one artery have a strong bearing on the prevalence of events in the other artery. Nevertheless, the exact correspondence between the two arteries is unclear, with sometimes contradictory study results. More research is needed to identify the full extent of risk factors for severe stenosis and cardio- or cerebral vascular events, among which, inflammatory biomarkers such as hs-CRP and prior vascular events are likely to play a key role.

Plasma metalloproteinase-9 and restrictive filling pattern as major predictors of outcome in patients with ischemic cardiomyopathy

OBJECTIVE

Assessment of plasma matrix metalloproteinase-9 (MMP-9) and Doppler markers of increased left ventricular (LV) filling pressure may be added to risk stratify patients with ischemic cardiomyopathy (IC). Therefore, we aimed at investigating the value of plasma MMP-9 and restrictive filling pattern (RFP) in IC patients.

METHODS

Eighty-eight consecutive patients hospitalized for heart failure (LV ejection fraction ≤ 40%) due to IC were enrolled. A complete M-mode and two-dimensional echo-Doppler examination were performed. Patients were defined as having RFP if they had a mitral E wave deceleration time<150 ms. Plasma MMP-9 and N-terminal protype-B natriuretic peptide levels were assessed at the time of the index echocardiogram. The end point was all-cause mortality or hospitalization for worsening HF. Follow-up period was 25 ± 17 months.

RESULTS

Median value of MMP-9 was 714 ng/ml. On univariate analysis, a number of measurements predicted the composite end point: NYHA class>2, RFP, MMP-9>60.5 ng/ml, LV ejection fraction<27%, anemia, pulmonary pressure ≥ 35 mm Hg, N-terminal protype-B natriuretic peptide>1742 pg/ml, and glomerular filtration rate<60 ml/min/1.73 m(2). Independent variables of outcome were anemia (HR=1.9, p=0.031), and the combination of plasma MMP-9 and RFP (HR=3.2, p=0.004). On Kaplan-Meier survival curves, patients with elevated MMP-9 levels and RFP had the lowest event-free survival rate (log-rank: 29.0, p<0.0001). The net reclassification improvement showed a significant increase in the prediction model when elevated MMP-9 and RFP were added to the base model that included clinical, biochemical and echocardiographic parameters (p<0.0001).

CONCLUSION

MMP-9 levels and RFP have an incremental predictive value to risk classify IC patients.

Left ventricular markers of global dyssynchrony predict limited exercise capacity in heart failure, but not in patients with preserved ejection fraction

BACKGROUND

The aim of this study was to prospectively examine echocardiographic parameters that correlate and predict functional capacity assessed by 6 min walk test (6-MWT) in patients with heart failure (HF), irrespective of ejection fraction (EF).

METHODS

In 147 HF patients (mean age 61 ± 11 years, 50.3% male), a 6-MWT and an echo-Doppler study were performed in the same day. Global LV dyssynchrony was indirectly assessed by total isovolumic time - t-IVT [in s/min; calculated as: 60 - (total ejection time + total filling time)], and Tei index (t-IVT/ejection time). Patients were divided into two groups based on the 6-MWT distance (Group I: ≤ 300 m and Group II: >300 m), and also in two groups according to EF (Group A: LVEF ≥ 45% and Group B: LVEF < 45%).

RESULTS

In the cohort of patients as a whole, the 6-MWT correlated with t-IVT (r = -0.49, p < 0.001) and Tei index (r = -0.43, p < 0.001) but not with any of the other clinical or echocardiographic parameters. Group I had lower hemoglobin level (p = 0.02), lower EF (p = 0.003), larger left atrium (p = 0.02), thicker interventricular septum (p = 0.02), lower A wave (p = 0.01) and lateral wall late diastolic myocardial velocity a' (p = 0.047), longer isovolumic relaxation time (r = 0.003) and longer t-IVT (p = 0.03), compared with Group II. In the patients cohort as a whole, only t-IVT ratio [1.257 (1.071-1.476), p = 0.005], LV EF [0.947 (0.903-0.993), p = 0.02], and E/A ratio [0.553 (0.315-0.972), p = 0.04] independently predicted poor 6-MWT performance (<300 m) in multivariate analysis. None of the echocardiographic measurements predicted exercise tolerance in HFpEF.

