Enhanced external counterpulsation in the treatment of chronic refractory angina: a long-term follow-up outcome from the International Enhanced External Counterpulsation Patient Registry

BACKGROUND

The management of patients who suffer from medically refractory angina and are unsuitable for conventional revascularization therapy is often unsatisfactory. Enhanced external counterpulsation (EECP) is a noninvasive treatment that is safe and effective immediately after a course of treatment. However, the duration of benefit is less certain.

HYPOTHESIS

To evaluate the 3-year outcome of EECP treatment.

METHODS

One thousand four hundred and twenty seven patients from 36 centers registered in the International EECP Patient Registry (IEPR)-Phase 1 was prospectively followed for a median of 37 months. Two hundred and twenty patients (15.4%) died, while 1,061 patients (74.4%) completed their follow-up.

RESULTS

The mean age was 66+/-11 years and 72% were men. Seventy-six percent had multivessel coronary disease for 11+/-8 years. Eighty-eight percent had a prior percutaneous or surgical revascularization and 82% were unsuitable for further coronary intervention. Immediately post-EECP, the proportion of patients with severe angina (Canadian Cardiovascular Angina Classification [CCS] III/IV) were reduced from 89% to 25%, p<0.001. The CCS class was improved by at least 1 class in 78% of the patients and by at least 2 classes in 38%. This was sustained in 74% of the patients during follow-up.Thirty-six percent of the patients had CCS II or less angina, which was better than pre-EECP state without a major adverse cardiovascular event during follow-up. More severe baseline angina and a history of heart failure or diabetes were independent predictors of unfavorable outcome.

CONCLUSION

An EECP improves angina and quality of life immediately after a course of treatment. For most of the patients, these beneficial effects are sustained for 3 years.

The associations between tricuspid annular plane systolic excursion (TAPSE), ventricular dyssynchrony, and ventricular interaction in heart failure patients

AIMS

Ventricular interactions may be mediated by loading conditions and biventricular timing and coordination. We sought to understand the relationships between right (RV) and left ventricular (LV) function and dyssynchrony, examine the RV correlates of LV dyssynchrony, and determine whether improved loading conditions affect inter-ventricular interaction.

METHODS AND RESULTS

In 25 heart failure patients [15 with left ventricular ejection fraction (LVEF) < 40%; 10 with LVEF >/= 50%], Doppler echocardiography and invasive bi-ventricular pressure-volume haemodynamics were obtained at baseline and 30 min after infusion of the recombinant B-type natriuretic peptide vasodilator nesiritide. RV and LV intra-ventricular dyssynchrony was measured invasively using a pressure-conductance catheter. Patients with reduced LVEF had greater LV dyssynchrony (31 +/- 3 vs. 24 +/- 7%; P = 0.003) compared to those with preserved LVEF. Tricuspid annular plane systolic excursion (TAPSE) had the highest correlation with LV dyssynchrony (r = -0.52; P = 0.0002) compared to other RV echocardiographic parameters. The association between TAPSE and LV dyssynchrony was independent of RVEF and LVEF (P = 0.008). There were no acute changes in the correlations between LV dyssynchrony and TAPSE after nesiritide.

CONCLUSION

TAPSE and LV dyssynchrony are strongly associated, independent of RV and LV ejection fraction. Of the RV echocardiographic parameters, TAPSE has the highest predictive value of LV dyssynchrony, and remained significant after vasodilator unloading.

Stent fracture following stenting of a myocardial bridge: report of two cases

Myocardial bridge is the most common congenital coronary anomaly. Patients with this anomaly are usually asymptomatic, but it may cause myocardial ischemia that may lead to myocardial infarction. Treatment for myocardial bridge remains controversial. Current recommendations include medical therapy, surgical treatment (unroofing myotomy), coronary artery bypass, and percutaneous coronary stenting. We report two cases of stent fracture following stenting of a myocardial bridge. The risk of stent fracture leading to restenosis and/or stent thrombosis should be considered when assessing the risks and benefits of coronary revascularization of a myocardial bridge.

