Left ventricular volumes determined by two-dimensional echocardiography in a normal adult population

Revisiting Echocardiographic Ranges of Left Ventricular End-Diastolic Volume Index: An Analysis of the Discrepancies Between the 2006 and the 2015 Recommendation for Chamber Quantification Guidelines

BACKGROUND

Indexed left ventricular end-diastolic volume (LVEDVi) is a left ventricle (LV) size marker. The "Recommendations for Chamber Quantification" guideline was published in 2006 and updated in 2015. Although the previous guideline maintained uniform cutoff points for both men and women, the latest revision introduced new thresholds that vary between genders. We evaluated the extent of change in labeled indexed LV diastolic volumes in men and women following the adoption of the 2015 guideline.

METHODS

Data were extracted from a web-based registry from March 2020 to October 2022. LV indexed volume variables were categorized on the basis of the 2006 and 2015 guidelines.

RESULTS

Among the 7598 individuals, the classification of LVEDVi differed in 910 (12.0%) individuals. In 213 (5.5%) female subjects, substantial reclassification (i.e., transitioning from normal to moderate LV enlargement to mild to severe LV enlargement) occurred on the basis of the 2015 guideline. All females classified as having moderately abnormal LVEDVi according to the 2006 guideline were reclassified as having severely abnormal LVEDVi according to the 2015 guideline. Age, LV ejection fraction (LVEF), and significant aortic regurgitation (AR) were common factors contributing to the observed discrepancy in both men and women. Significant mitral regurgitation (MR) and regional or global motion abnormality were correlated with the reclassification of LVEDVi to higher abnormal partitions only in women.

CONCLUSION

The observed disparities underscore the importance of ongoing dedicated research to reassess the range of indexed echocardiographic parameters, considering various outcomes and differences in countries.

Comparison of Left Ventricular Stroke Volume in 2nd- and 3rd-Trimester Fetuses Measured by the Product of VTI and Aortic Annular Area With That Assessed by Simpson's Single-Plane Rule Using the STE Technique

OBJECTIVES

The aim of the study was to compare left ventricle stroke volume in healthy, eutrophic fetuses in the 2nd and 3rd trimesters evaluated using the velocity time integral and aortic annulus area with left ventricular stroke volume measured using Simpson's single-plane rule and to determine the discrepancy equation.

METHODS

The study included 354 fetuses. In each fetus, during the same examination, simultaneous assessment of stroke volume was performed by pulsed-wave Doppler using the product of the velocity time integral and aortic annulus area and by the fetalHQ® software using Simpson's single-plane rule. The Mann-Whitney U test was used to compare the "product-derived" stroke volume and stroke volume using fetalHQ® software values in the 2nd and 3rd trimesters separately. The agreement between the two methods were verified using Bland-Altman analysis. A linear regression model was used to obtain the discrepancy equation.

RESULTS

In the 2nd trimester, the mean percentage difference between both the techniques showed that the stroke volume values determined using pulsed-wave Doppler were, on average, 88% higher than the stroke volume values determined using fetalHQ®. The upper limit of agreement between the compared techniques was approximately 146% and the lower limit of agreement was equal to 29.6%. In the 3rd trimester, the results indicated that the stroke volume values determined using pulsed-wave Doppler were, on average, 76% higher than the stroke volume values determined using fetalHQ®. The upper limit of agreement between the compared techniques was approximately 129% and the lower limit of agreement was 23%. Based on the results of the linear regression models, discrepancy formulas of the stroke volume values were obtained. The equations to calculate the predicted mean and standard deviations were used to compute the reference intervals for the mean, 5th and 95th centiles.

CONCLUSION

The calculation of left ventricular stroke volume using pulsed Doppler has higher result in relation to stroke volume determined using Simpson's rule significantly. The aortic annulus area showed a higher correlation regarding stroke volume than the velocity time integral in both the 2nd and 3rd trimesters. Stroke volume increased with the increase in aortic annulus area, whereas the velocity time integral remained relatively constant. The retrospective analysis of the collected material enabled the determination of the discrepancy equation.

Central Nervous System Actions of Leptin Improve Cardiac Function After Ischemia–Reperfusion: Roles of Sympathetic Innervation and Sex Differences

Background

Therapeutic strategies for preventing paradoxical reperfusion injury after myocardial ischemia are limited. We tested whether central nervous system actions of leptin induce important protective effects on cardiac function and metabolism after myocardial ischemia/reperfusion (I/R) injury, the role of cardiac sympathetic innervation in mediating these effects, and whether there are major sex differences in the cardioprotective effects of chronic central nervous system leptin infusion.

Methods and Results

Myocardial I/R was induced by temporary ligation of the left descending coronary artery in male and female Wistar rats instrumented with intracerebroventricular cannula in the lateral ventricle. Vehicle or leptin (0.62 μg/h) infusion was started immediately after reperfusion and continued for 28 days using osmotic minipumps connected to the intracerebroventricular cannula. Cardiac function was assessed by echocardiography, ventricular pressures, and exercise performance. Intracerebroventricular leptin treatment markedly attenuated cardiac dysfunction post‐I/R as evidenced by improved ejection fraction (56.7±1.9 versus 22.6%±1.1%), maximal rate of left ventricle rise (11 680±2122 versus 5022±441 mm Hg) and exercise performance (−4.2±7.9 versus −68.2±3.8 Δ%) compared with vehicle‐treated rats. Intracerebroventricular leptin infusion reduced infarct size in females, but not males, when compared with ad‐lib fed or pair‐fed saline‐treated rats. Intracerebroventricular leptin treatment also increased cardiac NAD + /NADH content (≈10‐fold) and improved mitochondrial function when compared with vehicle treatment. Cervical ganglia denervation did not attenuate the cardiac protective effects of leptin after I/R injury.

Conclusions

These data indicate that leptin, via its central nervous system actions, markedly improves overall heart function and mitochondrial metabolism after I/R injury regardless of sex, effects that are largely independent of cardiac sympathetic innervation.

Automatic cardiac evaluations using a deep video object segmentation network

BACKGROUND

Accurate cardiac volume and function assessment have valuable and significant diagnostic implications for patients suffering from ventricular dysfunction and cardiovascular disease. This study has focused on finding a reliable assistant to help physicians have more reliable and accurate cardiac measurements using a deep neural network. EchoRCNN is a semi-automated neural network for echocardiography sequence segmentation using a combination of mask region-based convolutional neural network image segmentation structure with reference-guided mask propagation video object segmentation network.

RESULTS

The proposed method accurately segments the left and right ventricle regions in four-chamber view echocardiography series with a dice similarity coefficient of 94.03% and 94.97%, respectively. Further post-processing procedures on the segmented left and right ventricle regions resulted in a mean absolute error of 3.13% and 2.03% for ejection fraction and fractional area change parameters, respectively.

CONCLUSION

This study has achieved excellent performance on the left and right ventricle segmentation, leading to more accurate estimations of vital cardiac parameters such as ejection fraction and fractional area change parameters in the left and right ventricle functionalities, respectively. The results represent that our method can predict an assured, accurate, and reliable cardiac function diagnosis in clinical screenings.

Low- vs high-dose ARNI effects on clinical status, exercise performance and cardiac function in real-life HFrEF patients

Purpose

Only a few studies are available on dose-related effects of sacubitril/valsartan (angiotensin receptor neprilysin inhibition (ARNI)) in real-life patients with heart failure and reduced ejection fraction (HFrEF). We sought to investigate clinical and functional effects in real-life HFrEF patients receiving ARNI at a different cumulative dose.

Methods

This was an observational study in consecutive outpatients admitted for HFrEF from October 2017 to June 2019. The PARADIGM criteria were needed for enrolment. ARNI was uptitrated according to blood pressure, drug tolerability, renal function and kaliemia. At least 10-month follow-up was required in each patient. Clinical assessment, Kansas City Cardiomyopathy Questionnaire (KCCQ) score, 6-min walk test and strain echocardiography were performed in each patient on a regular basis during the observational period. At the end of the study, patients were divided into two groups based on the median yearly dose of the ARNI medication.