CONCLUSION

In patients with HF, the limited exercise capacity, assessed by 6-MWT, is related mostly to severity of global LV dyssynchrony, more than EF or raised filling pressures. The lack of exercise predictors in HFpEF reflects its multifactorial pathophysiology.

Prolonged total isovolumic time is related to reduced long-axis functional recovery following valve replacement surgery for severe aortic stenosis

BACKGROUND

The left ventricular (LV) long axis (Lax) function is very sensitive in documenting myocardial abnormalities in aortic stenosis (AS). We hypothesized that Lax recovery after aortic valve replacement (AVR) is related to the extent of cavity dyssynchrony measured by total isovolumic time (t-IVT).

METHODS

A consecutive 107 patients (aged 70 ± 7 years, 70 male) with severe AS and Lax impairment were studied. T-IVT was measured before and after AVR. Reduced Lax function and its post-operative recovery were defined as mitral annular plane systolic excursion (MAPSE) ≦10 mm and an increase of MAPSE >10%, respectively.

RESULTS

LV function improved (EF: 43 ± 8 to 48 ± 10%; MAPSE: 7.9 ± 1.0 to 11.0 ± 2.4 mm) and t-IVT shortened (9.7 ± 3.7 to 7.0 ± 2.8s/min, p<0.01 for all) after AVR. Sixty-five (61%) patients had Lax recovery after a median of 32-month follow-up. Univariate predictors were LV size, LA dimensions, the presence of restrictive LV filling and prolonged t-IVT. Only LV end-systolic dimension, restrictive filling and t-IVT (OR 0.61, 95% CI 0.47-0.79, p<0.01) were independent predictors. A pre-operative t-IVT ≦ 9.3s/min was 81% sensitive and 63% specific in predicting Lax recovery (AUC 0.81, p<0.001). The prevalence of CAD or concomitant CABG were similar in 2 patient groups with different t-IVT.

CONCLUSIONS

Lax recovery was evident in the majority of AS patients after AVR. The lower prevalence of Lax recovery seen in patients with prolonged t-IVT suggests that dyssynchrony may play an important role in the process of adverse LV remodeling.

Independent and incremental value of severely enlarged left atrium in risk stratification of very elderly patients with chronic systolic heart failure

The authors sought to assess the impact on survival of demographic, clinical, and echo-Doppler parameters in patients with chronic heart failure due to left ventricular systolic dysfunction divided according to age groups. This study included 734 patients (age 69±11 years) who were classified into tertiles of age: I (22-66 years), II (67-76 years), and III (77-94 years). Severely enlarged left atrial size was defined as ≥52 mm in men and ≥47 mm in women. Multivariable analysis identified male sex (P=.018) and severely enlarged left atrium (P=.024) as significant correlates of all-cause mortality in the very elderly cohort, while restrictive filling pattern (RFP) (P=.004) and New York Heart Association class III or IV (P=.005) among patients of the first tertile and RFP (P=.028) among patients in the second tertile were independently associated with mortality after 30±21 months of follow-up. At the interactive stepwise model in the very elderly population, a severely enlarged left atrium, added to the model after clinical parameters and ejection fraction, moved the chi-square value from 20.7 to 25.8 (P=.048). RFP emerged as the single best predictor of all-cause mortality in the younger and intermediate ranges, whereas severely enlarged left atrium was the best predictor in the very elderly.

Independent and incremental prognostic value of Doppler-derived left ventricular total isovolumic time in patients with systolic heart failure

BACKGROUND

A prolonged total isovolumic time (T-IVT) has been shown to be associated with worsening survival in patients submitted to coronary artery surgery. However, it is not known whether it has prognostic significance in patients with chronic systolic heart failure (HF).

