The assessment of left ventricular systolic asynchrony in patients with primary hyperparathyroidism

Left bundle branch potential predicts better electrical synchrony in bradycardia patients receiving left bundle branch pacing

Background

Left bundle branch pacing (LBBP) is a novel physiological pacing technology. We aim to explore the relation between LBB potential (LBB Po) and left ventricular (LV) electrical/mechanical synchrony in bradycardia patients without heart failure (HF) receiving LBBP.

Methods

A total of 62 patients undergoing LBBP were categorized by LBB Po: the LBB Po positive (+) group and the LBB Po negative (−) group. The perioperative electrocardiographic and echocardiography parameters related to cardiac synchrony were analyzed.

Results

There were 42 (67.74%) patients in the LBB Po (+) group and 20 patients in the LBB Po (−) group. Paced QRS duration (113.50 ± 17.65 ms vs. 123.40 ± 13.18 ms, P = 0.031) and stimulus left ventricular activation time (71.76 ± 3.53 ms vs. 74.45 ± 3.12 ms, P = 0.005) were shorter in the LBB Po (+) group than in the LBB Po (−) group. No significant differences in the LV mechanical synchrony (Ts-SD-12, 36.55 ± 19.76 vs. 39.95 ± 16.04, P = 0.505; PSD, 51.14 ± 17.69 vs. 45.65 ± 10.55, P = 0.205) between the two groups. There was not statistically difference in ventricular lead parameters measured intraoperative between the two groups. Compared with the LBB Po (−) group, the LBB Po (+) group showed a dramatically higher total procedure duration time (93.52 ± 9.18 min vs. 86.25 ± 10.54 min, p = 0.007) and fluoroscopy time for ventricle lead implantation (18.95 ± 3.43 min vs. 14.00 ± 3.16 min, p < 0.001).

Conclusions

The appearance of LBB Po may suggest better electrical synchrony during LBBP, but similar in LV mechanical synchrony. However, the total operation duration and fluoroscopy time of ventricular lead implantation in the LBB Po (+) group were longer. Therefore, it may be unnecessary to deliberately recognize the LBB Po when it is difficult to detect LBB Po and meet the LBBP criterion.

Nontraditional Aspects of Sporadic Primary Hyperparathyroidism

Nontraditional aspects of primary hyperparathyroidism refer to the condition's rheumatic, gastrointestinal, cardiovascular, and neuropsychological effects. Although gastrointestinal and rheumatic symptomatology were features of classical primary hyperparathyroidism, they do not seem to be a part of the modern presentation of primary hyperparathyroidism. In contrast, neuropsychological symptoms such as altered mood and cognition, as well as cardiovascular disease, have been associated with the form of primary hyperparathyroidism seen today, but the relationship is not clearly causal. Evidence does not support reversibility after parathyroidectomy and therefore none of the nontraditional manifestations are considered sole indications for recommending surgery at this time.

Assessment of left ventricular dyssynchrony in patients with psoriasis

BACKGROUND

Psoriasis is an inflammatory disorder, which has been reported to be associated with cardiovascular (CV) risks. Although increased CV risks in psoriasis are well established, there are no data about changes of contraction synchrony in psoriasis. Therefore, we aimed to study the left ventricular (LV) contraction synchrony in patients with psoriasis with narrow QRS and normal ejection fraction.

METHODS

Fifty patients with psoriasis and 50 age- and sex-matched control subjects were included in the study. LV dyssynchrony was investigated by color-coded tissue Doppler imaging.

RESULTS

In the psoriasis group, the mean high-sensitive C-reactive protein values were significantly higher compared with the controls. Peak A velocity, deceleration time, isovolumetric relaxation time, and E/E' values were higher in the psoriasis group; however, E/A ratio and average Em were higher in the control group. LV systolic dyssynchrony parameters [including standard deviation of Ts of the 12 LV segments (Ts-SD-12), maximal difference in Ts between any two of the 12 LV segments, standard deviation of Ts of the six basal LV segments, and maximal difference in Ts between any two of the six basal LV segments] were found to be higher in the psoriasis group. The patients with ventricular dyssynchrony (a Ts-SD-12 >34.4 ms) were higher in the psoriasis group than the control group (34% vs. 6%, P < 0.01).

CONCLUSION

In patients with psoriasis with normal ejection fractions and narrow QRS, LV systolic dyssynchrony is an early manifestation of heart involvement and may coexist with diastolic dysfunction.