Results

A total of 90 patients, 64 ± 11 years, 82% males, were enrolled. The cut-off dose was established in 75 mg BID, and the study population was divided into group A (≤ 75 mg), 52 patients (58%), and group B (> 75 mg), 38 patients (42%). The follow-up duration was 12 months (range 11–13). NYHA class, KCCQ score and 6MWT performance ameliorated in both groups, with a quicker time to benefit in group B. The proportion of patients walking > 350 m increased from 21 to 58% in group A (p < 0.001), and from 29 to 82% in group B (p < 0.001). A positive effect was also disclosed in the left ventricular remodelling, strain deformation and diastolic function.

Conclusion

One-year ARNI treatment was effective in our real-life HFrEF patient population, leading to clinical and functional improvement in both study groups, slightly greater and with a shorter time to benefit in group B.

Supplementary information

The online version contains supplementary material available at 10.1007/s00228-021-03210-0.

Restoration of Cardiac Function After Myocardial Infarction by Long-Term Activation of the CNS Leptin-Melanocortin System

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Leptin protects against progression to heart failure after myocardial infarction.

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This beneficial effect requires activation of the brain melanocortin system.

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Stimulation of brain MC4R recapitulates the cardiac protective effects of leptin.

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Leptin-MC4R activation improves cardiac substrate oxidation and mitochondrial function.

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It also improves Ca²⁺ coupling and contractile function in viable cardiomyocytes after MI.

Heart failure has a high mortality rate, and current therapies offer limited benefits. The authors demonstrate that activation of the central nervous system leptin-melanocortin pathway confers remarkable protection against progressive heart failure following severe myocardial infarction. The beneficial cardiac-protective actions of leptin require activation of brain melanocortin-4 receptors and elicit improvements in cardiac substrate oxidation, cardiomyocyte contractility, Ca²⁺ coupling, and mitochondrial efficiency. These findings highlight a potentially novel therapeutic approach for myocardial infarction and heart failure.

Effects of Sacubitril/Valsartan in Patients with High Arrhythmic Risk and an ICD: A Longitudinal Study

PURPOSE

Patients affected by heart failure with reduced ejection fraction (HFrEF) receive clinical and functional beneficial effects from treatment with sacubitril/valsartan. However previous studies have shown that patients with an implantable cardioverter defibrillator (ICD) could obtain even greater benefit, but only make up a only a small proportion of patients. In the current study we evaluated the effect of sacubitril/valsartan in patients with an ICD.

METHODS

Thirty-five outpatients with HFrEF (aged 60 ± 11 years, 28 were males), on optimal medical therapy were studied. All patients received an ICD at least 6 months before enrollment or were non-responders to ICD plus resynchronization (CRT-D). An open-label sacubitril/valsartan treatment was established at the maximum tolerated dose. Clinical assessment, 6-min walk test (6MWT) and echocardiography, were performed during follow-up at 90, 180, and 360 days. Quality of life score and perceived fatigue on exercise were assessed.

RESULTS

Clinical conditions dramatically improved in most patients, especially within the first 6 months of therapy (76 % were in NYHA-I and 24 % in NYHA-II at the end of study vs 71 % NYHA-II and 29 % NYHA III at enrollment, p < 0.001). Quality of life and exercise performance significantly improved according to N-terminal pro-brain natriuretic peptide (NT-proBNP) serum levels lowering. Walking distance at 6MWT increased from 274 ± 97 to 389 ± 53 m and walking speed from 0.74 ± 0.27 to 1.07 ± 0.15 m/s (p < 0.001), while oxygen saturation did not differ significantly (from 90 ± 1 % to 91 ± 2 %). More gradual was left ventricular reverse remodeling. Ejection fraction improved mildly (+ 5 points %, p < 0.001). Global longitudinal strain and diastolic function were also assessed over time.

CONCLUSION

Sacubitril/valsartan therapy for HFrEF may lead to significant clinical and functional improvements even in patients with ICD at greater arrhythmic risk. Clinical improvement is obtained within the first 6 months of treatment while reverse remodeling needs more time.

Gender difference and genetic variance in lipoprotein receptor-related protein 1 is associated with mortality

Cardiovascular diseases are an important health resource problem and studies have shown a genetic association between single nucleotide polymorphisms (SNPs) and cardiovascular diseases. According to the literature, lipoprotein receptor-related protein 1 (LRP1) is associated with coronary artery disease. The aim of the present study was to evaluate a possible association between different genotypes of LRP1 and all-cause and cardiovascular mortality from a gender perspective. In the present study, 489 elderly community-living people were invited to participate. Clinical examination, echocardiography and blood sampling including SNP analyses of LRP1 (rs1466535) were performed, including the T/T, C/T and C/C genotypes, and the participants were followed for 6.7 years. During the follow-up period, 116 (24%) all-cause and 75 (15%) cardiovascular deaths were registered. In the female population, the LRP1 of the T/T or C/T genotype exhibited a 5.6-fold increased risk of cardiovascular mortality and a 2.8-fold increased risk of all-cause mortality compared with the C/C genotype. No such genotype differences could be seen in the male population. Gender differences could be seen regarding the risk of mortality in the different genotypes. Females with the LRP1 T/T or C/T genotypes exhibited a significantly increased risk of both all-cause and cardiovascular mortality compared with the C/C genotypes. Therefore, more individualized cardiovascular prevention and treatment should be prioritized. However, since this was a small study, the observations should only be regarded as hypothesis-generating.

Evaluation of Fetal Left Ventricular Size and Function Using Speckle-Tracking and the Simpson Rule

OBJECTIVES

This study was conducted to evaluate left ventricular (LV) size and function in healthy fetuses and to test a cohort of fetuses at risk for abnormal function using speckle-tracking software.

METHODS

Two hundred control fetuses were examined between 20 and 40 weeks' gestation. With the use of offline speckle-tracking software, the end-diastolic and end-systolic volumes were measured and the following computed: stroke volume (SV), SV per kilogram, cardiac output (CO), CO per kilogram, and ejection fraction. These were regressed against 7 independent variables related to the size, weight, and age of the fetuses. Five fetuses with risk factors for LV dysfunction were examined to sample the validity of the data from the control group.

RESULTS

The R² values for measurements of the end-diastolic volume, SV, and CO correlated with the 7 independent variables of fetal size and age (0.7-0.78), whereas the SV/kg, CO/kg, and ejection fraction had lower R² values (0.02-0.1). The measurements were normally distributed (Shapiro-Wilke > 0.5). The 5 fetuses at risk for abnormal LV function had measurements of LV size and function that were consistent with the expected pathologic condition.

CONCLUSIONS

Speckle tracking can provide a comprehensive evaluation of the size and function of the fetal LV.

Comparison between Bolus Intracoronary versus Bolus Intravenous Injection Regimens of Eptifibatide during Primary Percutaneous Coronary Intervention in Patients with Anterior ST-Segment Elevation Myocardial Infarction

Background.Eptifibatide achieves high local concentration via direct intracoronary (I/V) injection as it promotes clot disaggregation, but it remains unclear if it is of superior benefit than the routine intravenous (I/V) administration. Aim. The current study aimed to examine the safety and efficacy of I/C vs I/V bolus regimen dose of eptifibatide during primary percutaneous coronary intervention (PPCI).

Material and methods. Prospective, controlled, randomized study enrolled 100 patients with acute anterior ST-segment elevation myocardial infarction (STEMI) eligible for PPCI equally divided into 2 groups (group A received bolus I/C eptifibatide and group B received it I/V) followed by 12-hour continuous I/V infusion. Features related to of myocardial salvage in the form of TIMI flow grade 3, myocardial blush grade 3, ST segment resolution and left ventricular systolic function were evaluated with short-term follow up for 1 month.