AIM

To determine the prognostic value of T-IVT in comparison with other clinical, biochemical and echocardiographic variables in patients with chronic systolic HF.

METHODS

Patients (n=107; age 68±12 years, 25% women) with chronic systolic HF, left ventricular ejection fraction (EF)<45%, and sinus rhythm, underwent a complete Doppler echocardiographic study, that included tissue Doppler long axis velocities and total isovolumic time (T-IVT), determined as [60-(total ejection time+total filling time)]. Plasma N-terminal pro-B natriuretic peptide (NT-pro-BNP) was also measured. The associations of dichotomous variables selected according to the Receiver Operator Characteristic analysis were assessed using the Cox proportional hazard model.

RESULTS

Follow-up period was 37±18 months. Multivariate predictors of events were T-IVT≥12.3% s/min, mean E/Em ratio≥10, log NT-pro-BNP levels≥2.47 pg/ml and LV EF≤32.5%. On Kaplan-Meier analysis, patients with prolonged T-IVT, high mean E/Em ratio, increased NT-pro-BNP levels and decreased LV EF had a worse outcome compared with those without. The addition of T-IVT and NT-pro-BNP to conventional clinical and echocardiographic variables significantly improved the chi-square for the prediction of the outcome from 33.1 to 38.0, (P<0.001).

CONCLUSIONS

Prolonged T-IVT added to the prognostic stratification of patients with systolic HF.

Aortic valve replacement normalizes left ventricular twist function

The aim of this study was to assess the effect of aortic valve replacement (AVR) on left ventricular (LV) twist function. We studied 28 severe aortic stenosis (AS) patients with normal LV ejection fraction (EF) before and six months after AVR. LV long axis function was assessed using M-mode and tissue Doppler and twist function using speckle tracking echocardiography. The data were compared with 28 age and sex-matched normal controls. In patients, LVEF remained unchanged after AVR. LV long axis function was reduced before surgery but normalized after AVR. LV twist was increased before (19.7 ± 5.7° vs. 12.9 ± 3.2°, P<0.001) and normalized after AVR (14.4 ± 5.2 °, P < 0.001). In normals, LV twist correlated with LV fractional shortening (r = 0.81, P<0.001) but not with EF. This relationship was reversed in patients before ( r= 0.52, P < 0.01) and after AVR (r = 0.34, P = ns). In patients with severe AS and normal EF, LV twist is exaggerated suggesting potential compensation for the reduced long axis function. These disturbances normalize within six months of AVR but lose their relationship with basal LV function.

Predictors of exercise capacity in patients with chronic heart failure

BACKGROUND

Heart failure is a major and growing societal problem characterized by high mortality, frequent hospitalization, reduced quality of life and a complex therapeutic regimen. The six-minute walking test (6-MWT) may serve as a useful and reproducible test for assessing exercise capacity in heart failure patients and has been suggested as a simple, well-tolerated and inexpensive alternative to cardiopulmonary exercise testing (CPET). The CPET and 6-MWT are the most broadly used for assessing functional limitation in patients with heart failure. Echocardiography is well qualified to meet the growing need for noninvasive imaging in the expanding heart failure population.

METHODS

This study included 132 consecutive patients (61 ± 10 years, 45% women) with stable heart failure. All patients underwent 6-MWT and Doppler echocardiographic examination on the same day. Clinical, biochemical and echocardiographic predictors were analyzed to assess predictors of exercise capacity. Patients were divided into two groups based on the 6-MWT distance. The first group comprised patients with limited exercise performance (≤ 300 m), and the second group, patients with good exercise performance (>300 m).

