Effect of preload reduction by hemodialysis on left atrial volume and echocardiographic Doppler parameters in patients with end-stage renal disease

Comparison of left atrial deformation parameters between renal transplant and hemodialysis patients

Background

Renal transplantation (RT) has been demonstrated to improve left ventricular systolic function. However, only few studies have attempted to reveal the effects of transplantation on left atrial (LA) function. In our study, we aimed to compare LA function between RT and hemodialysis patients.

Methods

This cross-sectional study included 75 consecutive patients with RT, and 75 age- and gender-matched patients on maintenance hemodialysis. LA strain and strain rate (SR) analyzed by two-dimensional (2D) speckle tracking echocardiography (STE) were compared between the groups in addition to standard echocardiographic parameters.

Results

LA strain during reservoir phase (29.88 ± 5.76% vs 26.11 ± 5.74%, P < .001), LA strain during conduit phase (− 15.28 ± 5.00% vs − 12.92 ± 4.38%, P = .003), and LA strain during contraction phase (− 14.60 ± 3.32% vs − 13.19 ± 3.95%, P = .020) were higher in the transplantation group. Similarly, LA peak SR during reservoir phase (1.54 ± 0.33 s^− 1 vs 1.32 ± 0.33 s^− 1, P < .001), LA peak SR during conduit phase (− 1.47 ± 0.49 s^− 1 vs − 1.12 ± 0.42 s^− 1, P < .001), and LA peak SR during contraction phase (− 2.13 ± 0.46 s^− 1 vs − 1.83 ± 0.58 s^− 1, P = .001) were higher in the transplantation group as well.

Conclusions

LA function assessed by 2D STE was better in RT patients than hemodialysis patients. This may suggest favorable effects of RT on LA function.

On the search for the right definition of heart failure with preserved ejection fraction

The definition of heart failure with preserved ejection fraction (HFpEF) has evolved from a clinically based "diagnosis of exclusion" to definitions focused on objective evidence of diastolic dysfunction and/or elevated left ventricular filling pressures. Despite advances in our understanding of HFpEF pathophysiology and the development of more sophisticated imaging modalities, the diagnosis of HFpEF remains challenging, especially in the chronic setting, given that symptoms are provoked by exertion and diagnostic evaluation is largely conducted at rest. Invasive hemodynamic study, and in particular - invasive exercise testing, is considered the reference method for HFpEF diagnosis. However, its use is limited as opposed to the high number of patients with suspected HFpEF. Thus, diagnostic criteria for HFpEF should be principally based on non-invasive measurements. As no single non-invasive variable can adequately corroborate or refute the diagnosis, different combinations of clinical, echocardiographic, and/or biochemical parameters have been introduced. Recent years have brought an abundance of HFpEF definitions. Here, we present and compare four of them: 1) the 2016 European Society of Cardiology criteria for HFpEF; 2) the 2016 echocardiographic algorithm for diagnosing diastolic dysfunction; 3) the 2018 evidence-based H2FPEF score; and 4) the most recent, 2019 Heart Failure Association HFA-PEFF algorithm. These definitions vary in their approach to diagnosis, as well as sensitivity and specificity. Further studies to validate and compare the diagnostic accuracy of HFpEF definitions are warranted. Nevertheless, it seems that the best HFpEF definition would originate from a randomized clinical trial showing a favorable effect of an intervention on prognosis in HFpEF.

Relationship between volume status and possibility of pulmonary hypertension in dialysis naive CKD5 patients

Background

Chronic fluid overload is common in patients with chronic kidney disease (CKD) and can with time lead to poor prognosis regarding to the cardiovascular events. Serum NT-proBNP and OH/ECW might reflect fluid status of the patients, and the maximal tricuspid regurgitation velocity (TRVmax) could reflect systolic pulmonary artery pressure (SPAP). We investigated the relationship between markers of volume status and marker of pulmonary hypertension (PH) in non-dialysis CKD5 (CKD5-ND) patients.

Methods

Bioimpedance spectroscopy (BIS), echocardiography, and measurement of serum NT-proBNP were performed in 137 consecutive patients on the same day. TRVmax greater than or equal to 2.9 m/s, corresponding to SPAP of approximately 36 mmHg, was used as a definition of the possibility of PH in the absence of left heart disease and chronic respiratory disease (PH group).

Results

Patients with possibility of PH (TRVmax ≥ 2.9 m/s) was found in 27 (19.70%) patients. Among the values obtained from BIS, those reflecting the fluid balance (OH, OH/ECW, and E/I ratio) were significantly higher in the PH group. The OH/ECW in patients with PH were significantly higher than those patients without (26.76 ± 15.07 vs. 13.09 ± 15.05, P < 0.001). NT-proBNP was also significantly higher in PH group compared to the non-PH group (median = 10,112 pg/ml, IQR = 30,847 pg/ml vs. median = 1,973 pg/ml, IQR = 7,093 pg/ml, P < 0.001). OH/ECW was positively associated with TRVmax (r = 0.235, P = 0.006). Multivariate logistic regression revealed that increased OH/ECW and serum NT-proBNP were significantly associated with an increased risk of PH.

Conclusions

A significant number of patients showed increased TRVmax, which was closely related to volume status in CKD5-ND patients. Echocardiography and BIS could be important players in a high possibility of PH detection and treatment in asymptomatic CKD patients. Therefore, these measures could be helpful to improve the cardiac outcomes after initiating renal replacement therapy. Further research may be needed to validate the consistency of this association across other stages of CKD.

The atrial uremic cardiomyopathy regression in patients after kidney transplantation - the prospective echocardiographic study

BACKGROUND

In patients with end stage renal disease (ESRD), left ventricular (LV) hypertrophy with impaired LV function, which is called uremic cardiomyopathy (UC) is often observed. The UC historically has been considered a contraindication for kidney transplantation (KTx). Currently, moderate LV dysfunction does not exclude the possibility of KTx. The amelioration of uremia after KTx improved cardiac function in patients with LV dysfunction. There is a little information on the function of the left atrium (LA) after the KTx procedure. There are no studies evaluating (LA) changes in patients with UC after KTx and determining the possibility of inhibiting the occurrence of LA unfavourable changes (remodelling) and even a possible LA recovery process (reverse remodelling) as a result of a successful KTx. The aim of the study was to assess the LA reverse remodelling in patients with ESRD undergoing KTx.

METHODS

The study group consisted of 42 patients, aged 43.3 ± 12.6 followed for 36 months after a deceased donor KTx. The patients were studied at five time points: 1, 3, 6, 12 and 36 months after KTx. In all patients transthoracic echocardiography was performed in order to assess the following LA planimetric parameters: LAmax, LAmin, LAwaveP. LAshortmax, LAshortmin, LAshortwaveP, LAlongmax, LAlongmin, LAlongwaveP, LAcircmax and LAareamax, volumentric parameters: LA volume (LAV), LA volume index (LAVI), and hemodynamic indices: LA ejection fraction (LAEF), LA active emptying fraction (LAAE), LA passive emptying fraction (LAPE), LA index of expansion (LAIE) and LA fractional shortening (LAFS).

