Electrocardiographic Abnormalities in Patients with Right Ventricular Dilation due to Acute Pulmonary Embolism

In a study of 190 patients with acute pulmonary embolism, right ventricular dilation was present in 64 (34%), mean age 58 +/- 15 years. The 18 electrocardiographic abnormalities on the 12-lead electrocardiogram had a sensitivity of 8-69%, a specificity of 70-98%, a positive predictive value of 23-69%, a negative predictive value of 64-83%, a likelihood ratio for a positive test of 1.3-4.4, and a likelihood ratio for a negative test of 0.41-1.10 in predicting right ventricular dilation in patients with acute pulmonary embolism.

Inter- and intraobserver variability in LVH and RVH reporting in pediatric ECGs

BACKGROUND

Physicians' diagnoses are often used as the gold standard for evaluating computer electrocardiogram (ECG) interpretation programs. As part of a larger study to evaluate the Glasgow pediatric ECG analysis program, inter- and intraobserver variability in the ECG reporting of two pediatric cardiologists was examined.

METHODS

The ECGs of 984 children were sent for reporting independently by two cardiologists with all identifying information except age and sex removed. Three hundred twenty ECGs had no clinical indication available, and they were thus reported "blind." For 664 ECGs, the clinical indication was known and included with the ECG trace. All ECGs reported as right ventricular hypertrophy (RVH) or left ventricular hypertrophy (LVH) were returned to the cardiologists without their knowledge for reporting a second time "blind" as to the clinical indication.

RESULTS

When the cardiologists' reports were compared with each other, the provision of clinical information led to greater agreement between them for the diagnosis of LVH (kappa increased from 0.44 to 0.52) but did not substantially affect their agreement in diagnosing RVH (kappa fell from 0.66 to 0.63). Intraindividual comparisons in 166 ECGs revealed that one cardiologist was more consistent in diagnosing RVH and the other more consistent in diagnosing LVH.

CONCLUSIONS

This study has demonstrated the difficulties in using cardiologists' diagnoses as the gold standard with which to evaluate pediatric ECGs.

Isquemia de ventrículo derecho y cor pulmonale

48 year old man with chronic obstructive pulmonary disease (COPD) secondary to pulmonary hypertension with domiciliary non-invasive ventilation was seen. He came to the emergency department with acute exacerbation of COPD. The patient was admitted to the Cardiology Service with the diagnosis of congestive heart failure. Diagnostic imaging (chest X-ray, transthoracic Doppler-echocardiography, multidetector row spiral CT and myocardial perfusion imaging) revealed an enlarged right ventricle. ECG was consistent with right ventricular failure. The heart perfusion imaging (pharmacologic stress testing with dobutamine) showed cor pulmonale and right ventricle ischemia induced by drug stress with dobutamine. Although right ventricle myocardial chronic dysfunction rarely causes right ventricular failure, it can occur when cor pulmonale and ischemia heart disease are present.

Case of tetralogy of Fallot associated with hypoplasia of the right pulmonary artery

A three-month-old girl was referred to pediatric cardiology unit for evaluation of mild cyanosis and murmur. Chest roentgenogram revealed a boot-shaped heart. Echocardiography demonstrated subaortic ventricular septal defect, aortic override and infundibular stenosis. Then, the patient diagnosed as tetralogy of Fallot (TOF). Cardiac catheterization and angiocardiography revealed infundibular narrowing, hypoplasia of the right pulmonary artery and the enlarged right internal mammary artery originating from the right subclavian artery supplied blood flow into the right lung. The patient was performed complete repair. Post-operative period was uneventful. This is the first report presented about a case which pulmonary blood flow is provided by the enlarged right internal mammary artery in TOF associated with hypoplasia of the right pulmonary artery.

Early changes of cardiac structure and function in COPD patients with mild hypoxemia

BACKGROUND

COPD is often associated with changes of the structure and the function of the heart. Although functional abnormalities of the right ventricle (RV) have been well described in COPD patients with severe hypoxemia, little is known about these changes in patients with normoxia and mild hypoxemia.