Results. Mean age of the study population was 50.95±8.45years, there was statistically insignificant difference between both groups regarding baseline characteristics in age (p=0.062), gender (p=0.488), coronary artery disease risk factors (p>0.05), time from onset of pain to admission (p=0.86) or door to balloon (p=0.12). Group A achieved statistically significant better myocardial blush grade 3 (42% vs 10%, p=0.005), ejection faction 30 days after PPCI (46.11±7.81% vs 40.88±6.26%, p=0.005) but statistically insignificant TIMI flow grade 3 (p=0.29) and ST resolution (p=0.34). Incidence of complications in the hospital and 30 days after discharge was statistically insignificant (p>0.05).

Conclusion. Both regimens were safe and effective in STEMI patients undergoing PPCI and regimen of I/C bolus eptifibatide achieved better myocardial blush grade and systolic function. 

Relationship between climate and hemodynamics according to echocardiography

Studies performed in controlled laboratory conditions have shown that environmental thermal application may induce various circulatory changes. We aimed to demonstrate the effect of local climate on hemodynamics according to echocardiography. Echocardiographic studies conducted in ambulatory patients, 18 yr of age or older, between January 2012 and July 2016, at our medical center, for whom climate data on the day of the echocardiogram study were available, were retrospectively included in case climate data. Discomfort index, apparent temperature, temperature-humidity index, and thermal index were computed. Echocardiograms conducted in hotter months (June-November) were compared with those done in colder months (December-May). The cohort consisted of 11,348 individuals, 46.2% women, and mean age of 57.9 ± 18.1 yr. Climate indexes correlated directly with stroke volume ( r = 0.039) and e' (lateral r = 0.047; septal r = 0.038), and inversely with systolic pulmonary artery pressure (SPAP; r = -0.038) (all P values < 0.05). After adjustment for age and sex, echocardiograms conducted during June-November had a lower chance to show e' septal < 7 cm/s (odds ratio 0.88, 95% confidence interval 0.78-0.98, P = 0.017) and SPAP > 40 mmHg (odds ratio 0.81, 95% confidence interval 0.67-0.99, P = 0.04) compared with those conducted in other months. The authors concluded that climate may affect hemodynamics, according to echocardiographic assessment in ambulatory patients. NEW & NOTEWORTHY In the present study, we examined 11,348 individuals who underwent ambulatory echocardiography. Analyses of the echocardiographic studies demonstrated that environmental thermal stress, i.e., climate, may affect hemodynamics. Most notably were the effects on diastolic function. Higher values of mitral e', stroke volume, as well as ejection fraction, and lower values of systolic pulmonary artery pressure and tricuspid regurgitation were demonstrated on hotter days and seasons.

A Langendorff-like system to quantify cardiac pump function in adult zebrafish

Zebrafish are increasingly used as a vertebrate model to study human cardiovascular disorders. Although heart structure and function are readily visualized in zebrafish embryos because of their optical transparency, the lack of effective tools for evaluating the hearts of older, nontransparent fish has been a major limiting factor. The recent development of high-frequency echocardiography has been an important advance for in vivo cardiac assessment, but it necessitates anesthesia and has limited ability to study acute interventions. We report the development of an alternative experimental ex vivo technique for quantifying heart size and function that resembles the Langendorff heart preparations that have been widely used in mammalian models. Dissected adult zebrafish hearts were perfused with a calcium-containing buffer, and a beat frequency was maintained with electrical stimulation. The impact of pacing frequency, flow rate and perfusate calcium concentration on ventricular performance (including end-diastolic and end-systolic volumes, ejection fraction, radial strain, and maximal velocities of shortening and relaxation) were evaluated and optimal conditions defined. We determined the effects of age on heart function in wild-type male and female zebrafish, and successfully detected hypercontractile and hypocontractile responses after adrenergic stimulation or doxorubicin treatment, respectively. Good correlations were found between indices of cardiac contractility obtained with high-frequency echocardiography and with the ex vivo technique in a subset of fish studied with both methods. The ex vivo beating heart preparation is a valuable addition to the cardiac function tool kit that will expand the use of adult zebrafish for cardiovascular research.

Determination of Fetal Left Ventricular Volume Based on Two-Dimensional Echocardiography

Determination of fetal left ventricular (LV) volume in two-dimensional echocardiography (2DE) is significantly important for quantitative analysis of fetal cardiac function. A backpropagation (BP) neural network method is proposed to predict LV volume more accurately and effectively. The 2DE LV border and volume are considered as the input and output of BP neural network correspondingly. To unify and simplify the input of the BP neural network, 16 distances calculated from the border to its center with equal angle are used instead of the border. Fifty cases (forty frames for each) were used for this study. Half of them selected randomly are used for training, and the others are used for testing. To illustrate the performance of BP neural network, area-length method, Simpson's method, and multivariate nonlinear regression equation method were compared by comparisons with the volume references in concordance correlation coefficient (CCC), intraclass correlation coefficient (ICC), and Bland-Altman plots. The ICC and CCC for BP neural network with the volume references were the highest. For Bland-Altman plots, the BP neural network also shows the highest agreement and reliability with volume references. With the accurate LV volume, LV function parameters (stroke volume (SV) and ejection fraction (EF)) are calculated accurately.

Reduced exercise capacity in genetic haemochromatosis

BACKGROUND

Many patients with genetic haemochromatosis complain about fatigue and reduced physical capacity. Exercise capacity, however, has not been evaluated in larger series of haemochromatosis patients treated with repeated phlebotomy.

DESIGN AND METHODS

We performed exercise echocardiography in 152 treated haemochromatosis patients (48+/-13 years, 26% women) and 50 healthy blood donors (49+/-13 years, 30% women), who served as controls. Echocardiography was performed at rest and during exercise in a semiupright position on a chair bicycle, starting from 20 W, increasing by 20 W/min. Transmitral early and atrial velocity and isovolumic relaxation time were measured at each step. Ventilatory gas exchange was measured by the breath-to-breath-technique.

RESULTS

Compared with healthy controls, haemochromatosis patients were more obese and less trained. More of them smoked, and 17% had a history of cardiovascular or pulmonary disease. Adjusted for training, the left ventricular function and dimensions at rest did not differ between the groups. During exercise the haemochromatosis patients obtained a significantly lower peak oxygen (O2) uptake (28.1 vs. 34.4 ml/kg per min, P<0.001). In a multiple regression analysis haemochromatosis predicted lower peak O2 uptake independently of significant contributions of sex, age, and height, as well as of systolic blood pressure and log-transformed isovolumic relaxation time at peak exercise, whereas no independent association was found with weight or physical activity (multiple R=0.74, P<0.001). Adding genotype, s-ferritin, prevalence of smoking, or history of cardiopulmonary disease among the covariates in subsequent models did not change the results.

CONCLUSION

Genetic haemochromatosis, even when treated with regular phlebotomy, is associated with lower exercise capacity independently of other covariates of exercise capacity.

Effects of Levosimendan on Left Ventricular Functional Remodelling and Exercise Intolerance: A Tissue Doppler Study

Levosimendan is a calcium sensitizer that demonstrates enhanced myocardial contractility. There is little information concerning the effect of levosimendan on left ventricular tissue parameters and exercise capacity. We evaluated the effects of a 24-h course of levosimendan therapy on cardiac tissue parameters in 30 patients, aged 48-70 years, admitted to our hospital for the management of decompensated heart failure. All patients underwent echocardiographic examination using tissue Doppler imaging (TDI) and a 6-min walk test. Systolic myocardial velocity of the mitral annulus (Sm) was significantly increased in levosimendantreated patients compared with placebotreated patients. There was a positive correlation between Sm and exercise capacity. Levosimendan might be expected to increase cardiac contractile force, especially Sm velocity, in parallel with exercise tolerance. The study has also shown that the progress of ventricular function after levosimendan treatment in patients with exercise intolerance could be monitored effectively by Sm velocity measurements using TDI.