RESULTS

The LAVI values were 34.63 ± 10.34 ml/m2, 32.24 ± 9.59 ml/m2 (p < 0,001), 31.36 ± 9.20 ml/m2 (p < 0,001), 28.29 ± 8.32 ml/m2 (p < 0,001) and 27.57 ± 8.40 ml/m2 (p < 0,001), after: 1, 3, 6, 12 and 36 months after KTx, respectively. The reduction of the LA size was accompanied by gradual LA contractility improvement, which was manifested as an increase of the LA hemodynamic indices such as LAEF, LAAE, LAIE, LAFS and a decrease of LAPE.

CONCLUSIONS

LA remodelling secondary to atrial uraemic cardiomyopathy is an example of complex cardiomyopathy with elements characteristic of both congestive and infiltrative cardiomyopathy. Early LAVI reduction post KTx mostly depends on changed haemodynamic conditions, whereas the main reason for further decrease of LAVI values is related to resolution of uraemic toxaemia.

Load Dependency of Left Atrial Strain in Normal Subjects

BACKGROUND

Left atrial (LA) longitudinal strain is a novel parameter used for the evaluation of LA function, with demonstrated prognostic value in several cardiac diseases. However, the extent of load dependency of LA strain is not well known. The aim of this study was to evaluate the impact of acute changes in preload on LA strain, side by side with LA volume, in normal subjects.

METHODS

Twenty-five healthy volunteers (13 men; mean age, 31 ± 2 years) were prospectively enrolled, who underwent two-dimensional and three-dimensional echocardiographic imaging during acute stepwise reductions in preload using a tilt maneuver: baseline at 0°, followed by 40° and 80°. Left ventricular and LA size and function parameters were measured using standard methodology, and LA strain-time curves were obtained using speckle-tracking software (TomTec), resulting in reservoir, conduit, and contractile strain components. All parameters were compared among the three loading conditions using one-way analysis of variance for repeated measurements.

RESULTS

Although there were no significant changes in blood pressure, heart rate increased significantly with tilt. As expected, LA volumes, left ventricular volumes, and left ventricular ejection fraction, as well as E wave, A wave, and e' significantly decreased with progressive inclination. In parallel, LA reservoir, conduit, and contractile strain values decreased with reduction in preload (reservoir: 42.9 ± 3.9% to 27.5 ± 3.8%, P < .001; conduit: 29.3 ± 2.7% to 20.2 ± 5.0%, P < .001; contractile: 13.6 ± 2.9% to 7.3 ± 3.5%, P < .001). Paired post hoc analysis showed that all LA strain values were significantly different among all three tilt phases. Of note, percentage change in LA reservoir strain was significantly smaller than that in LA maximum volume.

CONCLUSIONS

In normal subjects, LA strain is preload dependent but to a lesser degree than LA volume. This difference underscores the relative advantage of LA strain over maximum volume, when LA assessment is used as part of the diagnostic paradigm.

Factors associated with reduction of left ventricular mass in children on peritoneal dialysis

AIM

This study aimed to investigate sensitive factors involved in left ventricular mass reduction in children with end-stage renal disease (ESRD) undergoing peritoneal dialysis.

METHODS

Thirty-five subjects on peritoneal dialysis were enrolled. Two successive echocardiographic and clinical data for each subject were obtained. Blood pressure and left ventricular mass index (LVMI) were indexed through a division with the normal 95^th percentile value. Differences in numeric data between two datasets were calculated.

RESULTS

The mean age was 12.9 ± 4.6 years. Predictors of left ventricular hypertrophy and its persistence were systolic blood pressure index (P = 0.019 and P = 0.046) and E' velocity (P = 0.035 and P = 0.031) in univariate analysis. However, differences in these predictors between the datasets were not related to the change in indexed LVMI. Reduction in indexed LVMI was correlated to a reduction of indexed left atrial volume (R = 0.638, P = 0.001), trans-mitral A velocity (R = 0.443, P = 0.011), and serum blood urea nitrogen level (R = 0.372, P = 0.028) and an elevation of haemoglobin level (R = -0.374, P = 0.027).

CONCLUSION

The extent of circulating volume expansion is potentially the main predictive factor for change of LVMI, because the volume dependent diastolic functional variables correlate to the change of LVMI. Further study with a large number of ESRD children including a group under fluid volume control is needed to investigate the role of volume expansion on the change of LVMI.

Left ventricular dysfunction by conventional and tissue Doppler echocardiography in pediatric hemodialysis patients: relation with plasma brain natriuretic peptide levels

INTRODUCTION

Tissue Doppler imaging (TDI) is a relatively new echocardiography method in children with chronic kidney disease (CKD). The aims of this study were to evaluate left ventricular (LV) diastolic function in pediatric CKD patients using conventional pulsed-wave Doppler echocardiography (cPWD) and TDI methods and correlate them with BNP levels.

MATERIAL AND METHODS

Thirty children on regular hemodialysis (HD) were included. Left ventricular systolic and diastolic indices and BNP levels were measured immediately before and after HD.

RESULTS

After HD, LV and left atrium diameters were significantly decreased (p < 0.001 and p < 0.001, respectively). Transmitral E velocity and E/A ratio decreased (p < 0.001 and p < 0.001, respectively). Also, there were significant decreases in the early diastolic velocity E' of LV wall, septal wall, and anterior wall (p = 0.001, p = 0.004 and p < 0.001, respectively). Mean E/E' ratio and ratios of septal and lateral walls were decreased significantly (p = 0.004, p = 0.002 and p = 0.017, respectively). BNP levels decreased significantly during HD when comparing concentrations before and after HD (p < 0.001). BNP strongly correlated with LV diastolic function indices (before HD: mean E/E' (r = 0.401, p = 0.028), lateral E/E" (r = 0.291, p = 0.025), septal E'(r = -0.398, p = 0.029), lateral wall E' (r = -0.452, p = 0.012) and mean E' (r = -0.469, p = 0.009), after HD: mean E/E' (r = 0.38, p = 0.038) and lateral E/E" (r = 0.474, p = 0.008) and lateral wall E' (r = -0.270, p = 0.037)).

CONCLUSIONS

The cPWD and TDI-derived LV indices are influenced by HD. The diagnostic utility of BNP in the presence of deteriorating renal function may be compromised to some extent.