STUDY OBJECTIVES

To assess the structural and functional cardiac changes in COPD patients with normal Pa(O2) and without signs of RV failure.

METHODS

In 25 clinically stable COPD patients (FEV1, 1.23 +/- 0.51 L/s; Pa(O2), 82 +/- 10 mm Hg [mean +/- SD]) and 26 age-matched control subjects, the RV and left ventricular (LV) structure and function were measured by MRI. Pulmonary artery pressure (PAP) was estimated from right pulmonary artery distensibility.

RESULTS

RV mass divided by RV end-diastolic volume as a measure of RV adaptation was 0.72 +/- 0.18 g/mL in the COPD group and 0.41 +/- 0.09 g/mL in the control group (p < 0.01). LV and RV ejection fractions were 62 +/- 14% and 53 +/- 12% in the COPD patients, and 68 +/- 11% and 53 +/- 7% in the control subjects, respectively. PAP estimated from right pulmonary artery distensibility was not elevated in the COPD group.

CONCLUSION

From these results, we conclude that concentric RV hypertrophy is the earliest sign of RV pressure overload in patients with COPD. This structural adaptation of the heart does not alter RV and LV systolic function.

Evaluation of pediatric electrocardiogram diagnosis of ventricular hypertrophy by computer program compared with cardiologists

This study aimed to evaluate the diagnosis of pediatric left ventricular hypertrophy (LVH) and right ventricular hypertrophy (RVH) by the Glasgow electrocardiogram (ECG) interpretation program compared to interpretations provided by two pediatric cardiologists. ECGs had all identifying information removed and were sent to the cardiologists independently with the patient's age and sex and the clinical indication for the ECG, if known. A total of 984 ECGs were included in the study, of which 664 were reported "with clinical indication" and 320 were reported "blind." With respect to an averaged diagnosis of the two cardiologists, the sensitivity of the program for RVH was better when the cardiologists reported blind (73.3%) than with the clinical indication (53.5%), with the same trend for the program compared with individual cardiologists. The specificity of the program was at least 94.4% in all cases. For LVH, the program had high specificity (=95.8%) for "reported blind" and "with clinical indication" cases but low sensitivities throughout (the highest was 44.4% with respect to an averaged diagnosis of the two cardiologists reporting with the clinical indication). Subsequent discussion revealed that if the cardiologists had disagreed with one another initially, their consensus opinion was twice as likely to be in agreement with the program.

Magnetic resonance imaging in experimental Chagas disease: a brief review of the utility of the method for monitoring right ventricular chamber dilatation

Chagas' disease caused by infection with Trypanosoma cruzi leads to a myocardiopathy that evolves from the acute to the chronic phase. Magnetic resonance imaging (MRI) is an important tool for monitoring cardiac morphology and function both in humans and in animals. In the present work, we present a brief review of MRI applications for the study of ventricular hypertrophy and dilatation of the right ventricle in murine models of Chagas' disease. Studies using MRI demonstrate an increase in right ventricular chamber dimension during both phases of infection, indicating that increase of the right ventricle is a marker for experimental chagasic myocardiopathy. Based on previous studies using MRI in these models we propose that this technique is an excellent approach for monitoring heart functionality from the acute through the chronic phase of infection in different parasite-host pairs and for monitoring the efficacy of cardioprotective or immune-therapeutic agents.

Structure and function of distance runners' heart

OBJECTIVE

To compare ultra-long distance runners' heart morphologic and functional parameters at rest with those of long distance runners' and middle distance runners'.

MATERIALS AND METHODS

Standard Doppler, M-mode and 2-D-mode echocardiography was performed at rest to 22 middle, 31 long and 11 ultra-long adult male distance runners.