Physiology of the Third Heart Sound: Novel Insights from Tissue Doppler Imaging

BACKGROUND

The third heart sound (S(3)) is thought to be caused by the abrupt deceleration of left ventricular (LV) inflow during early diastole, increased LV filling pressures, and decreased LV compliance. We sought to determine whether the ratio of early mitral inflow velocity to diastolic velocity of the mitral annulus (E/E') could confirm the proposed mechanism of the S(3).

METHODS

A total of 90 subjects underwent phonocardiography, echocardiography, tissue Doppler imaging, and left-sided heart catheterization.

RESULTS

Phonocardiography detected an S(3) in 21 patients (23%). Subjects with an S(3) had lower ejection fraction (P = .0006) and increased E deceleration rate (P < .0001), E/E' (P < .0001) and filling pressures (P < .0001). The phonocardiographic S(3) confidence score correlated with E/E' (r = 0.46; P < .0001) and E deceleration rate (r = 0.43, P = .0001). Of the echocardiographic variables, only E/E' was independently associated with the S(3) confidence score (P = .009), independently of invasively determined LV filling pressures (P = .001).

CONCLUSIONS

The most important determinants of the pathologic S(3) are an increased deceleration rate of early mitral inflow, elevated LV filling pressures, and abnormal compliance of the myocardium as measured by tissue Doppler imaging.

Hemodynamic rounds series: Left heart catheterization and mitral balloon valvuloplasty in a patient with a mechanical aortic valve

Patients with rheumatic heart disease and a history of mechanical aortic valve replacement will occasionally present with significant mitral stenosis for consideration of mitral balloon valvuloplasty. The conventional retrograde trans-aortic method for left heart catheterization cannot be done for patients with a mechanical aortic valve. We present a patient with a mechanical aortic valve who underwent successful left heart catheterization and mitral valvuloplasty via a transseptal approach. A 5 French pigtail catheter was advanced through the left atrial 8 French Mullins sheath into the left ventricle, for simultaneous pressure measurement across the mitral valve. This manuscript discusses the strengths and weaknesses of several approaches for left heart catheterization in patients with a mechanical aortic valve.

The effects of enhanced external counterpulsation on time- and frequency-domain measures of heart rate variability

BACKGROUND AND PURPOSE

We hypothesized that symptom improvement from enhanced external counterpulsation (EECP) is related to improved heart rate variability (HRV).

METHODS

This prospective, multicenter study enrolled 27 patients with angina who underwent 48-hour ambulatory electrocardiogram monitoring at baseline, immediately after 35 hours of EECP, and at 1 month. Primary end points included change in time-domain (SD of normal-to-normal intervals) and frequency-domain HRV.

RESULTS

Twenty-four patients completed the full course of EECP therapy and 3 ambulatory electrocardiograms. There were no significant changes in time-domain HRV measures after EECP. Patients younger than 65 years and those with heart failure had improved SD of normal-to-normal interval after EECP (P = .02). Although frequency-domain HRV measures did not change in the overall cohort, patients with diabetes had improved daytime low-frequency power (P = .016).

CONCLUSIONS

There was no significant change in the time- or frequency-domain HRV measures after EECP. In diabetic individuals, there was an increase in low-frequency HRV, which has been associated with reduced mortality.

Computerized acoustic cardiographic insights into the pericardial knock in constrictive pericarditis

BACKGROUND

One of the clinical hallmarks of constrictive pericarditis is the pericardial knock, a high-pitched early diastolic heart sound. Making the clinical diagnosis of constrictive pericarditis is challenging, as is accurate auscultation of the pericardial knock.

HYPOTHESIS

We sought to assess the utility of a computerized acoustic cardiographic device in the assessment of the pericardial knock in patients with constrictive pericarditis.

METHODS

We report a case series in which computerized acoustic cardiography (Audicor, Inovise Medical Inc., Portland, OR) is performed in patients with constrictive pericarditis.