Classification of left ventricular size: diameter or volume with contrast echocardiography?

Background

Left ventricular (LV) size is an important clinical variable, commonly assessed at echocardiography by measurement of the internal diameter in diastole (IDD). However, this has recognised limitations and volumetric measurement from apical views is considered superior, particularly with the use of echocardiographic contrast. We sought to determine the agreement in classification of LV size by different measures in a large population of patients undergoing echocardiography.

Methods and results

Data were analysed retrospectively from consecutive patients (n=2008, 61% male, median 62 years) who received echocardiographic contrast for LV opacification over 3 years in a single institution. Repeat studies were not included. LVIDD was measured, and LV end-diastolic volume (LVEDV) calculated using Simpson's biplane method. Both measures were indexed (i) to body surface area and categorised according to the American Society of Echocardiography (ASE) guidelines as normal, mild, moderate or severely dilated. Of 320 patients with a severely dilated LVEDVi, only 95 (30%) were similarly classified by LVIDD, with 86 patients (27%) measuring in the normal range. LVIDDi agreement was poorer, with only 43 patients (13%) classified as being severely dilated, and 173 (54%) measuring in the normal range.

Conclusions

Currently recommended echocardiographic measures of LV size show limited agreement when classified according to currently recommended cut-offs. LV diameter should have a limited role in the assessment of LV size, particularly where a finding of LV dilation has important diagnostic or therapeutic implications.

Characterization of echocardiographic measures of cardiac structure and function in healthy octogenarians

BACKGROUND

Currently, there is not enough echocardiographic information regarding aging-associated changes in the octogenarian population. We aimed to characterize echocardiographic measures of structure and function among a group of healthy octogenarians.

METHODS

Approximately 350 octogenarians, residing in nursing homes, were screened in Ankara, Turkey. According to inclusion criteria, 40 octogenarians were enrolled. These subjects underwent conventional and tissue Doppler echocardiography according to the guidelines of the American Society of Echocardiography (ASE). The population was also separated into various groups according to gender, body mass index (BMI, <25 vs. 25-29.9), and blood pressure (<80/120 mmHg vs. 80-89/120-139 mmHg). All measurements were indexed by dividing to body surface area (BSA) for standardization.

RESULTS

Left ventricular mass (LVM), posterior wall thickness, right ventricular diameter, tricuspid E/A ratio, and septal e'-wave velocity were significantly higher in men, which lost significance after adjusting for BSA. There was no significant difference between groups formed by BMI and blood pressure. Moreover, mild global left and right ventricular dysfunction including a prominent diastolic counterpart, however, with normal ejection fraction was revealed using conventional and tissue Doppler techniques. Finally, we checked our results with the current reference values of the ASE and observed the following differences: ventricular septum, relative wall thickness, LVM, and mass index values were above ASE reference range, posterior wall measurements were close to upper range. On the contrary, left ventricular diameters and volumes were below ASE reference range.

CONCLUSIONS

We described echocardiographic measures of structure and function in a group of healthy octogenarians.

Transesophageal Echocardiography in Healthy Young Adult Male Baboons (Papio hamadryas anubis): Normal Cardiac Anatomy and Function in Subhuman Primates Compared to Humans

Implantable, viable tissue engineered cardiovascular constructs are rapidly approaching clinical translation. Species typically utilized as preclinical large animal models are food stock ungulates for which cross species biological and genomic differences with humans are great. Multiple authorities have recommended developing subhuman primate models for testing regenerative surgical strategies to mitigate xenotransplant inflammation. However, there is a lack of specific quantitative cardiac imaging comparisons between humans and the genomically similar baboons (Papio hamadryas anubis). This study was undertaken to translate to baboons transesophageal echocardiographic functional and dimensional criteria defined as necessary for defining cardiac anatomy and function in the perioperative setting. Seventeen young, healthy baboons (approximately 30 kg, similar to 5 year old children) were studied to determine whether the requisite 11 views and 52 measurement parameters could be reliably acquired by transesophageal echocardiography (TEE). The obtained measurements were compared to human adult normative literature values and to a large relational database of pediatric "normal heart" echo measurements. Comparisons to humans, when normalized to BSA, revealed a trend in baboons toward larger mitral and aortic valve effective orifice areas and much larger left ventricular muscle mass and wall thickness, but similar pulmonary and tricuspid valves. By modifying probe positioning relative to human techniques, all recommended TEE views except transgastric could be replicated. To supplement, two transthoracic apical views were discovered that in baboons could reliably replace the transgastric TEE view. Thus, all requisite echo views could be obtained for a complete cardiac evaluation in Papio hamadryas anubis to noninvasively quantify cardiac structural anatomy, physiology, and dimensions. Despite similarities between the species, there are subtle and important physiologic and anatomic differences when compared to human.

Changes in left atrial mechanics following pericardiectomy for pericardial constriction

BACKGROUND

Although impaired left ventricular (LV) filling in constrictive pericarditis (CP) is attributable to external constraints by a tethered pericardium, impaired left atrial (LA) function can further impair LV filling. Previous studies focused on the impact of a tethered pericardium on LV diastolic behavior, but its impact on LA function has been largely overlooked. The objectives of this study were to evaluate LA mechanics in CP and to assess the impact of pericardiectomy on LA mechanics.

METHODS

A total of 52 patients with CP (mean age, 57 ± 12 years) and 19 control subjects were studied retrospectively. All patients with CP underwent echocardiography before (median, 12 days; interquartile range, 5-34 days) and after pericardiectomy (median, 20 days; interquartile range, 5-64 days). Global LA longitudinal strain (ε) was calculated, which included peak negative ε (εnegative), peak positive ε (εpositive), and the sum of those values, total LA ε (εtotal), using speckle-tracking echocardiography with Velocity Vector Imaging. The regional difference of LA ε between the septal and lateral walls was assessed before and after the procedure.

RESULTS

Patients with CP showed depressed global LA εnegative, LA εtotal, and LA εpositive compared with controls. LA contractile (global LA εnegative) and reservoir functions (global LA εtotal) showed significant increases after pericardiectomy. Regional analysis revealed that the improvement in LA function after surgery was more apparent in lateral segments, while the regional function of septal walls was depressed after surgery.

CONCLUSIONS

Patients with CP have impaired LA mechanics, presumably because of the constrictive tethering process involving the left atrium. Speckle-tracking echocardiography showed consistent results of changes in LA mechanics with conventional echocardiographic parameters early after the procedure. Regional ε analysis aided in recognition of the impact of constrictive tethering and pericardiectomy on LA function.

5/6 Area length method for left-ventricular ejection-fraction measurement in adults with repaired tetralogy of Fallot: comparison with cardiovascular magnetic resonance

In patients with repaired tetralogy of Fallot (rTOF), left-ventricular ejection fraction (LVEF) predicts adverse outcomes. Two-dimensional echocardiographic (2DE) methods of measuring LVEF require geometric assumptions and may be limited in this population due to altered ventricular geometry. This study evaluated the performance of the 5/6 area × length (AL) method in this population as well as which factors limit agreement with the results of cardiovascular magnetic resonance (CMR). In 20 patients with rTOF (28.5 ± 14.7 years old) and CMR and 2DE within 3 months, two investigators blinded to CMR measured LVEF from 2DE by the AL method, biplane Simpson's (BiS) method, and visual estimate. Two investigators blinded to 2DE measured LVEF from CMR by Simpson's and AL methods. The AL method on 2DE more closely approximated LVEF by CMR (r = 0.73, p = 0.0003) than BiS method (r = 0.53, p = 0.02). AL method was not limited by geometric assumptions, as AL method on CMR closely approximated Simpson's method on CMR (r = 0.90, p < 0.0001) despite median left-ventricular diastolic eccentricity index of 1.24. AL method on 2DE was primarily limited by short-axis area measurement rather than foreshortening of the ventricle. In conclusion, in adults with rTOF, AL method on 2DE moderately approximates LVEF by CMR, even in the context of altered left-ventricular geometry. Although the AL method may be the most appropriate 2DE method in this population, significant limitations remain for LVEF assessment by 2DE, and strategies to optimize image position and border detection are essential.