RESULTS

Long and ultra-long distance runners' left ventricular mass and left ventricular mass index were larger (p<0.05) than that of middle distance runners' (groups' means--approximately 288, 305 and 250 g as well as 153, 160 and 130 g/m(2), respectively) due to both larger (p<0.05) end-diastolic interventricular wall thickness (10.6, 11.1 and 9.8 mm, respectively) and left ventricular posterior wall thickness (10.7, 11.5 and 10.0 mm, respectively). Ultra-long distance runners' left ventricular mass and mass index did not differ significantly from long distance runners' (p>0.05), but end-diastolic posterior wall thickness was higher (p<0.05). Relative left ventricular wall thickness was larger in ultra-long distance runners as compared with middle distance runners (0.402 and 0.362, respectively; p<0.05). Ultra-long distance runners' right ventricular end-diastolic diameter was significantly larger (p<0.05) than that of middle and long distance runners (groups' means--25.8, 20.7 and 21.4 mm, respectively). Right ventricular end-diastolic free wall was thicker in ultra-long distance runners as compared with middle distance runners (groups' means--6.7 and 5.9 mm, respectively; p<0.05). Diastolic left ventricular function (evaluated as E/A) as well as end-diastolic left ventricular diameter (groups' mean--55.5-56.4 mm) did not differ between groups (p>0.05).

CONCLUSIONS

The hypertrophy of ultra-long (as well as long) distance runners' myocardium of both ventricles is more pronounced than that of middle distance runners'.

Two cases of familial primary pulmonary hypertension

Case 1, a 28-year-old woman (third daughter of Case 2) delivered her first child in September 2000, but leg edema and dyspnea on exertion appeared the following January. At the time of our first examination of the patient in May 2001, a chest X-ray showed cardiomegaly and pulmonary artery enlargement. Echocardiography demonstrated enlargement of the right ventricle and small left ventricular dimensions, and an electrocardiogram revealed right ventricle hypertrophy. After perfusion-ventilation lung scintigraphy and cardiac catheterization, she was diagnosed as having primary pulmonary hypertension (PPH). Although she was discharged with prescriptions for a diuretic, warfarin and beraprost sodium, she died of a pulmonary hypertensive crisis twenty days after readmission. Case 2, a 60-year-old woman(mother of Case 1) developed the same symptoms as those in Case 1, in May 2001, but recovered after medication. PPH is a rare disease and only a few familial cases are reported. In this family, the eldest daughter of Case 2 had also died of pulmonary hypertension ten years ago, several months after her first delivery. In contrast to the daughters, the mother's symptoms developed gradually.

Survival to the Age of 52 Years in a Man with Unrepaired Tetralogy of Fallot

Tetralogy of Fallot is the most common cyanotic congenital heart defect during infancy. It is composed of a ventricular septal defect, an overriding aorta, obstruction of right ventricular outflow, and right ventricular hypertrophy. Most patients experience cyanosis at birth and die in childhood without surgical intervention. The rate of survival at 40 years without surgical correction is only 3%. We present the case of a man with tetralogy of Fallot who survived until the age of 52 years without surgical intervention.

Live Three-Dimensional Transthoracic Echocardiographic Delineation of Patent Ductus Arteriosus

We report an adult patient with a patent ductus arteriosus in whom live three-dimensional transthoracic echocardiography provided comprehensive assessment of the morphology and pathophysiology of the lesion.

Effects of epoprostenol on right ventricular hypertrophy and dilatation in pulmonary hypertension

OBJECTIVES

To gain more knowledge of changes in main pulmonary artery flow and right ventricular mass and volumes in patients with pulmonary hypertension during epoprostenol therapy.

METHODS

Eleven patients (9 women) were evaluated before the start of therapy and every 4 months thereafter. Right and left ventricular volumes and masses were measured by cine MRI. Flow was measured with MRI velocity quantification. At the same times, 6-min walking tests were performed. Right-heart catheterizations were performed at baseline and after 1 year.

RESULTS

Right ventricular mass in the patient group was significantly higher from that in a control group of healthy volunteers (95 +/- 26 g vs 42 +/- 10 g, p < 0.05 [mean +/- SD]), whereas the stroke volume was lower (34 +/- 11 mL vs 81 +/- 11 mL, p < 0.05). The greatest improvement in right ventricular stroke volume (to 41 +/- 11 mL, p < 0.05) took place in the first 4 months. During the 1-year follow-up, right ventricular end-diastolic volume and mass did not change, and mean pulmonary artery pressure remained nearly stable at 55 mm Hg at baseline and 53 mm Hg after 1 year. Pulmonary vascular resistance decreased by 12.5% (p = 0.06).