Association between E/e´ ratio and fluid overload in patients with predialysis chronic kidney disease

Background

Chronic fluid overload is common in patients with chronic kidney disease (CKD) and can with time lead to diastolic dysfunction and heart failure. We investigated whether markers of fluid status, such as NT-proBNP and bioimpedance spectroscopy (BIS), can predict echocardiographic findings of diastolic dysfunction in non-dialysis CKD5 patients.

Methods

BIS, echocardiography, and measurement of serum NT-proBNP were performed in patients with non-dialysis CKD stage 5 at a single study visit. E/e´ ratio reflect mean LV diastolic pressure and a ratio greater than 15 was used as a definition of diastolic dysfunction.

Results

Eighty-four patients were analyzed. Forty-six patients (54.76%) had E/e´ ratio ≤15 and 38 patients (45.24%) had E/e´ > 15 (diastolic dysfunction). Patients with E/e´>15 had significantly higher serum NT-proBNP (14,650 pg/mL) than patients with to E/e´≤15 (4,271 pg/mL) and had more overhydration (OH), 5.1 liters compared to 2.4 liters. The cut-off values predicting diastolic dysfunction were found to be 2,797 pg/mL for NT-proBNP and 2.45 liters for OH.

Conclusions

Regular monitoring of fluid status by BIS and NT-proBNP can be used to find patient with risk of developing diastolic dysfunction. Treatments to correct fluid overload may reduce the risk of developing diastolic dysfunction and improve cardiovascular outcome in patients with CKD.

Impact of extracorporeal blood flow rate on blood pressure, pulse rate and cardiac output during haemodialysis

BACKGROUND

If blood pressure (BP) falls during haemodialysis (HD) [intradialytic hypotension (IDH)] a common clinical practice is to reduce the extracorporeal blood flow rate (EBFR). Consequently the efficacy of the HD (Kt/V) is reduced. However, only very limited knowledge on the effect of reducing EBFR on BP exists and data are conflicting. The aim of this study was to evaluate the effect and the potential mechanism(s) involved by investigating the impact of changes in EBFR on BP, pulse rate (PR) and cardiac output (CO) in HD patients with arteriovenous-fistulas (AV-fistulas).

METHODS

We performed a randomized, crossover trial in 22 haemodynamically stable HD patients with AV-fistula. After a conventional HD session each patient was examined during EBFR of 200, 300 and 400 mL/min in random order. After 15 min when steady state was achieved CO, BP and PR were measured at each EFBR, respectively.

RESULTS

Mean (SD) age was 71 (11) years. Systolic BP was significantly higher at an EBFR of 200 mL/min as compared with 300 mL/min [133 (23) versus 128 (24) mmHg; P < 0.05], but not as compared with 400 mL/min [133 (23) versus 130 (19) mmHg; P = 0.20]. At EBFR of 200, 300 and 400 mL/min diastolic BP, mean arterial pressure, PR and CO remained unchanged.

CONCLUSION

Our study does not show any consistent trend in BP changes by a reduction in EBFR. Reduction in EBFR if BP falls during IDH is thus not supported. However, none of the patients experienced IDH. Further studies are required to evaluate the impact of changes in EBFR on BP during IDH.

Left Ventricular Diastolic Dysfunction in End-Stage Kidney Disease: Pathogenesis, Diagnosis, and Treatment

Diastolic dysfunction is frequently observed in end-stage kidney disease (ESKD), and ESKD patients have many risk factors for heart failure (HF), including hypertension, diabetes, and coronary artery disease. Diastolic HF, also called HF with preserved ejection fraction, refers to a clinical syndrome in which patients have symptoms and signs of HF, normal or near normal left ventricular (LV) systolic function, and evidence of diastolic dysfunction manifested by abnormal LV filling and elevated filling pressure. Recent reports suggest that HF with preserved ejection fraction is more common in hemodialysis patients than HF with low ejection fraction. Diastolic HF in ESKD patients is a strong predictor of death. In this article, we review the information available in the literature on the pathogenesis, diagnosis, and potential treatment strategies of diastolic dysfunction or diastolic HF based on evidence obtained in the general population that is potentially applicable to ESKD patients.

Predictive value of echocardiographic parameters for clinical events in patients starting hemodialysis

Echocardiographic parameters can predict cardiovascular events in several clinical settings. However, which echocardiographic parameter is most predictive of each cardiovascular or non-cardiovascular event in patients starting hemodialysis remains unresolved. Echocardiography was used in 189 patients at the time of starting hemodialysis. We established primary outcomes as follows: cardiovascular events (ischemic heart disease, cerebrovascular disease, peripheral artery disease, and acute heart failure), fatal non-cardiovascular events, all-cause mortality, and all combined events. The most predictable echocardiographic parameter was determined in the Cox hazard ratio model with a backward selection after the adjustment of multiple covariates. Among several echocardiographic parameters, the E/e' ratio and the left ventricular end-diastolic volume (LVEDV) were the strongest predictors of cardiovascular and non-cardiovascular events, respectively. After the adjustment of clinical and biochemical covariates, the predictability of E/e' remained consistent, but LVEDV did not. When clinical events were further analyzed, the significant echocardiographic parameters were as follows: s' for ischemic heart disease and peripheral artery disease, LVEDV and E/e' for acute heart failure, and E/e' for all-cause mortality and all combined events. However, no echocardiographic parameter independently predicted cerebrovascular disease or non-cardiovascular events. In conclusion, E/e', s', and LVEDV have independent predictive values for several cardiovascular and mortality events.

Heart function disturbances in chronic kidney disease - echocardiographic indices

INTRODUCTION

In chronic kidney disease (CKD) patients left ventricular (LV) diastolic dysfunction occurs frequently and is associated with heart failure (HF) and higher mortality. Left ventricular systolic dysfunction is associated with coronary artery disease (CAD) and is a major determinant of prognosis. The aim of this study was to assess indices of LV diastolic dysfunction in CKD patients.

MATERIAL AND METHODS

Study included 118 CKD patients. All patients underwent transthoracic echocardiography. Diastolic function based on E and A, E/A ratio and pulmonary vein flow velocities as well as EF%, deceleration time, RA, LA volume were assessed. In dialysis patients examination was carried out before and after dialysis.

RESULTS

In CKD patients the stage of renal failure was associated with the significant increase in LV mass (268.0 ±47.6 CKD I/II vs. 432.7 ±122.4 CKD V/dialysis, p < 0.0001), systolic LV (37.3 ±4.5 vs. 51.2 ±8.9, p < 0.0001) and diastolic LV (CKD I-II 44.7 ±4.1 vs. CKD III 48.5 ±6.7 vs. CKD IV 47.1 ±5.6; p = 0.004) dimensions and in the size of the LA (40.4 ±2.0 vs. 41.9 ±2.7 vs. 42.3 ±3.2 vs. 44.8 ±3.1; p < 0.0001). The increase the E/E' ratio between groups of patients (6.7 ±1.5 vs. 8.9 ±2.4 vs. 11.5 ±4.0 vs. 13.5 ±5.0; p < 0.0001) was seen in this study. The reduction in deceleration time (247.2 ±34.5 in CKD I/II vs. 197.4 ±61.0 in CKD IV, p = 0.0005) along with the decrease in estimated glomerular filtration rate was also observed in this study.