Distribution and categorization of left ventricular measurements in the general population: results from the population-based Gutenberg Heart Study

BACKGROUND

Echocardiography, the dominant imaging modality for quantification of left ventricular metrics, has undergone continuing development in the past few decades. However, given the lack of population-based data, current guidelines are still based on restricted and small data sets analyzed with methods including expert opinion. This work presents empirically derived reference values from a large-scale, epidemiologic study conducted with state-of-the-art imaging technology and methods.

METHODS AND RESULTS

The distribution of echocardiographic measurements of the left ventricle was analyzed in a population-based sample of 5000 mid-Europeans from the Gutenberg Heart Study in Germany. The randomly selected, noninstitutionalized sample provides data on apparently healthy individuals, as well as on those with prevalent disease. Standardized echocardiograms were recorded in a comprehensive data set at a single site with centralized training and certification of sonographers. Sex-specific reference limits and categories indicating the grade of deviation from the reference were calculated, and nomograms were created by quantile regression. Detailed information is given on the association between left ventricular geometry and age.

CONCLUSIONS

The rapidly evolving echocardiographic technology with persistent improvements in image quality and new measurement conventions require the evaluation of new reference limits for left ventricular metrics. The present investigation formulates reference limits and nomograms from state-of-the-art technology and methods based on a large population-based data set. The distribution of echocardiographic measures of left ventricular geometry presents, in part, nonlinear associations with age, which should be the subject of future investigations.

Effects of fluid resuscitation on cardiovascular performance after posttraumatic pneumonectomy

BACKGROUND

: Several factors have been implicated in the high-mortality rate of posttraumatic pneumonectomy. In this study, we evaluated the hemodynamic and echocardiographic changes induced by pneumonectomy and fluid resuscitation after hemorrhagic shock.

METHODS

: Fourteen dogs were bled to a target mean arterial pressure of 40 mmHg. The animals were assigned to two groups: control (no fluid resuscitation) and lactated Ringer's (3 x shed blood volume). The left pulmonary hilum was cross clamped, and the animals were observed for 60 minutes. Systemic hemodynamics was evaluated using Swan-Ganz, arterial catheter, and ultrasonic flow probe. Systemic O2-derived variables were calculated. Ejection fraction was determined by two-dimensional echocardiography.

RESULTS

: Fluid resuscitation improved the mean arterial pressure and systemic oxygen delivery. After pneumonectomy, no significant increase in right ventricular pressure was observed in the LR group. No signs of major ventricular dilation or changes in arterial oxygenation were observed.

CONCLUSION

: Our data suggest that pneumonectomy is not associated with early pulmonary hypertension; gentle fluid resuscitation improves cardiovascular performance and is not associated with an increase in right ventricular pressure.

Gender differences in systolic tissue velocity: role of left ventricular length

AIMS

Previous research has described differences in left ventricular (LV) systolic tissue velocity between genders. This study aimed to determine the association between LV tissue velocity and LV size in healthy controls and in those with type 2 diabetes (T2DM).

METHODS AND RESULTS

LV tissue velocities were measured in 71 controls and 222 patients with T2DM by pulsed-wave Doppler and colour-coded tissue Doppler (TDI) during systole (S' and S(m)) and diastole (early, E' and E(m), and late, A' and A(m)) at the basal septum and lateral wall. Both systolic tissue velocities were higher in males than in females within controls (S': 7.3 +/- 1.2 vs. 6.6 +/- 1.0 cm/s; P = 0.017, S(m): 6.2 +/- 1.0 vs. 5.5 +/- 0.7 cm/s; P = 0.002) but only by colour-coded TDI in patients with T2DM (S(m): 5.7 +/- 1.7 vs. 4.9 +/- 1.7 cm/s; P = 0.025). Correction for LV length negated the difference between genders in the controls and patients with T2DM (P > 0.05 for all). In controls, LV length was the strongest predictor of S' (beta = 0.393, P = 0.002), whereas height was the strongest predictor of S(m) (beta = 0.394, P = 0.003).

CONCLUSION

In controls, systolic tissue velocities are significantly higher in males compared with females, which may be explained by the increased chamber size of men.

Anti-remodelling effect of canrenone in patients with mild chronic heart failure (AREA IN-CHF study): final results

AIMS

To test whether canrenone, an aldosterone receptor antagonist, improves left ventricular (LV) remodelling in NYHA class II heart failure (HF). Aldosterone receptor antagonists improve outcome in severe HF, but no information is available in NYHA class II.

METHODS AND RESULTS

AREA IN-CHF is a randomized, double-blind, placebo-controlled study testing canrenone on top of optimal treatment in NYHA class II HF with low ejection fraction (EF) to assess 12-month changes in LV end-diastolic volume (LVEDV). Brain natriuretic peptide (BNP) was also measured. Information was available for 188 subjects on canrenone and 194 on placebo. Left ventricular end-diastolic volume was similarly reduced (-18%) in both arms, but EF increased more (P = 0.04) in the canrenone (from 40% to 45%) than in the placebo arm (from 40-43%). Brain natriuretic peptide (n = 331) decreased more in the canrenone (-37%) than in the placebo arm (-8%; P < 0.0001), paralleling a significant reduction in left atrial dimensions (-4% vs. 0.2%; P = 0.02). The composite endpoint of cardiac death and hospitalization was significantly lower in the canrenone arm (8% vs. 15%; P = 0.02).

CONCLUSION

Canrenone on top of optimal treatment for HF did not have additional effects on LVEDV, but it increased EF, and reduced left atrial size and circulating BNP, with potential beneficial effects on outcome. A large-scale randomized study should be implemented to confirm benefits on cardiovascular outcomes in patients with HF in NYHA class II.

Early predictors of late dilation and remodeling after thrombolized anterior transmural myocardial infarction

BACKGROUND AND HYPOTHESIS

Dilation of the left ventricle after myocardial infarction is associated with an adverse prognosis. There are no clinical studies on the role viable myocardium in the infarcted area assumes in relation to the development of late ventricular remodeling. The hypothesis of this study was to define the relation between remodeling and the presence of viable but akinetic myocardium in the infarct area and to identify early predictors of left ventricular (LV) dilation at 1 year.

METHODS

In all, 92 consecutive patients with myocardial infarction were divided into two groups according to their ventricular volumes. Group I included 57 patients with normal volumes at discharge (9 +/- 3 days after acute infarction) and after 12 months or with LV dilation at discharge who had a normalization of their volumes over a 12-month period. Group II included 35 patients who, independent of their initial volumes, developed LV dilation during follow-up. Low-dose dobutamine infusion was utilized at discharge for echocardiographic evaluation of contractile recovery of viable myocardial segments.