CONCLUSIONS

From these data we conclude that epoprostenol lowers pulmonary vascular resistance, leading to an increase in pulmonary artery flow. This increase in pulmonary artery flow corresponds well with the increase in 6-min walking distance and can be noninvasively monitored by MRI (flow quantification). Right ventricular dilatation and hypertrophy are not reversed by epoprostenol therapy, but do not progress either.

[Pulmonary hypertension, involvement of the right and left cardiac parts in patients with ankylosing spondylarthritis]

The literature states that pulmonary hypertension (PH) may develop in ankylosing spondylarthritis (AS); however, there are virtually no evidence for its incidence and the specific features of lesions of the right and left cardiac portions. This study was undertaken to determine the incidence of PH and its specific features in patients with AS. Fifty-five patients with AS were examined. There were prevalent patients with predominantly spinal lesions (50.9%), moderate progression of the disease (61.8%), and Grade III sacroileitis (49.1%). PH was detected in 70.96% of the patients, hypertrophy of the right ventricle (RV) was observed in 47.3%, RV dilation was in 34.5%. There were increases in the end systolic size and volume of the left ventricle (LV) in patients with AS (p < 0.05 and p < 0.05, respectively), ventricular septal thickening (p < 0.05), and a tendency for the posterior LV wall to be thickened. LV diastolic dysfunction occurred in 25.9% of the patients with AS. The found changes were interrelated with the duration of disease, the involvement of the vertebral column, the thoracic part in particular. Thus, the high incidence of PH was ascertained in patients with AS. The study confirms that echocardiography is of high informative value in the detection of PH and right cardiac changes in patients with AS, which shows this method to be screening in identifying the above pathology.

[Prevalence of electrocardiographic signs of pulmonary hypertension in a sample of male population of Novosibirsk]

Prevalence of ECG signs of right ventricular hypertrophy and pulmonary hypertension was assessed in a representative sample (n=715) of nonorganized male population (age 25-64 years) of Novosibirsk studied within a framework of WHO MONICA project. Other methods of investigation included Rose questionnaire, anthropometry, ECG interpreted with Minnesota code, and echocardiography. Echocardiography data were used as reference for determination of sensitivity and specificity of ECG-criteria of pulmonary hypertension.

Diagnostic value of electrocardiographic investigations in preoperative evaluation of patients with lung cancer

The pulmonary hypertension and cor pulmonale in patients before lung tissue resection must be predicted even if invasive studies are required. The purpose of the study was to evaluate the diagnostic value of electrocardiographic investigation for patients with lung cancer, considered to be candidates for lung tissue resection. The study comprised 50 male patients with bronchial carcinoma before lung tissue resection. All of them had gasometric, and hemodynamic parameters of pulmonary circulation assessed at rest and after exercise. The ECG and spirographic investigations were done in all patients. It was found that 23 of 50 patients had electrocardiographic traits of right ventricle hypertrophy and only one of them had normal pulmonary circulation parameters. There were also found correlations between ECG curve and FEV1%, most of gasometric and some of pulmonary hemodynamic parameters.

[Electrocardiographic picture in patients with congenital defect of atrial septum operated upon in adult age]

Electrocardiograms from 30 patients with congenital atrial septal defect operated upon in adult age were analyzed. One of frequent variants of QRS configuration in standard leads was SIqIII type. It was observed in 50% of patients. Most frequent (in 67% of patients) variants of QRS configuration in lead V1 were rSr' and rSR'. Signs of right ventricular hypertrophy were most often found in a group of patients with high pulmonary hypertension. Changes of terminal portion of ventricular complex such as negative or biphasic T waves were found in 29 of 30 patients (in 63% of cases these changes were localized in leads V1-V3).