CONCLUSIONS

Early identification of factors involved is necessary to prevent this devastating process. Many indexes of contractility are used and each of them has imperfections. It seems that TVI, E, E/A and E/E' are good instruments for the early detection of left ventricular hypertrophy and diastolic dysfunction.

Echocardiography in hemodialysis patients: uses and challenges

Patients with end-stage renal disease undergoing hemodialysis have high rates of morbidity and mortality. Cardiovascular disease accounts for almost half of this mortality, with the single most common cause being sudden cardiac death. Early detection of abnormalities in cardiac structure and function may be important to allow timely and appropriate cardiac interventions. Echocardiography is noninvasive cardiac imaging that is widely available and provides invaluable information on cardiac morphology and function. However, it has limitations. Echocardiography is operator dependent, and image quality can vary depending on the operator's experience and the patient's acoustic window. Hemodialysis patients undergo regular hemodynamic changes that also may affect echocardiographic findings. An understanding of the prognostic significance and interpretation of echocardiographic results in this setting is important for patient care. There are some emerging techniques in echocardiographic imaging that can provide more detailed and accurate information compared with conventional 2-dimensional echocardiography. Use of these novel tools may further our understanding of the pathophysiology of cardiac disease in patients with end-stage renal disease undergoing hemodialysis.

Non invasive evaluation of cardiac hemodynamics in end stage renal disease (ESRD)

OBJECTIVE

Volume overload is typical of haemodialysis patients; correct volume status evaluation is crucial in achieving blood pressure homeostasis, hypertension management and good treatment planning. This study evaluates the effect of acute volume depletion on ultrasonographic parameters and suggests two of them as able to predict patients volume overload.

PATIENTS AND INTERVENTION

27 patients with end stage renal disease treated with haemodialysis underwent a complete echocardiographic exam before, after 90 min and at the end of the dialysis.

MAIN OUTCOME AND RESULTS

Blood pressure levels significantly drop during the first 90 min of dialysis (139 ± 20 vs 126 ± 18; p < 0.0001), reaching a steady state with significantly lower values compared to baseline (130 ± 28; p = 0.02). LV and left atrial volume significantly decreased (baseline vs end dialysis 98 ± 32 vs 82 ± 31 p = 0.003 and 28 ± 10 vs. 21 ± 9 cc/m(2) p < 0.001). A significant reduction of systolic function (EF 61.6 % ± 9 vs 58.7 % ± 9 p = 0.04), of diastolic flow velocities (E/A 1.13 ± 0.37 vs. 0.87 ± 0.38 p < 0.001) and mitral annulus TDI tissue velocity (i.e. E' lat 10.6 ± 3 vs. 9.4 ± 3 cm/s; p 0.0001) were observed. Stroke work (SW) and LV end-diastolic diameter (LVEDd) indexed to height 2.7(LVEDdi) were able to predict volume overload: cut off values of respectively 13.5 mm/m(2.7) for LVEDdi and 173 cJ for SW were able to predict with a specificity of 100 % the presence of a volemic overload of at least 4 %.

CONCLUSIONS

Blood pressure, cardiac morphology and function are significantly modified by acute volume depletion and such variations are strictly interrelated. SW and LVEDd/height(2.7) may identify ESRD patients carrying an higher volume load.

A look at the upper heart chamber: the left atrium in chronic kidney disease

Altered left ventricular (LV) mass and function are classical hallmarks of cardiomyopathy in chronic kidney disease (CKD). The left atrium (LA), a heart chamber exquisitely sensitive to volume overload and diastolic function, is an independent predictor of death and adverse cardiovascular (CV) events in high-risk patients such as those with hypertension and/or with heart failure. In this review we focus on the relationship of LA size with LV diastolic function, and the association between LA enlargement and CV and renal outcomes in patients with CKD, including patients with end-stage renal disease. Increased LA size emerges as a powerful predictor of mortality and major adverse CV events in both end-stage and early CKD, and some studies also show a close association between enlarged LA and renal disease progression. Secondary analyses of clinical trials suggest that the LA has the potential to be elected as a surrogate end point in CKD patients but the issue remains to be tested in specifically designed clinical studies.

Effect of preload on left atrial function: evaluated by tissue Doppler and strain imaging

AIMS

Both strain and strain rate (SR) measure the regional myocardial deformation and can assess phasic left atrial (LA) function. However, there is still a lack of evidence for their volume independency. In this study, strain and SR determined by tissue Doppler imaging were used to evaluate the effect of preload reduction in end-stage renal disease patients who were undergoing regular haemodialysis (HD).

METHODS AND RESULTS

Forty-one subjects who underwent transthoracic echocardiography just before and after HD were enrolled. LA strain was measured during late systole, and LA peak tissue velocity and SR were measured during systole and during early and late diastolic periods. The values of tissue velocity, strain, and SR were obtained in the basal septal, lateral, inferior, and anterior walls of the LA. The mean strain value was 23.89 ± 7.29% at baseline and decreased to 21.88 ± 5.85% after HD (P = 0.019). SR during systole (before HD 1.55 ± 0.40; after HD 1.38 ± 0.35, P = 0.001) and early diastole (before HD -1.41 ± 0.54; after HD -1.16 ± 0.45, P = 0.001) also changed. However, the acute preload change caused by HD did not affect the peak tissue velocity (before HD -6.34 ± 1.58 cm/s; after HD -6.46 ± 1.54 cm/s, P = 0.436) and the SR (before HD -1.36 ± 0.45/s; after HD -1.34 ± 0.29/s, P = 0.621) measured during late diastole.

CONCLUSION

Both tissue velocity and SR during late diastole, representing the contractile function of the LA, are relatively preload-independent parameters and are available for the evaluation of the LA function.

Effect of food intake on commonly used pulsed Doppler and tissue Doppler measurements

OBJECTIVE

This study evaluates the effect of food intake on commonly used pulsed Doppler and tissue Doppler measurements.

METHODS

Twenty-three healthy subjects aged 25.6 ± 4.5 years were investigated. A wide selection of pulsed Doppler and tissue Doppler variables were measured before a standardized meal as well as and 30 and 110 minutes afterwards.

RESULTS

The following variables increased significantly (P < 0.05) 30 minutes after food intake: left ventricular stroke volume, left ventricular cardiac output, left ventricular outflow velocity-time integral, peak of early diastolic (E) and late diastolic (A) mitral flow velocities, pulmonary vein peak velocities in systole (S) and in diastole (D), S/D, pulsed tissue Doppler peak systolic velocities, and late diastolic velocities. Deceleration time of E-wave decreased significantly (P < 0.05). The change in measured variables between fasting and 30 minutes after the food intake ranged from 7% to 28%. There were no significant (P > 0.05) changes in E/A, early diastolic tissue Doppler velocities (e'), and E/e'. Most, but not all variables returned to baseline values 110 minutes after food intake.