RESULTS

Three patients with constrictive pericarditis underwent computerized acoustic cardiographic recordings at the time of cardiac catheterization. In each case, initial physical examination by the internist and referring cardiologist did not appreciate a pericardial knock. Acoustic cardiography demonstrated a high-pitched early diastolic sound in each case. Time-frequency representation analyses showed the high-frequency components of the pericardial knock sound. Repeat acoustic cardiography demonstrated resolution of the pericardial knock after pericardiectomy in two patients.

CONCLUSIONS

Non-invasive computerized acoustic cardiography can demonstrate the high-pitched pericardial knock in patients with constrictive pericarditis. This may aid the bedside assessment of patients with diastolic heart failure, improving the clinician's ability to appreciate the ausculatory findings in constrictive pericarditis.

Residual high-grade angina after enhanced external counterpulsation therapy

OBJECTIVE

We evaluated the degree of residual angina on the outcomes of enhanced external counterpulsation (EECP) therapy for chronic stable angina.

BACKGROUND

Angina refractory to medical therapy is common in the pool of patients who are not completely revascularized by angioplasty or bypass surgery.

METHODS

We examined 902 patients enrolled from 1998 to 2001 in the Second International Enhanced External Counterpulsation Patient Registry. Baseline and outcome variables were stratified by the last recorded Canadian Cardiovascular Society class.

RESULTS

Residual Class 3 (12.1%) or 4 (2.3%) angina was uncommon among patients with severe coronary artery disease after treatment with EECP. Prevalence of diabetes, hypertension, dyslipidemia, and heart failure was similar among the anginal post-EECP anginal classes. Multivessel coronary disease was more common in those with higher-grade angina at completion. More frequent and severe angina at entry was more common in those with the higher anginal classes at EECP (P<.001). There were no differences in the rates of chronic medications utilized or prior revascularization. At 3-year follow-up, rates of death, myocardial infarction, percutaneous coronary intervention, and coronary artery bypass surgery tended to be higher across increasing residual angina classes. The composite cardiac event rates were 34%, 33%, and 44% for those with Class 0, Class 1/2, and Class 3/4 angina at EECP completion (P=.01), respectively. Multivariate analysis for the composite endpoint found residual Class 3/4 angina (OR=1.59, 95% CI=1.19-2.17, P=.002), diabetes (OR=1.57, 95% CI=1.23-2.01, P=.0003), age (per decile OR=1.17, 95% CI=1.04-1.31, P=.007), and greater EECP augmentation (OR=0.79, 95% CI=0.65-0.96, P=.02) as significant predictors.

CONCLUSIONS

Residual high-grade angina after EECP occurs in those with more severe angina and multivessel disease at baseline and is associated with cardiac events over the next 3 years. These data suggest that close clinical observation and intensive management of those with high-grade angina post-EECP are warranted.

Effect of chronic sustained-release dipyridamole on myocardial blood flow and left ventricular function in patients with ischemic cardiomyopathy

Dipyridamole increases adenosine levels and augments coronary collateralization in patients with coronary ischemia. This pilot study tested whether a 6-month course of sustained-release dipyridamole/aspirin improves coronary flow reserve and left ventricular systolic function in patients with ischemic cardiomyopathy. Six outpatients with coronary artery disease and left ventricular ejection fraction (LVEF) <40% were treated with sustained-release dipyridamole 200 mg/aspirin 25 mg twice daily for 6 months. Myocardial function and perfusion, including coronary sinus flow at rest and during intravenous dipyridamole-induced hyperemia, were measured using velocity-encoded cine magnetic resonance stress perfusion studies at baseline, 3 months, and 6 months. There was no change in heart failure or angina class at 6 months. LVEF increased by 39%+/-64% (31.0%+/-13.3% at baseline vs 38.3%+/-10.7% at 6 months; P=.01), hyperemic coronary sinus flow increased more than 2-fold (219.6+/-121.3 mL/min vs 509.4+/-349.3 mL/min; P=.01), and stress-induced relative myocardial perfusion increased by 35%+/-13% (9.4%+/-3.4% vs 13.9%+/-8.5%; P=.004). Sustained-release dipyridamole improved hyperemic myocardial blood flow and left ventricular systolic function in patients with ischemic cardiomyopathy.