RESULTS

At the first control, patients in Group I presented an end-diastolic volume index (EDVI) of 100 +/- 7 ml/m2 which decreased to 68.8 +/- 6.5 ml/m2 12 months later (p < 0.0001), and an end-systolic volume index (ESVI) of 47.6 +/- 6.7 ml/m2 at the first control and 30.5 +/- 8.8 ml/m2 after 12 months (p < 0.001). Patients in Group II presented a mean EDVI of 116.2 +/- 8.1 ml/m2 at the first control and 138.8 +/- 8 ml/m2 12 months later (p < 0.001), and a mean ESVI of 68.8 +/- 6.5 ml/m2 at the first control and 79.5 +/- 5.4 after 12 months (p < 0.01). Ventricular mass index (VMI) in Group I increased from 106.4 +/- 11 to 122.3 +/- 15 g/m2 (p < 0.01), while in Group II it decreased from 101.1 +/- 10 to 98.7 +/- 8 g/m2 (p = NS). In Group I, mass-to-volume ratio was 1.15 +/- 0.1 g/ml at the first control and 1.67 +/- 0.1 g/ml 12 months later (p < 0.001), while in Group II it declined from 0.88 +/- 0.1 to 0.69 +/- 0.1 g/ml (p < 0.01). The multivariate analysis revealed that ejection fraction < or = 40%, restrictive filling pattern, wall motion score index > 2.5 in response to dobutamine infusion, and mass-to-volume ratio < or = 1 g/ml, all at discharge, as well as an occluded left anterior descending artery discriminate in favor of late LV dilation and remodeling.

CONCLUSIONS

Correct use of noninvasive strategies should result in early identification of postinfarct patients who are at risk of developing LV remodeling.

Prediction of postinfarction remodeling of the left ventricle from parameters of tissue Doppler echocardiography

The possibility of predicting undesirable postinfarction remodeling of the left ventricle from parameters of tissue doppler echocardiography was evaluated in 55 patients with a history of acute myocardial infarction. Low diastolic rates of normal segments and the absence of the peak of isovolumetric contraction in the dysfunction zone were the most significant predictors of unfavorable remodeling.

Cardiac morphological and functional changes during early septic shock: a transesophageal echocardiographic study

OBJECTIVE

The objective was to prospectively evaluate cardiac morphological and functional changes using transesophageal echocardiography (TEE) during early septic shock.

DESIGN

Prospective, observational study.

SETTING

Medical-surgical intensive care unit of a teaching hospital.

PATIENTS AND PARTICIPANTS

Ventilated patients with septic shock, sinus rhythm and no cardiac disease underwent TEE within 12h of admission (Day0), after stabilization of hemodynamics by fluid loading (median volume: 4.9l [lower and upper quartiles: 3.7-9.6l]) and vasopressor therapy, and after vasopressors were stopped (Dayn).

MEASUREMENTS AND RESULTS

Thirty-five patients were studied (median age: 60 years [range 44-68]; SAPS II: 53 [46-62]; SOFA score: 9 [8-11]) and 9 of them (26%) died while on vasopressors. None of the patients exhibited TEE findings of cardiac preload dependence. Between Day0 and Dayn (7 days [range 6-9]), mean left ventricular (LV) ejection fraction (EF) increased (47 +/- 20 vs. 57 +/- 14%: p < 0.05), whereas mean LV end-diastolic volume decreased (97 +/- 25 vs. 75 +/- 20ml: p < 0.0001). Out of 16 patients (46%) with LV systolic dysfunction on Day0, 12 had normal LVEF on Dayn and 4 patients fully recovered by Day28. Only 4 women had LV dilatation (range, LV end-diastolic volume: 110-148ml) on Day0, but none on Dayn. Doppler tissue imaging identified an LV diastolic dysfunction in 7 patients (20%) on Day0 (3 with normal LVEF), which resolved on Dayn.

CONCLUSIONS

This study confirms that LV systolic and diastolic dysfunctions are frequent, but LV dilatation is uncommon in fluid-loaded septic patients on vasopressors. All abnormalities regressed in survivors, regardless of their severity.

DESCRIPTORS

Shock: clinical studies (38), Cardiovascular monitoring (34).

Prognostic value of reduced kidney function and anemia in patients with chronic heart failure

OBJECTIVES

The present study aimed to evaluate the prognostic value of B-type natriuretic peptide (N-proBNP), renal dysfunction and anemia in chronic heart failure (CHF) patients.

METHODS

We analyzed data from a prospective cohort of 153 patients (mean age 64 years) with CHF referred to our hospital center. Clinical, echocardiographic and laboratory data were drawn during hospital recovery in all patients. Kidney dysfunction was defined as a glomerular filtration rate (GFR) < 60 ml/min and anemia as a hematocrit < 35%. After discharge, patients attended the outpatient clinic of our institution.

RESULTS

Kidney dysfunction was diagnosed in 37% of cases, whereas anemia was present in 25% of patients. During follow-up (median time 456 days), 32 patients died. Multivariate Cox proportional hazard model revealed that N-proBNP [hazard ratio (HR) = 1.002; P < 0.001] and GFR (HR = 0.972; P < 0.005) were significant predictors for mortality after adjustment for confounding variables. Kaplan-Maier analysis demonstrated a progressive decrease in survival from lowest to highest tertiles of N-proBNP values (log rank = 28.7; P < 0.001) and from higher to lower GFR values (log rank = 5.63; P < 0.01). Moreover, parametric survival analysis by the Weibull model demonstrated that the estimated probability of survival adjusted for N-proBNP values was higher in patients with GFR > or = 60 ml/min than in those with GFR < 60 ml/min (P < 0.001).

CONCLUSION

Increased N-proBNP and decreased kidney function, but not anemia, are independent risk factors for mortality in patients with CHF.

NT-proBNP, IGF-I and survival in patients with chronic heart failure

OBJECTIVE

Growth hormone (GH) resistance with a reduction of insulin-like growth factor-I (IGF-I) serum concentrations seems to be implicated in the catabolic process associated with chronic heart failure (CHF). However, data concerning the prognostic value of these alterations in CHF patients without cachexia are scant. In this study, we aimed to determine in CHF patients the prognostic value of IGF-I/GH ratio and its relationships with N-terminal brain natriuretic peptide (NT-proBNP), a known marker of prognosis in these patients.

DESIGN

We enrolled 82 non-cachectic patients, mean age 61+/-13 years, with ejection fraction <40% and predischarge New York Heart Association (NYHA) functional classes II-IV. All patients underwent clinical examination, two-dimensional echocardiography and NT-proBNP, GH and IGF-I measurement with log IGF-I/GH ratio calculation. Mortality and clinical status was documented at follow-up (18.4+/-8.1 months).

RESULTS

During follow-up 17 patients died of cardiac causes. Non-survivors were at baseline in higher NYHA class (P<0.05) and showed higher values of NT-proBNP (P<0.001) than survivors; differently IGF-I, and log IGF-I/GH ratio were lower (P<0.05). At Cox multivariate analysis, NT-proBNP (P<0.001) and IGF-I/GH ratio (P<0.05) were independent predictors of death.

CONCLUSIONS

High NT-proBNP levels and low IGH-I/GH ratio may be useful to stratify CHF patients at higher risk of cardiac death.

Predictors of Therapeutic Response to Beta-blockers in Patients with Heart Failure in Taiwan

BACKGROUND/PURPOSE

Chinese are more sensitive to beta-blockers than Caucasians. However, data regarding beta-blocker therapy in heart failure (HF) patients in Taiwan are lacking. We aimed to evaluate the improvement of left ventricular function and the potential predictors of response to beta-blocker therapy in Taiwanese HF patients.

METHODS

We enrolled 34 HF patients with baseline left ventricular ejection fraction (LVEF) </= 40%. Beta-blockers were titrated up to the maximum tolerable dose. LVEF prior to beta-blocker usage and at the stable dose were obtained. We also sequenced the entire gene encoding beta1-adrenoceptor to assess the relationships between LVEF improvement and gene polymorphisms.