CONCLUSIONS

This study shows that food intake affects several echocardiographic variables used to routinely assess diastolic function and hemodynamics. Further studies are warranted in older healthy subjects and in patients with various cardiac diseases to determine whether the findings are reproducible in such populations.

Perioperative assessment of diastolic dysfunction

Assessment of diastolic function should be a component of a comprehensive perioperative transesophageal echocardiographic examination. Abnormal diastolic function exists in >50% of patients presenting for cardiac and high-risk noncardiac surgery, and has been shown to be an independent predictor of adverse postoperative outcome. Normalcy of systolic function in 50% of patients with congestive heart failure implicates diastolic dysfunction as the probable etiology. Comprehensive evaluation of diastolic function requires the use of various, load-dependent Doppler techniques This is further complicated by the additional effects of dehydration and anesthetic drugs on myocardial relaxation and compliance as assessed by these Doppler measures. The availability of more sophisticated Doppler techniques, e.g., Doppler tissue imaging and flow propagation velocity, makes it possible to interrogate left ventricular diastolic function with greater precision, analyze specific stages of diastole, and to differentiate abnormalities of relaxation from compliance. Additionally, various Doppler-derived ratios can be used to estimate left ventricular filling pressures. The varying hemodynamic environment of the operating room mandates modification of the diagnostic algorithms used for ambulatory cardiac patients when left ventricular diastolic function is evaluated with transesophageal echocardiography in anesthetized surgical patients.

Hemodialysis does not impair ventricular functions over 2 years

We aimed to evaluate the long-term effect of hemodialysis (HD) treatment on left and right ventricular (LV and RV) functions in patients with end-stage renal disease. The study population consisted of 22 patients with newly diagnosed end-stage renal disease. Before an arteriovenous fistula was surgically created for HD, the patients were evaluated by echocardiography for systolic and diastolic functions. After the first HD session (mean 24.22 ± 2.14 months), the second echocardiographic evaluations were performed. Left ventricular and RV functions before and after long-term HD treatment were compared. The mean age was 55 ± 13 years and 10 (45%) of the patients were female. After long-term HD treatment, the isovolumic relaxation time was significantly decreased; however, the peak early (E) and late (A) diastolic mitral inflow velocities, E/A ratio, and deceleration time of E wave were not significantly different from the baseline measurements. Also, there was no significantly change in the early diastolic velocity (Ea) of the lateral mitral anulus and the E/Ea ratio. Pulmonary vein peak diastolic velocity, peak atrial reversal velocity, and peak atrial reversal velocity duration remained almost unchanged even though the pulmonary vein peak systolic velocity and the pulmonary vein peak systolic velocity/pulmonary vein peak diastolic velocity ratio were significantly lower after long-term HD treatment. In addition, LV systolic functions, LV diameters, LV mass index, left atrium size, and RV diastolic functions were not statistically different after long-term HD treatment. The myocardium is exposed to hemodynamic, metabolic, and neuro-humoral abnormalities during HD treatment; however, the long-term effects of HD on ventricular functions are not clearly known. The present study showed that the long-term effects of HD on LV and RV functions were insignificant in patients with end-stage renal disease. We have demonstrated that the LV and RV functions did not change significantly after long-term HD treatment. We suggest that this result may be due to regulated blood pressure levels of the patients, treatment of anemia and other metabolic disorders during the HD period and the prevention of weight gain and hypervolemia.

Effect of maintenance hemodialysis on diastolic left ventricular function in end-stage renal disease

PURPOSE

To analyze the effect of maintenance hemodialysis on left ventricular diastolic function in patients with end-stage renal disease.

METHODS

Study population consisted of 42 patients with end-stage renal disease. Before an arteriovenous fistula was surgically created, the patients were evaluated by conventional and Doppler echocardiography and Doppler tissue imaging. Then, the patients undergoing hemodialysis treatment when the arteriovenous fistula was compleated. After the first hemodialysis session (mean 76.14 ± 11.37 days) the second echocardiographic evaluations were performed.

RESULTS

Mean age was 58 ± 13 years and 21 (%50) of the patients were female. After maintenance hemodialysis treatment; peak early (E) and peak late (A) diastolic mitral inflow velocities and E/A ratio were not significantly change however the deceleration time of E wave and left atrial diameter were significantly increased. Also there was no change in the early (Em) and late (Am) diastolic myocardial velocities and Em/Am ratios of lateral and septal walls of left ventricular. E/Em ratio was decreased insignificantly. Pulmonary vein velocities and right ventricular functions are remained almost unchanged after hemodialysis treatment.

DISCUSSION

The acute and long-term effect of hemodialysis on left ventricular diastolic function is unclearly. Patients with end-stage renal disease treatment with hemodialysis via arteriovenous fistula experience a variety of hemodynamic and metabolic abnormalities that predispose to alterations in left and right ventricular functions. The present study showed that left ventricular diastolic function except left atrial diameter and right ventricular functions were not significantly change, however left ventricular systolic functions were impaired after maintenance hemodialysis treatment in patients with end-stage renal disease.

CONCLUSION

It has been suggested that echocardiographic parameters are useful markers for evaluation of left ventricular and right ventricular functions in patients with end-stage renal disease. However, in patients with endstage renal disease treated with hemodialysis, repeated assessment of echocardiographic examinations to observe serial changes in left and right ventricular functions are not yet well established. In this study, we showed that acute changes of volume status and electrolytes and autonomic regulation by hemodialysis session did not affect left ventricular diastolic and right ventricular functions in a relatively long term.

Cardiac assessment in chronic kidney disease

Patients with chronic kidney disease are well recognized to develop a wide range of cardiac structural and functional abnormalities. These changes may be progressive and relate directly to a grossly aggravated risk of cardiovascular events and reduced survival. Although conventional methods of cardiac assessment have been shown to be useful, they are limited by insufficient sensitivity and specificity, to fully appreciate the overall degree of myocardial distress that is common in these patients. This article aims to review the use of established and emerging cardiac imaging tools and, in particular, their application in patients with chronic kidney disease.