RESULTS

In univariate analysis, patients' age [0.931 (0.895-0.968), P < 0.001], arterial hypertension [0.481 (0.239-0.967), P = 0.040], blood urea level [0.860 (0.759-0.975), P = 0.019], New York Heart Association (NYHA) class [0.441 (0.245-0.795), P = 0.006], early diastolic E wave [1.014 (1.000-1.029), P = 0.047], total isovolumic time (t-IVT) [0.868 (0.796-0.947), P = 0.001], Tei index [0.112 (0.028-0.450), P = 0.002], and E' of left-ventricular (LV) lateral wall [1.188 (1.099-1.400), P = 0.039] independently predicted poor 6-MWT performance (<300 m). In multivariate analysis, only patients' age [0.948 (0.902-0.996), P = 0.034], arterial hypertension [0.351 (0.133-0.922), P = 0.034], and t-IVT [0.828 (0.725-0.946), P = 0.005] independently predicted poor 6-MWT performance (<300 m).

CONCLUSION

In chronic stable heart failure patients, in addition to age, systemic hypertension as well as LV asynchrony, as reflected by prolonged t-IVT, are independent predictors of poor exercise capacity.

Left ventricular asynchrony and raised filling pressure predict limited exercise performance assessed by 6 minute walk test

BACKGROUND

Six minute walking test (6-MWT) may serve as a reproducible test for assessing exercise capacity in heart failure (HF) patients and can be clinically predicted. We aimed in this study to ascertain if global markers of ventricular asynchrony can predict 6MWT distance in a group of patients with HF and left ventricular (LV) ejection fraction (EF) <45%.

METHODS AND RESULTS

This study included 77 consecutive patients (60 ± 12 years) with stable HF. LV end-diastolic and end-systolic dimensions, shortening fraction (SF), EF, myocardial velocities, t-IVT, and Tei index were measured, as well as 6-MWT distance. Patients with limited exercise performance (≤ 300 m) had lower SF (p = 0.02) and EF (p = 0.017), longer t-IVT (p = 0.001), higher Tei index (p = 0.002) and higher E/E' ratio (p < 0.001) compared with good performance patients. In multivariate analysis, only E/E' ratio [0.800 (0.665-0.961), p = 0.017], and t-IVT [0.769 (0.619-0.955), p = 0.018] independently predicted poor exercise performance.

CONCLUSIONS

In heart failure patients, the higher the filling pressures and the more asynchronous the left ventricle, the poorer is the patient's exercise capacity. These findings highlight specific LV functional disturbances that should be targeted for better optimization of medical and/or electrical therapy.

Left and right ventricular diastolic function in hemodialysis patients

The aim of this prospective study was the assessment of left ventricular and right ventricular diastolic function in patients on hemodialysis (HD) and the correlation of this function with the duration of HD. The study included 42 patients (22 females and 20 males) with chronic renal failure (CRF), treated with HD, and 40 healthy subjects (24 females and 16 males) with no history of cardiovascular disease and with normal renal function, who constituted the control group. The groups were matched for age and sex. All study patients and control subjects underwent detailed history taking and physical examination. They also underwent electrocardiogram, echocardiography and biochemical and hematological blood analyses. Significant differences were noted between the two groups in the two-dimensional and M-mode echocardiography findings concerning aortic root dimension, transverse diameter of the left atrium, thickness of the interventricular septum, thickness of the left ventricular posterior wall, left ventricular diastolic diameter, left ventricular systolic diameter, shortening fraction, ejection fraction as well as findings from the pulse Doppler study, including E wave, A wave, E/A ratio, deceleration time of E wave (DT-E), acceleration time of E wave (AT-E), tricuspid E and A waves (E tr and A tr ) and E tr /A tr , ratio. There were significant changes in HD patients without arterial hypertension as well in the control group subjects. Our study suggests that the left ventricular and left atrial dimensions as well as the left ventricular wall thickness are augmented in patients with CRF treated with HD compared with the control group. Additionally, the left and right ventricular diastolic function is also reduced in these patients. These differences were also noted in patients with CRF without arterial hypertension. Left ventricular diastolic dysfunction had no correlation with the duration of HD.