Sporadic primary hyperparathyroidism: medical and surgical updates

This review discusses recent findings on the clinical presentation, evaluation, medical and surgical management of primary hyperparathyroidism. Medical management includes the use of cinacalcet and bisphosphonates for bone loss and correction of vitamin D deficiency. Surgical updates reviewed recent studies on the preoperative localization of the disease, specifically, sestamibi scans, 4DCT and MRI. Focused parathyroidectomy continues to be the preferred surgical approach for a select group of patients, guided by intraoperative use of PTH and new technology, such as endoscopic and robotic platforms; however, there appears to be no difference in long-term success compared to the traditional approach.

Left ventricular synchronicity is impaired in patients with active acromegaly

Acromegaly is associated with a variety of cardiovascular disturbances such as left ventricular hypertrophy, diastolic cardiac dysfunction, and hypertension. Left ventricular (LV) dyssynchrony means the impairment of synchronicity and is defined as the loss of the simultaneous peak contraction of corresponding cardiac segments. The objective of this study was to investigate whether acromegalic patients have left ventricular dyssynchrony. Dyssynchrony was evaluated in 30 patients with active acromegaly and 30 controls. All the patients and controls were subjected to a tissue synchronization imaging. The time to regional peak systolic tissue velocity (Ts) in LV by the six-basal-six-mid-segmental model was measured on ejection phase TSI images and four TSI parameters of systolic dyssynchrony were computed. All TSI parameters of LV dyssynchrony increased in patients with acromegaly compared to the controls: the standard deviation (SD) of the 12 LV segments Ts (43.5 ± 13.5 vs 26.2 ± 12.5, p < 0.001); the maximal difference in Ts between any 2 of the 12 LV segments (133.3 ± 38 vs 84.6 ± 37.6, p < 0.001); the SD of the 6 basal LV segments (41.1 ± 15.9 vs 25.4 ± 14.8, p = 0.001); and the maximal difference in Ts between any 2 of the 6 basal LV segments (102.6 ± 37.5 vs 65.2 ± 36.9, p = 0.001). In addition, there were significant relationships between the levels of growth hormone/insulin-like growth factor-1 and Ts-SD-12. LV synchronicity has been impaired in patients with acromegaly. Left ventricular dyssynchrony is associated with disease activity and it may contribute to the harmful cardiovascular effects of acromegaly.

Article Commentary: Nonclassical Symptoms of Primary Hyperparathyroidism and Their Response to Parathyroidectomy

An estimated 100,000 new patients are diagnosed with primary hyperparathyroidism (PHPT) each year in the United States.1 In the past, patients with PHPT typically presented with “stones, bones, abdominal groans, and psychic moans” but today patients often present with more subtle symptoms and physiologic changes associated with earlier stages of disease. Patients without the classic symptoms of PHPT are often referred to as “asymptomatic.” These patients frequently pose a conundrum for clinicians. Uncertainties remain as to which symptoms truly represent PHPT and which are related to comorbidities or the aging process. To address these uncertainties, we review most recent literature regarding the nonclassical manifestations of PHPT and their response to parathyroidectomy.

Nontraditional manifestations of primary hyperparathyroidism

Classical primary hyperparathyroidism (PHPT) was previously a multisystemic symptomatic disorder not only with overt skeletal and renal complications but also with neuropsychological, cardiovascular, gastrointestinal, and rheumatic effects. The presentation of PHPT has evolved, and today most patients are asymptomatic. Osteitis fibrosa cystica is rarely seen today, and nephrolithiasis is less common. Gastrointestinal and rheumatic symptoms are not part of the clinical spectrum of modern PHPT. It remains unclear whether neuropsychological symptoms and cardiovascular disease, neither of which are currently indications for recommending parathyroidectomy (PTX), are part of the modern phenotype of PHPT. A number of observational studies suggest that mild PHPT is associated with depression, decreased quality of life, and changes in cognition, but limited data from randomized controlled trials (RCTs) have not indicated consistent benefits after surgery. The increased cardiovascular morbidity and mortality in severe PHPT has not been definitively demonstrated in mild disease, although there is some evidence for more subtle cardiovascular abnormalities, such as increased vascular stiffness, among others. Results from observational studies that have assessed the effect of PTX on cardiovascular health have been conflicting. The single RCT in this area did not demonstrate that PTX was beneficial. Despite recent progress in these areas, more data from rigorously designed studies are needed to better inform the clinical management of patients with asymptomatic PHPT.