RESULTS

Beta-blocker therapy (25 +/- 22 months) with a mean stable dose of 12 +/- 8 mg carvedilol/day significantly improved LVEF (from 28 +/- 8% to 40 +/- 15%, p < 0.001). Stepwise multiple linear regression analysis identified dilated cardiomyopathy (beta = 18.32, p = 0.0004), baseline LVEF (beta = -0.85, p = 0.0020), use of amiodarone (beta = -22.58, p = 0.0034) and square of digoxin dose (beta = -314.25, p = 0.0059) at stable beta-blocker dose as independent predictors of LVEF improvement, where beta is the estimated regression coefficient. We did not find any novel variant of beta1-adrenoceptor gene other than those previously reported at codons 49 and 389, with the allele distributions similar to those found in Caucasians, and these polymorphisms did not imply therapeutic response to beta-blocker.

CONCLUSION

We demonstrated the therapeutic effects of beta-blockers in Taiwanese HF patients with a dose lower than what has been reported in Western people. Moreover, patients with the etiology of dilated cardiomyopathy or lower baseline LVEF predicted a greater LVEF improvement. The beta1-adrenoceptor gene polymorphisms were not responsible for the difference in sensitivity to beta-blockers in this Taiwanese population.

Cardiovascular Responses During Thermoneutral, Head-Out Water Immersion in Patients With Coronary Artery Disease

PURPOSE

Water is frequently recommended as a therapeutic medium for cardiac patients. Reports on the cardiovascular response to immersion often differ, however, depending, for instance, if full or partial immersion were considered. The purpose of this study was to examine the cardiovascular responses to 2 immersion protocols in 3 age and gender-matched groups of patients each with a specific coronary artery disease.

METHODS

Fifteen patients with coronary artery disease entered water using a stepwise immersion (STEP) protocol (5 stages in 15 minutes) and an immediate, complete immersion (IM) protocol (2 stages in 6 minutes). Cardiac indices were monitored by transthoracic echocardiography. The heart rate was generated from the electrocardiogram, and blood pressure was measured using a manual mercury manometer.

RESULTS

The end-diastolic volume, end-systolic volume, stroke volume, and cardiac output decreased during STEP but increased during IM. As a consequence, the preload on the heart was greater during IM. Changes in systolic blood pressure were comparable in the 2 situations. The immersion-related decrease of heart rate was seen during STEP, but not during IM. Nevertheless, the hemodynamic responses to the initial stages of STEP up to the ankle joint were quite similar to those observed during immediate immersion to the neck.

CONCLUSION

The cardiovascular responses to IM and STEP differed between protocols and even among subgroups within the same protocol. The findings further suggest that isolated immersion of body extremities can be beneficial to patients with coronary artery disease as preliminary preparation before complete water immersion is undertaken.

High serum matrix metalloproteinase-9 level predict increased risk of in-hospital cardiac events in patients with type 2 diabetes and ST segment elevation myocardial infarction

INTRODUCTION

The purpose of this study was to compare serum matrix metalloproteinase (MMP)-9 levels in a population of type 2 diabetic versus non-diabetic patients hospitalized with ST-segment elevation myocardial infarction (STEMI) and to examine the relationship between serum MMP-9 levels and the incidence of in-hospital cardiac events, including death and cardiogenic shock.

METHODS

We recruited 120 patients with STEMI, of whom 48 were type 2 diabetic and 72 non-diabetic. Serum MMP-9 levels were measured on admission, using a commercially available ELISA. The primary study endpoint was cardiac death in-hospital and cardiogenic shock.

RESULTS

Mean serum MMP-9 levels were significantly higher in type 2 diabetic patients compared to non-diabetic patients (240+/-52 ng/mL versus 185+/-47 ng/mL; P<0.0001). In multivariable analysis, type 2 diabetes was an independent factor for mortality [OR: 1.75 (1.40-2.30); P=0.005] and cardiogenic shock [OR: 1.55 (1.20-1.70); P=0.03] when the variable MMP-9 level was not introduced into the model, but it was less significantly associated with mortality [OR: 1.60 (1.40-2.10); P=0.01] and no longer associated with cardiogenic shock when MMP-9 was in the model.

CONCLUSION

After STEMI, type 2 diabetes is independently associated with high serum MMP-9 levels. This elevated MMP-9 is strongly associated with the increased incidence of in-hospital mortality and cardiogenic shock observed in type 2 diabetes. Our findings clearly indicate that serum MMP-9 provides a highly valuable prognostic information on in-hospital outcome after STEMI, in particular in type 2 diabetic patients.

Prospective analysis of prevalence, distribution, and rate of recovery of left ventricular systolic dysfunction in patients with subarachnoid hemorrhage

OBJECT

Subarachnoid hemorrhage (SAH) has been associated with cardiac injury and left ventricular (LV) dysfunction. The incidence and natural history of neurocardiogenic injury after SAH remains poorly understood. The objective of this study was to describe the incidence, time course, recovery rate, and segmental patterns of LV dysfunction after SAH.

METHODS

Echocardiography was performed three times over a 7-day period in 173 patients with SAH. The incidence of global (ejection fraction [EF] < 50%) and segmental (any regional wall-motion abnormality [RWMA]) LV dysfunction was measured. The time course of LV dysfunction was determined by comparing the prevalence of LVEF less than 50% and RWMA at 0 to 2, 3 to 5, and 6 to 8 days after SAH. The recovery rate was defined as the proportion of patients with partial or complete normalization of function. The distribution of RWMAs among 16 LV segments was also determined. An LVEF less than 50% was found in 15% of patients, and 13% had an RWMA with a normal LVEF. There was a trend toward increased dysfunction at 0 to 2 days after SAH, compared with 3 to 8 days after SAH. Recovery of LV function was observed in 66% of patients. The most frequently abnormal LV segments were the basal and middle ventricular portions of the anteroseptal and anterior walls. The apex was rarely affected.

CONCLUSIONS

Left ventricular systolic dysfunction occurs frequently after SAH and usually improves over time. The observed segmental patterns of LV dysfunction often do not correlate with coronary artery distributions.

Rise and fall of B-type natriuretic peptide levels in patients with coronary artery disease and normal left ventricular function after cardiac revascularization

BACKGROUND

Recently, it was shown that B-type natriuretic peptide levels are increased in patients with acute coronary syndromes.

AIMS

To assess the relation between B-type natriuretic peptide and ischemia in patients with stable and unstable angina pectoris with normal left ventricular function in relation to the extent of ischemia and response to revascularization.

METHODS

Fifty-nine consecutive patients were enrolled in the study, patients were divided into two groups: stable angina patients (group I, n=18), and unstable coronary patients (group II, n=41). Baseline characteristics were compared with 15 age-matched and sex-matched participants. B-type natriuretic peptide levels were measured at baseline and 3, 7 and 90 days after coronary revascularization in group I and II.

RESULTS

Patients with unstable angina pectoris had increased B-type natriuretic peptide levels compared with stable angina pectoris patients (B-type natriuretic peptide levels: controls 15.5+/-13 pg/ml, stable angina pectoris group 28.4+/-19 pg/ml, unstable angina pectoris group 104+/-81 pg/ml; P<0.01). A relationship between the number of affected coronary vessels and B-type natriuretic peptide was assessed (one-vessel 29.9+/-21 pg/ml, two-vessel 93.8+/-87 pg/ml, three-vessel 119+/-88 pg/ml; P<0.01). After revascularization, B-type natriuretic peptide levels decreased in groups I and II (25+/-20 vs. 39+/-28 pg/ml) and were similar after 90 days in percutaneous transluminal coronary angiograghy and in coronary artery bypass grafting groups (percutaneous transluminal coronary angiography 26+/-22 pg/ml, coronary artery bypass grafting 36+/-26 pg/ml; NS).

CONCLUSIONS

B-type natriuretic peptide levels increase in unstable angina pectoris patients and are linked to the extent of coronary disease in patients with normal left ventricular systolic function, and returned to baseline level after surgical or catheter revascularization.