Performance of phonoelectrocardiographic left ventricular systolic time intervals and B-type natriuretic peptide levels in the diagnosis of left ventricular dysfunction

BACKGROUND

Systolic time intervals measured by echocardiography and carotid artery tracings are validated methods of assessing left ventricular function. However, the clinical utility of phonoelectrocardiographic systolic time intervals for predicting heart failure using newer technology has not been evaluated.

METHODS

We enrolled 100 adult patients undergoing left heart catheterization. Participants underwent computerized phonoelectrocardiographic analysis, left ventricular end-diastolic pressure (LVEDP) measurement, transthoracic echocardiographic measurement of left ventricular ejection fraction (LVEF), and B-type natriuretic peptide (BNP) testing. The heart rate-adjusted systolic time intervals included the time from the Q wave onset to peak S1 (electromechanical activation time, EMAT), Q wave onset to peak S2 (electromechanical systole, Q-S2), and peak S1 to peak S2 (left ventricular systolic time, LVST). Left ventricular dysfunction was defined as the presence of both LVEDP >15 mmHg and LVEF <50%.

RESULTS

EMAT (r =-0.51; P < 0.0001), EMAT/LVST (r =-0.41; P = 0.0001), and Q-S2 (r =-0.39; P = 0.0003) correlated with LVEF, but not with LVEDP. An abnormal EMAT > or =15 (odds ratio 1.38, P < 0.0001) and EMAT/LVST > or =0.40 (OR 1.13, P = 0.002) were associated with left ventricular dysfunction. EMAT > or =15 had 44% sensitivity, 94% specificity, and a 7.0 likelihood ratio for left ventricular dysfunction, while EMAT/LVST > or =0.40 had 55% sensitivity, 95% specificity, and a 11.7 likelihood ratio. In patients with an intermediate BNP (100-500 pg/mL), the likelihood ratio increased from 1.1 using the BNP result alone to 11.0 when adding a positive EMAT test for predicting left ventricular dysfunction.

CONCLUSIONS

Phonoelectrocardiographic measures of systolic time intervals are insensitive but highly specific tests for detecting abnormalities in objective markers of left ventricular function. EMAT and EMAT/LVST provide diagnostic information independent of BNP for detecting patients with left ventricular dysfunction.

Two-year outcomes in patients with mild refractory angina treated with enhanced external counterpulsation

BACKGROUND

In the International Enhanced External Counterpulsation Patient Registry (IEPR), approximately 85% of the patients treated are in Canadian Cardiovascular Society (CCS) class III-IV with no option for further invasive coronary revascularization procedures.

HYPOTHESIS

This study sought to determine whether it is clinically important to establish whether the observed durable reduction in disabling severe angina with enhanced external counterpulsation (EECP) treatment can be extended to those with less severe CCS class II angina, who also have no option for further revascularization.

METHODS

This study evaluated the immediate response, durability and clinical events over a 2-year period after EECP treatment in 112 patients with Canadian Cardiovascular Society (CCS) class II angina versus 1346 patients with class III-IV angina using data from the International EECP Patient Registry (IEPR).

RESULTS

Treatment with EECP significantly (by at least one CCS class) reduced angina frequency, nitroglycerin use, and improved quality of life in both groups. At 2-year follow-up, 74% of class II and 70% of class III-IV patients remained free of major adverse cardiovascular events (MACE) and continued to demonstrate a durable CCS class improvement over baseline.

CONCLUSION

The robust effectiveness of EECP as a noninvasive device, together with its relatively low start-up and recurrent costs, makes it an attractive consideration for treating patients with milder refractory angina in addition to the patient with severely disabling angina treated in current practice.

Determination of adequate coronary stent expansion using StentBoost, a novel fluoroscopic image processing technique

OBJECTIVE

We tested the hypothesis that the use of motion-corrected fluoroscopic images results in enhanced coronary stent visualization and improved detection of inadequate stent expansion.