Left ventricular filling pressure by Doppler echocardiography in patients with end-stage renal disease

Left ventricular hypertrophy and systolic dysfunction predict mortality in patients with end-stage renal disease. However, the prognostic value of left ventricular filling pressure has remained uncertain in this population. We evaluated whether the early mitral inflow velocity to peak mitral annulus velocity (E/Em) ratio, an estimate of left ventricular filling pressure by tissue Doppler imaging, has significant additional prognostic value to conventional echocardiographic parameters and other clinical and biochemical parameters in 220 patients with end-stage renal disease. The E/Em ratio was elevated (>15) in 62% of the patients. Multivariate analysis showed that an elevated E/Em ratio had the highest correlation with left ventricular volume index, followed by loss of residual glomerular filtration rate, increasing age, worsening ejection fraction, and diabetes. During the median follow-up of 48 months, the E/Em ratio emerged as an independent predictor of all-cause mortality (adjusted hazard ratio: 1.027; 95% CI: 1.003 to 1.051; P=0.026) and cardiovascular death (adjusted hazard ratio: 1.033; 95% CI: 1.002 to 1.065; P=0.035) in the multivariable Cox regression analysis. In addition, the E/Em ratio added significant incremental prognostic value for all-cause mortality (P=0.035) and cardiovascular death (P=0.035) beyond the standard clinical, biochemical, and dialysis parameters and echocardiographic measurements. In conclusion, the E/Em ratio displayed important additional long-term prognostic information above and beyond that of left ventricular mass and systolic function. Our data suggest that left ventricular filling pressure should be estimated during echocardiographic examination for additional prognostication in patients with end-stage renal disease.

Prognostic value of left atrial size in chronic kidney disease

AIMS

Patients with chronic kidney disease (CKD) have high cardiovascular risk. Although stress imaging provides accurate risk estimation in this population, it is unknown if combinatorial cardiac imaging adds incremental value.

METHODS AND RESULTS

We performed transthoracic echocardiography and stress single photon emission computed tomography (SPECT) to assess their value in predicting late cardiovascular disease (CVD) mortality in 200 patients with creatinine clearance <60 mL/min without a history of coronary heart disease. During a median follow-up duration of 3.7 (3.5-4.0) years, there were 25 deaths because of CVD. Older age, abnormal SPECT, and increased indexed left atrial (LA) diameter were associated with CVD mortality on univariate analysis with P = 0.007, 0.01, and 0.004, respectively. In multivariable analysis, indexed LA diameter >24 mm/m(2) was independently predictive of CVD mortality [hazard ratio (HR) 2.75, confidence interval (CI) 1.14-6.59], but abnormal SPECT was not. Each mm/m(2) increase in indexed atrial diameter was associated with an HR 1.20 (95% CI 1.06-1.37).

CONCLUSIONS

In patients with CKD, the indexed LA diameter predicts CVD mortality independent of an abnormal SPECT result. Consideration should be given to this simple measurement as a prognostic tool in this population.

Isovolumic relaxation flow propagation velocity: a promising load-independent relaxation parameter in hemodialysis patients

The aim of this study is to evaluate whether isovolumic relaxation flow propagation velocity (IRFPV), a newly proposed relaxation parameter, is independent of load alterations. Thirty-nine uremic patients (21 men; age 62 +/- 10 y) who underwent echocardiography 1 h before and 1 h after hemodialysis (HD) were included. After HD, body weight, systolic blood pressure, early transmitral filling wave velocity (E), early diastolic mitral annular velocity (Ea) and early diastolic inflow propagation velocity (EPV) decreased significantly (p <or= 0.007), while IRFPV kept constant (p = 0.550). A subgroup analysis showed that in patients with body weight reduction <2.5 kg, E (p = 0.005) decreased significantly, but Ea (p = 0.078), EPV (p = 0.155) and IRFPV (p = 0.324) did not change after HD. In patients with body weight reduction >or=2.5 kg, E (p < 0.001), Ea (p = 0.001) and EPV (p = 0.001) decreased significantly but IRFPV (p = 0.715) was still constant after HD. In conclusion, IRFPV may be a load-independent parameter in assessing left ventricular diastolic function. However, Ea and EPV are load-independent only at minor load alterations. In evaluating left ventricular diastolic function in HD patients whose loading conditions frequently vary with time, IRFPV seems to be more adequate than Ea and EPV.

Three-dimensional echocardiographic analysis of left ventricular function during hemodialysis

BACKGROUND

The effects of hemodialysis (HD) on left ventricular (LV) function have been studied by various echocardiographic techniques (M-mode, 2D echocardiography). These studies are hampered by a low accuracy of measurements because of geometric assumptions regarding LV shape. Three-dimensional echocardiography (3DE) overcomes this limitation.

METHODS

We tested the feasibility of 3DE assessment of LV function during HD. Conventional biplane Simpson rule (BSR) and single plane area length method (SPM) for LV function analysis were used as a reference.

RESULTS

12 HD patients were studied and in 10 (83%) a total of 80 3D datasets were acquired. In 3 patients, one dataset (4%) was of insufficient quality and excluded from analysis. Correlation between SPM, BSR and 3DE for calculation of end-diastolic (EDV, r = 0.89 and r = 0.92, respectively), end-systolic volume (ESV, r = 0.92 and r = 0.93, respectively) and for ejection fraction (EF, r = 0.90 and r = 0.88, respectively) was moderate. Limits-of-agreement results for EDV and ESV were poor with confidence intervals larger than 30 ml. Both 2DE methods underestimated end-diastolic and end-systolic volume, while overestimating ejection fraction.

CONCLUSION

3DE is feasible for image acquisition during HD, which opens the possibility for accurate and reproducible measurement of LV function during HD. This may improve the assessment of the acute effect of HD on LV performance, and guide therapeutic strategies aimed at preventing intradialytic hypotension.

Preload Dependency of the Time Interval Between the Onset of Mitral Inflow and the Early Diastolic Annular Motion A Hemodialysis-Related Preload Reduction Study

BACKGROUND

The novel parameter T(E-E'), which is the time interval between the onset of the early diastolic mitral inflow velocity (E) and the early diastolic mitral annular velocity (E'), is reported to be related to the constant of the left ventricular (LV) relaxation, and T(E-E') is also reported to be useful for predicting the LV filling pressure.

METHODS AND RESULTS

To investigate the effect of preload reduction via hemodialysis on T(E-E'), 28 pairs of echocardiographic evaluations were performed just before and immediately after hemodialysis, including the measurement of the T(E-E') as well as measurement of the conventional echocardiographic parameters. The baseline T(E-E') was 17.9 +/-28.1 ms, which correlated with the ratio of E/E' (r=0.49, p=0.008). After hemodialysis, T(E-E') was shortened to -3.2+/-34.1 ms, which was a significant change from baseline (p=0.001).

CONCLUSIONS

As T(E-E') is a preload dependent parameter, the intravascular volume status should be taken into account when the clinical application of T(E-E') is considered as an index of LV relaxation.