Cardiovascular Function in Multi-Ethnic Study of Atherosclerosis: Normal Values by Age, Sex, and Ethnicity

OBJECTIVE

MRI provides accurate and high-resolution measurements of cardiac anatomy and function. The purpose of this study was to describe the imaging protocol and normal values of left ventricular (LV) function and mass in the Multi-Ethnic Study of Atherosclerosis (MESA).

SUBJECTS AND METHODS

Eight hundred participants (400 men, 400 women) in four age strata (45-54, 55-64, 65-74, 75-84 years) were chosen at random. Participants with the following known cardiovascular risk factors were excluded: current smoker, systolic blood pressure > 140 mm Hg, diastolic blood pressure > 90 mm Hg, fasting glucose > 110 mg/dL, total cholesterol > 240 mg/dL, and high-density lipoprotein (HDL) cholesterol < 40 mg/dL. Cardiac MR images were analyzed using MASS software (version 4.2). Mean values, SDs, and correlation coefficients in relationship to patient age were calculated.

RESULTS

There were significant differences in LV volumes and mass between men and women. LV volumes were inversely associated with age (p < 0.05) for both sexes except for the LV end-systolic volume index. For men, LV mass was inversely associated with age (slope = -0.72 g/year, p = 0.0021), but LV mass index was not associated with age (slope = -0.179 g/m2/year, p = 0.075). For women, LV mass (slope = -0.15 g/year, p = 0.30) and LV mass index (slope = 0.0044 g/m2/year, p = 0.95) were not associated with age. LV mass was the largest in the African-American group (men, 181.6 +/- 35.8 [SD] g; women, 128.8 +/- 28.1 g) and was smallest in the Asian-American group (men, 129.1 +/- 20.0 g; women, 89.4 +/- 13.3 g).

CONCLUSION

The normal LV differs in volume and mass between sexes and among certain ethnic groups. When indexed by body surface area, LV mass was independent of age for both sexes. Studies that assess cardiovascular risk factors in relationship to cardiac function and structure need to account for these normal variations in the population.

Improved assessment of left ventricular volumes and ejection fraction by contrast enhanced harmonic color Doppler echocardiography

AIMS

Test the accuracy of contrast enhanced harmonic color Doppler technique (CHCD) to determine left ventricular volumes and ejection fraction (LVEF) compared to equilibrium radionuclide ventriculography (MUGA).

METHODS AND RESULTS

A total of 35 patients were enrolled (male 74.3%) with the mean age of 64.5 +/- 10 years and 6.8 +/- 4.9 days between echo and MUGA scans. The correlation of LVEF by CHCD with MUGA was better (R2 = 0.89) than that of harmonic 2D (H2D) and of contrast enhanced harmonic 2D (CH2D) (R2 = 0.74, R2 = 0.82, respectively). The RMS residual of CHCD (0.056) was smaller than that of H2D and CH2D (0.079, 0.067, respectively). The LVED and LVES volumes by H2D, CH2D and CHCD correlate well with MUGA but there was a significant over estimation of LVED and LVES volumes by H2D and CH2D as compared to MUGA. Also, the RMS residuals were the lowest for the CHCD method. The CHCD had the highest mean inter-observer agreement (90.9%) for LVEF compared with H2D and CH2D (78.9% and 88.1%, respectively).

CONCLUSIONS

CHCD has been feasible in all patients in the present study and it has shown a good concordance with ejection fraction and volumes provided by MUGA.

Left ventricular diastolic function improvement by carvedilol therapy in advanced heart failure

Carvedilol treatment in chronic heart failure (CHF) patients has been demonstrated to reduce mortality by improving cardiac systolic function and reducing left ventricular adverse remodeling. However, the effects of the drug on left ventricular (LV) filling are less studied. In this study we evaluated early and long-term diastolic cardiac modifications by an echo-Doppler method during carvedilol therapy in patients with advanced CHF and pseudonormal or restrictive filling pattern. We studied 58 patients with severe but stable CHF (39 in class NYHA III and 19 in IV) having systolic and diastolic dysfunction caused by idiopathic or ischemic cardiomyopathy. Thirty-two patients were randomized to receive previous treatment plus carvedilol (group 1) and 26 continued standard therapy (group 2). In all subjects we evaluated LV volumes, LV mass, LV ejection fraction (EF), and the following transmitral filling parameters: early wave (E), atrial wave (A), E/A ratio, deceleration time (DT), and isovolumetric releasing time (IVRT). After 4 months of therapy, the carvedilol group showed a significant increase of A wave (P < 0.001), DT (P < 0.0001), IVRT (P < 0.0001), and a significant reduction of E/A ratio (P < 0.0005) with respect to group 2. Further improvement was observed at 12 months (A P < 0.0005; DT P < 0.00002; IVRT P < 0.000004; E/A P < 0.0008), although an E wave reduction was observed in group 1 with respect to controls (P < 0.001). Moreover, after 1 year of follow-up a reduction of systolic volume (P < 0.001) and pulmonary pressure (P < 0.0001) and consequent increase of EF (P < 0.001) was observed in the carvedilol group. Carvedilol treatment improved diastolic function in CHF with severe diastolic and systolic impairment at early time, converting a restrictive or pseudonormal filling pattern into an altered pattern. These changes remained significant after 1 year of therapy together with improvement in systolic function.

Relation of plasma brain natriuretic peptide levels in non-ST-elevation coronary disease and preserved systolic function to number of narrowed coronary arteries

Elevated plasma brain natriuretic peptide (BNP) levels have been described in patients with acute myocardial infarction and left ventricular dysfunction. The aim of the present study was to evaluate circulating BNP levels in patients with coronary artery disease without ST-segment elevation acute myocardial infarction and preserved systolic function and to evaluate the BNP levels in relation to the number of involved coronary vessels. We studied 88 patients with coronary artery disease: group 1 had stable angina, group 2 had unstable angina (UA), group 3 had non-Q-wave myocardial infarction (NSTEMI), and group 0 consisted of 15 healthy subjects. All recruited subjects underwent angiographic examination and echocardiographic evaluation. No patients had heart failure, previous myocardial infarction, or electrocardiographic ST elevation. A significant increase in BNP levels was observed in the UA and NSTEMI groups compared with the stable angina group (stable angina 31.3 pg/ml, UA 147.3 pg/ml, NSTEMI, 165.8 pg/ml, p <0.01), and no differences were found between the UA and NSTEMI groups. Analysis of BNP in relation to the number of involved vessels showed significantly higher BNP levels in patients with 3- than in those with 1- or 2-vessel disease (1 to 45.2, 2 to 127.3, and 3 to 220.8 pg/ml, respectively, p <0.05 and p <0.0001, 3 vs 1- and 2-vessel disease, p = 0.01, respectively). Patients with left anterior descending stenosis had higher BNP levels than those with stenosis in other areas (150.8 vs 52.2 pg/ml, p <0.01). In conclusion, circulating BNP levels appeared elevated in patients with acute coronary syndromes with diffuse coronary involvement, even in the absence of systolic dysfunction or heart failure. BNP was also associated with multivessel disease and left anterior descending involvement.

Assessment of age-related changes in left ventricular structure and function by freehand three-dimensional echocardiography

To determine age-related changes in left ventricular (LV) structure and function, the authors used freehand three-dimensional echocardiography, a previously validated tomographic technique, to measure LV mass, volumes, and derived parameters in 94 sedentary, but ambulatory and clinically healthy, adult male and female volunteers aged 20-94. LV volumes and mass were significantly greater in men than in women (p<0.001) and remained greater after adjustment for body surface area and height (p<0.05). Declines in end-diastolic and stroke volumes with age were reduced or absent after accounting for body size. By multivariate analysis, age accounted for only about 6%-11% of the variance among LV volumes and mass, in comparison with body surface area and gender, which accounted jointly for about 46%-77% of the variance. In conclusion, changes occur in LV structure and function with normal aging, but these changes are relatively minor when body size and gender are taken into account.