BACKGROUND

Intravascular ultrasound (IVUS) more accurately detects inadequate stent expansion when compared with coronary angiography. Stent under-expansion is associated with stent restenosis and thrombosis. Developing a technique to improve fluoroscopic-based assessment of stent expansion is desirable.

METHODS

We analyzed measurements of 48 coronary stents implanted in 30 patients using quantitative coronary angiography (QCA), IVUS, and StentBoost (SB), a novel fluoroscopic image processing technique. Correlations of stent diameter between the modalities were determined. Using established IVUS criteria for adequate stent deployment, we assessed the diagnostic test characteristics of SB to detect inadequate stent expansion.

RESULTS

Correlations of minimum stent diameter were highest between IVUS and SB (r=0.75; P<0.0001) when compared with QCA and IVUS (r=0.65; P<0.0001), and QCA and SB (r=0.49; P=0.0004). IVUS and SB demonstrated a small difference in minimum stent diameter, 0.043 mm (95% CI: 0.146-0.061 mm). The correlation between IVUS and SB was lower for vessels with intimal calcification (r=0.57; P=0.002) when compared with vessels with deeper calcification (r=0.84; P<0.0001). A SB minimum diameter of <2.5 mm predicted inadequate stent expansion by IVUS with 88% sensitivity, 70% specificity, and a positive likelihood ratio of 2.9.

CONCLUSIONS

SB had superior correlations for stent expansion measured by IVUS when compared with QCA. A minimum stent diameter by SB measurement<2.5 mm is associated with inadequate stent expansion using IVUS criteria.

Diagnostic characteristics of combining phonocardiographic third heart sound and systolic time intervals for the prediction of left ventricular dysfunction

BACKGROUND

The third heart sound (S3) and systolic time intervals (STIs) are validated clinical indicators of left ventricular (LV) dysfunction. We investigated the test characteristics of a combined score summarizing S3 and STI results for predicting LV dysfunction.

METHODS AND RESULTS

A total of 81 adults underwent computerized phonelectrocardiography for S3 and STI (Audicor, Inovise Medical Inc), cardiac catheterization for LV end-diastolic pressure (LVEDP), echocardiography for LV ejection fraction (LVEF), and B-type natriuretic peptide (BNP) testing. LV dysfunction was defined as both an LVEDP >15 mm Hg and LVEF <50%. The STI measured was the electromechanical activation time (EMAT) divided by LV systolic time (LVST). Z-scores for the S3 confidence score and EMAT/LVST were summed to generate the LV dysfunction index. The LV dysfunction index had a correlation coefficient of 0.38 for LVEDP (P = .0003), -0.53 for LVEF (P < .0001), and 0.35 for BNP (P = .0008). This index had a receiver operative curve c-statistic of 0.89 for diagnosis of LV dysfunction; a cutoff >1.87 yielded 72% sensitivity, 92% specificity, 9.0 positive likelihood ratio, and 88% accuracy.

CONCLUSIONS

In this preliminary study, the LV dysfunction index combined S3 and STI data from noninvasive electrophonocardiography, and yielded superior test characteristics compared to the individual tests for the diagnosis of LV dysfunction.

Effectiveness of repeat enhanced external counterpulsation for refractory angina in patients failing to complete an initial course of therapy

AIMS

This study examined the causes and results of retreatment of patients who failed to complete an initial 35-hour Enhanced External Counterpulsation (EECP) course.

METHODS AND RESULTS

Data of 2,311 successive angina patients from the International EECP Patient Registry were analyzed, 86.5% completed their EECP course (Complete cohort). Of the 13.5% patients failing to complete the initial course (Incomplete cohort), 28.3% had repeat EECP within 1 year vs. 10.1% of the Complete group. The predictors of failure to complete the initial course of EECP were: female gender, heart failure, use of angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, and use of nitroglycerin. For the Complete group, 83.4% had a reduction of at least one Canadian Cardiovascular Society (CCS) class after their initial EECP course, vs. 21.7% in the Incomplete group (p < 0.001). After repeat treatment, 66.2% of the Incomplete group achieved at least one CCS class reduction vs. 69.4% of the Complete group (p = NS) undergoing retreatment. The independent predictors for those who return to successfully complete their second course were patients who stopped their first course because of clinical events, and candidacy for coronary artery bypass grafting at the time of initial treatment.