Effect of preload reduction by hemodialysis on myocardial ultrasonic characterization, left atrial volume, and Doppler tissue imaging in patients with end-stage renal disease

The purpose of this study was to investigate the effect of hemodialysis (HD) on myocardial cyclic variation of integrated backscatter (CVIBS), left atrium (LA) volume and tissue Doppler imaging (TDI) in end-stage renal disease (ESRD) patients. We examined 25 patients with ESRD undergoing routine HD and 19 age-matched healthy volunteers. CVIBS, LA volume and left ventricular echocardiographic parameters were measured before and after HD in ESRD patients. CVIBS of both the intervetricular septum and posterior wall were significantly diminished after HD (8.2 +/- 2.5 dB vs. 6.5 +/- 1.8 dB, P < 0.001; 9.2 +/- 2.6 dB vs. 7.6 +/- 2.2dB, p < 0.05 respectively). LA volume decreased significantly after HD (P < 0.05). There was no change in the mitral annulus early diastolic velocity (Em) estimated by TDI. The results of our study demonstrate that HD leads to decrease of CVIBS in ESRD patients and that early mitral annulus velocity (Em) could be preload independent marker of left ventricular diastolic function in ESRD patients.

Impact of myocardial perfusion on left atrial remodeling following primary angioplasty for acute myocardial infarction

OBJECTIVES

To investigate the impact of myocardial perfusion on left atrial remodeling and its determinants after primary percutaneous coronary intervention for acute myocardial infarction.

BACKGROUND

Left atrial volume is an important predictor of morbidity and mortality in acute myocardial infarction, while thrombolysis in myocardial infarction (TIMI) myocardial perfusion (TMP) grade is an angiographic index associated with infarct size and mortality. As yet, however, the relationship between TMP grade and left atrial remodeling has not been investigated.

METHODS

Conventional transthoracic echocardiography was performed in 105 patients (55+/-13 years old, 92 men) with acute myocardial infarction within 24 h and after 6 months (mean 9+/-4, range 6-29 months) following successful primary percutaneous coronary intervention. Absolute left atrial volume was calculated using an elliptical model. Myocardial perfusion was evaluated, using TMP grade, by visual assessment on the coronary angiogram. Patients were divided into three groups on the basis of myocardial perfusion status, as TMP 0/1 (n=36), TMP 2 (n=36) and TMP 3 (n=33).

RESULTS

No difference was observed between baseline and follow-up left atrial volumes in the overall study population (42.5+/-16.1 vs. 43.5+/-17.4 ml, P=0.519). As regards TMP grade, follow-up left atrial volume significantly increased in the TMP 0/1 group (43+/-17 vs. 54.6+/-1.1 ml, P<0.001) and significantly decreased in the TMP 3 group (42.9+/-15.7 vs. 35.5+/-12.2 ml, P=0.001) compared with initial values. No change was observed in left atrial volume in the TMP 2 group. Multivariate analysis showed that TMP grade (P<0.001) and anterior location of myocardial infarction (P<0.001) were independent determinants of left atrial remodeling.

CONCLUSIONS

These results suggest that poor myocardial perfusion and anterior location of myocardial infarction can affect left atrial remodeling in patients with acute myocardial infarction undergoing primary percutaneous coronary intervention. It appears that adequate myocardial perfusion is crucial to prevent left atrial remodeling, a poor prognostic factor in acute myocardial infarction.

Left Atrial Volume Predicts the Risk of Atrial Fibrillation After Cardiac Surgery

OBJECTIVES

This study sought to identify preoperative predictors of postoperative atrial fibrillation (POAF) among patients undergoing cardiac surgery.

BACKGROUND

Postoperative atrial fibrillation is frequent after cardiac surgery and is associated with increased morbidity, mortality, prolonged hospital stay, and increased costs. Left atrial volume (LAV), a marker of chronically elevated left ventricular filling pressure, is a predictor of atrial fibrillation (AF) in the nonsurgical setting.

METHODS

A total of 205 patients (mean age 62 +/- 16 years; 35% women) undergoing cardiac surgery were prospectively enrolled. Clinical risk factors were obtained by detailed medical record review and patient interview. Preoperative transthoracic echocardiograms were performed for assessment of LAV, left ventricular ejection fraction, and diastolic function. Follow-up was complete. Detection of POAF was based on documentation of AF episodes by continuous telemetry throughout hospitalization.

RESULTS

Postoperative atrial fibrillation occurred in 84 patients (41.4%) at a median of 1.8 days after cardiac surgery. The LAV was significantly larger in patients in whom AF developed (49 +/- 14 ml/m2 vs. 39 +/- 16 ml/m2, p = 0.0001). Patients with LAV >32 ml/m2 had an almost five-fold increased risk of POAF, independently of age and clinical risk factors (adjusted hazard ratio 4.84, 95% confidence interval 1.93 to 12.17, p = 0.001). Age and LAV were the only independent predictors of POAF. The area under the receiver-operator characteristics curve to predict POAF was 0.729 for LAV and 0.768 for the combination of LAV and age (both p < 0.0001).

CONCLUSIONS

The LAV is a strong and independent predictor of POAF. Risk stratification using LAV and age enables clinicians to identify high-risk patients before cardiac surgery.

Left atrial volume in end-stage renal disease: a prospective cohort study

BACKGROUND

End-stage renal disease (ESRD) is a high-risk condition and left ventricular hypertrophy (LVH) is the strongest risk factor in this population.

OBJECTIVE AND METHODS

Since the prognostic value of left atrial (LA) size in ESRD is still unknown, we performed a prospective cohort study aimed at testing the prognostic value of LA volume in a cohort of 249 ESRD patients.

RESULTS

Both un-indexed and indexed LA volume (LAV) was significantly higher in dialysis patients than in healthy subjects (P < 0.001). On multivariate analysis only left ventricular mass index (LVMI), LV ejection fraction (LVEF), ratio of early (E) to late atrial (A) mitral Doppler peak flow velocity (E/A ratio) and antihypertensive treatment maintained an independent association with LAV. During the follow-up 113 patients died. LAV added significant prognostic power to a multivariate Cox model of all-cause death and the model based on height provided the best data fit. Notably, this index maintained an independent predictive value for death (P = 0.03) also when LVMI and LVEF were jointly forced into the Cox's model. Neither crude nor body surface area (BSA)-adjusted LAV had an independent association with death when tested in the Cox model including LVMI and LVEF.

CONCLUSIONS

In patients with ESRD, LAV indexed for height displays prognostic value beyond and above that provided by LV mass and function.

Occurrence of Regional Left Ventricular Dysfunction in Patients Undergoing Standard and Biofeedback Dialysis

BACKGROUND

Cardiac failure and cardiovascular death are extremely prevalent in dialysis patients. Recurrent subclinical myocardial ischemia is important in the genesis of heart failure in nondialysis patients. We examined whether this phenomenon occurs in response to the stress of hemodialysis (HD).