CONCLUSION

The results of retreatment of those who failed to complete their initial EECP course were comparable to those who completed their initial treatment, with similar reductions of CCS angina class.

Primer: practical approach to the selection of patients for and application of EECP

Over the past decade, the frequency of use of enhanced external counterpulsation (EECP) has increased in patients with angina, irrespective of medical therapy and coronary revascularization status. Many patients referred for EECP have one or more comorbidities that could affect this treatment's efficacy, safety, or both. By use of data from more than 8,000 patients enrolled in the International EECP Patient Registry, we provide practical guidelines for the selection and treatment of patients. We have focused on considerations for patients who have one or more of the following characteristics: age older than 75 years, diabetes, obesity, heart failure, and peripheral vascular disease. We have also reviewed outcomes and treatment recommendations for individuals with poor diastolic augmentation during treatment, for those with atrial fibrillation or pacemakers, and for those receiving anticoagulation therapy. Lastly, we examined relevant data regarding extended courses of EECP, repeat therapy, or both. While clinical studies have demonstrated the usefulness of EECP in selected patients, these guidelines permit recommendations for the extended application of this important treatment to subsets of patients excluded from clinical trials.

Nesiritide acutely increases pulmonary and systemic levels of nitric oxide in patients with pulmonary hypertension

BACKGROUND

Pulmonary hypertension (PH) is characterized by decreased pulmonary vascular expression of nitric oxide (NOx), a vasodilator that increases levels of smooth muscle cyclic guanosine monophosphate (cGMP). This study investigated mechanisms by which the vasodilator B-type natriuretic peptide (BNP) affects the systemic and pulmonary vasculature in PH patients.

METHODS AND RESULTS

Twenty PH patients with mean pulmonary artery (PA) pressure > 25 mm Hg were enrolled. Ten had precapillary (pulmonary capillary wedge pressure [PCWP] < or = 15 mm Hg) and 10 had postcapillary (PCWP > 15 mm Hg) PH. Right heart catheterization was performed before and 30 minutes after intravenous nesiritide infusion. NOx and cGMP levels from the PA and systemic (AO) arteries were obtained before and after nesiritide infusion. The postcapillary PH patients demonstrated significantly reduced pulmonary vascular resistance after nesiritide; there was no change in the precapillary PH cohort. NOx levels increased significantly in both AO (P < .0001) and PA (P = .0093), as did cGMP levels (P < .0001). There was a higher increase in NOx levels from the pulmonary arteries in precapillary PH patients compared to postcapillary PH patients (P = .020).

CONCLUSION

In PH patients, nesiritide infusion significantly increases NOx levels, suggesting a novel mechanism for its vasodilatory effects. These responses may differ between pre- and postcapillary PH patients.

High-sensitivity C-reactive protein and parameters of left ventricular dysfunction

BACKGROUND

Elevated levels of high-sensitivity C-reactive protein (CRP), an inflammatory marker, have been associated with heart failure. However, it is not known which parameters of left ventricular dysfunction correlate with elevated levels of CRP.

METHODS AND RESULTS

In this cross-sectional study of 98 patients referred for cardiac catheterization, we investigated whether commonly used clinical indices of left ventricular dysfunction correlated with CRP levels. CRP levels were elevated to a greater degree in participants with diabetes mellitus (P =.006) and heart failure (P =.003). Increased CRP levels were associated with increased plasma levels of B-type natriuretic peptide (BNP; P =.0001), decreased left ventricular ejection fraction (LVEF; P =.02), and increased left-ventricular end-diastolic pressure (LVEDP; P =.0005). After multivariable adjustment, LVEDP and CRP were independently associated (P =.046).

CONCLUSION

CRP is increased in patients with heart failure. Of the clinical parameters of left ventricular dysfunction, direct measurement of left ventricular end-diastolic pressure is most closely associated with CRP.