METHODS

Eight patients prone to intradialytic hypotension were recruited for a randomized crossover study to compare the development of left ventricular regional wall motion abnormalities during standard (HD) and biofeedback dialysis. Patients underwent serial echocardiography with quantitative analysis to assess ejection fraction and regional left ventricular systolic function during both types of dialysis. Blood pressure and hemodynamic variables also were measured by using continuous pulse wave analysis.

RESULTS

Forty-two new regional wall motion abnormalities developed in all 8 patients during HD compared with 23 regional wall motion abnormalities that developed in 7 patients during biofeedback dialysis (odds ratio, 1.8; 95% confidence interval, 1.1 to 3.0). The majority of regional wall motion abnormalities showed improvement in function by 30 minutes postdialysis. Overall mean regional function was significantly more impaired during HD (P = 0.022). At peak stress, ejection fraction (measured by percentage of change from baseline) was significantly lower during HD (P = 0.043). Blood pressure was higher during biofeedback dialysis, with significantly fewer episodes of hypotension (odds ratio, 2.0; 95% confidence interval, 1.01 to 4.4). Significantly smaller decreases in stroke volume and cardiac output and a greater increment in pulse rate were observed during biofeedback dialysis.

CONCLUSION

This study shows that reversible left ventricular wall motion abnormalities develop during dialysis with ultrafiltration. We also show that this phenomenon can be ameliorated by the improved hemodynamic stability of biofeedback dialysis and therefore is a potential target for intervention.

Mitral Peak Doppler E-wave to Peak Mitral Annulus Velocity Ratio Is an Accurate Estimate of Left Ventricular Filling Pressure and Predicts Mortality in End-stage Renal Disease

OBJECTIVE

The study aimed to assess whether the mitral peak Doppler E-wave to peak mitral annulus velocity ratio (E/Ea) estimates left ventricular (LV) filling pressure (LVFP) and predicts mortality in end-stage renal disease.

METHODS

In all, 125 candidates for renal transplant were prospectively studied. LV end-diastolic pressure of 15 mm Hg or greater at cardiac catheterization was defined as elevated LVFP.

RESULTS

Severe coronary artery disease, N- terminal pro-B-type natriuretic peptide level, left atrial size, flow propagation velocity, mitral E/Ea ratio, pulmonary atrial reversal velocity, and pulmonary-mitral atrial wave duration predicted an increased LVFP. However, the mitral E/Ea ratio (odds ratio 8.1, 95% confidence interval 5.1-9.6, P = .003) was the only independent predictor. An E/Ea of 15 or more, seen in 31 (25%) patients, predicted increased LVFP with sensitivity of 82% and specificity of 88%, and was associated with increased mortality (P = .005).

CONCLUSIONS

In end-stage renal disease, mitral E/Ea ratio 15 or higher accurately predicts increased LVFP and mortality.

Predictive Value of Normal Left Atrial Volume in Stress Echocardiography

OBJECTIVES

Our objective was to evaluate whether normal left atrial volume index (LAVI) is a predictor of a normal stress echocardiogram and thus a predictor of low ischemic risk.

BACKGROUND

Left atrial enlargement is closely related to the chronicity and intensity of the burden of increased ventricular filling pressure. Typically ischemic heart disease (IHD) has a long period of subclinical dysfunction. Increased filling pressure, reflected by enlarged LAVI, is hypothesized to mirror the burden of subclinical and overt IHD. We hypothesized that a normal LAVI might also be useful in predicting low IHD risk.

METHODS

One hundred eighty randomly selected patients (mean age, 63 +/- 15 years; 53% men) underwent outpatient exercise or dobutamine stress echocardiography for known or suspected coronary artery disease. Left atrial volume index was measured retrospectively with the biplane area-length method. The stress echocardiogram was interpreted as abnormal if wall motion abnormalities (WMAs) were noted at rest and/or with stress.

RESULTS

Left atrial volume index was categorized as < or =28 ml/m2 (normal), 28.1 to 32 ml/m2, 32.1 to 36 ml/m2, and >36 ml/m2. Abnormal stress echocardiography was identified in 57 patients (31.7%). The percentage of abnormal stress echocardiograms in each LAVI category was 5.7%, 21.9%, 38.7%, and 54.7%, respectively. The negative predictive value for LAVI < or =28 ml/m2 was 94.3%.

CONCLUSIONS

Normal resting LAVI (< or =28 ml/m2) was strongly predictive of a normal stress echocardiogram. Left atrial volume index might be a simple means of identifying patients with low ischemic risk and should be further evaluated as a complement to the assessment of ischemic risk.

Differing myocardial response to a single session of hemodialysis in end-stage renal disease with and without type 2 diabetes mellitus and coronary artery disease

Background

Though hemodialysis (HD) acutely improves cardiac function, the impact of background diseases like coronary artery disease (CAD) and Type 2 diabetes (DM) in the setting of end-stage renal disease (ESRD) is not known. Tissue velocity echocardiography (TVE) offers a fast choice to follow changes in myocardial function after HD in ESRD with concomitant DM and /or CAD.

Methods

46 subjects (17 with ESRD, Group 1; 15 with DM, Group 2; 14 with DM+CAD, Group 3) underwent standard and TVE prior to and shortly after HD. Besides standard Doppler variables, regional myocardial systolic and diastolic velocities, as well as systolic strain rate were post processed.

Results

Compared with pre-HD, post-HD body weight (kg) significantly decreased in all the three groups (51 ± 9 vs. 48 ± 8, 62 ± 10 vs.59 ± 10, and 61 ± 9 vs. 58 ± 9 respectively; all p < 0.01). Left ventricular end diastolic dimensions (mm) also decreased post- HD (46 ± 5 vs. 42 ± 7, 53 ± 7 vs. 50 ± 7, 51 ± 7 vs. 47 ± 8 respectively; all p < 0.01). Regional longitudinal peak systolic velocity in septum (cm/s) significantly increased post-HD in Group 1(5.7 ± 1.6 vs. 7.2 ± 2.3; p < 0.001) while remained unchanged in the other two groups. Similar trends were noted in other left ventricular walls. When the myocardial velocities (cm/s) were computed globally, the improvement was seen only in Group 1 (6.3 ± 1.5 vs. 7.9 ± 2.0; p < 0.001). Global early regional diastolic velocity (cm/s) improved in Group 1, remained unchanged in Group 2, while significantly decreased in Group 3(-5.9 ± 1.3 vs. -4.1 ± 1.8; p < 0.01). Global systolic strain rate (1/sec) increased in the first 2 Groups but remained unchanged (-0.87 ± 0.4 vs. -0.94 ± 0.3; p = ns) in Group 3.

Conclusion

A single HD session improves LV function only in ESRD without coexistent DM and/or CAD. The present data suggest that not only dialysis-dependent changes in loading conditions but also co-existent background diseases determine the myocardial response to HD.