Effect of external counterpulsation on plasma nitric oxide and endothelin-1 levels

Enhanced external counterpulsation (EECP) significantly augments diastolic blood flow and has been postulated to improve endothelial function by increased shear stress. We examined the effects of EECP on plasma nitric oxide and endothelin-1 (ET-1) levels. Plasma nitrate and nitrite (NOx) and ET-1 levels were measured serially in 13 patients with coronary artery disease who received 1-hour daily treatments of EECP over 6 weeks. During the course of EECP therapy, plasma NOx progressively increased and plasma ET-1 progressively decreased. After 36 hours of EECP, there was a 62 +/- 17% increase in plasma NOx compared with baseline (43.6 +/- 4.3 vs 27.1 +/- 2.6 micromol/L, p <0.0001) and a 36 +/- 8% decrease in plasma ET-1 (76.7 +/- 9.5 vs 119.5 +/- 8.5 pg/L, p <0.0001). At 3 months after completion of EECP, NOx remained 12 +/- 11% above baseline (p = 0.002), and ET-1 remained 11 +/- 10% below baseline (p = 0.0068). Our data provides neurohormonal evidence to support the hypothesis that EECP improves endothelial function.

Obese patients have lower B-type and atrial natriuretic peptide levels compared with nonobese

Obesity is a risk factor for the development of heart failure, but the causal mechanism remains unclear. Impaired production or enhanced clearance of natriuretic peptides, which regulate sodium balance and sympathetic activation, may play an important role. The authors investigated the relationship of plasma B-type natriuretic peptide and atrial natriuretic peptide levels to body mass index in 100 patients referred for left heart catheterization. Hemodynamic and echocardiographic data were obtained for all study participants. Atrial natriuretic peptide and B-type natriuretic peptide levels were compared in obese (body mass index > or = 30 kg/m2) and nonobese (body mass index < 30 kg/m2) subjects. Multivariate regression analyses were performed, adjusting for clinical and hemodynamic covariates. Obese patients had significantly lower B-type natriuretic peptide (p = 0.03) and atrial natriuretic peptide (p = 0.04) levels compared with nonobese. Multivariate analysis revealed lower B-type natriuretic peptide (p = 0.095) and atrial natriuretic peptide (p = 0.007) levels in obese patients while controlling for age, sex, left ventricular end-diastolic pressure, and left ventricular ejection fraction. Low levels of circulating natriuretic peptides are thus associated with obesity and may contribute to the development of heart failure.

Long-Term Mortality, Cause of Death, and Temporal Trends in Complications after Percutaneous Aortic Balloon Valvuloplasty for Calcific Aortic Stenosis

We sought to assess survival, predictors of adverse outcomes, and complication rates in a more recent series of adults undergoing percutaneous aortic balloon valvuloplasty (PABV) for symptomatic calcific aortic stenosis. While aortic valve replacement is the treatment of choice for adults with symptomatic calcific aortic stenosis, PABV has been used in selected patients who are not good surgical candidates. Registries of patients who underwent PABV over 15 years ago have shown poor long-term survival and high procedural complication rates. This single-center cohort study enrolled consecutive adults undergoing PABV between 1989 and 2005 for calcific aortic stenosis. Demographic, hemodynamic, and procedural data, as well as vital status, were collected by chart review and query of the National Death Index. The study included 78 patients: mean age 78 +/- 11 years, 51% female, 90% heart failure, 61% coronary disease, and 8% end-stage renal disease. While 22% had a major procedural complication, this rate tended to decrease over time (P=0.068). In the cohort, 87% died with a median survival of 6.6 months. According to NDI records, the primary cause of death was cardiac in 54% of deaths. Survival was significantly higher in patients <or=70 years and those bridged to aortic valve replacement. PABV in patients who are elderly and not candidates for bridge to aortic valve replacement is associated with poor long-term survival. The decrease in the complication rate over the past 15 years has important implications regarding the morbidity associated with percutaneous aortic valve replacement techniques.