Speckle tracking echocardiography in severe patient-prosthesis mismatch

BACKGROUND

Although aortic valve replacement (AVR) when successfully performed boasts low mortality rates in selected patients, prosthesis-patient mismatch (PPM) can be found in the majority of these individuals. Limited research is available supporting the benefit of two-dimensional speckle tracking echocardiography (2D-STE) in patients with severe PPM. This study sought to assess myocardial strain using 2D-STE to determine the relationship between subclinical left ventricular (LV) dysfunction and aortic PPM in patients undergoing AVR with preserved LV ejection fraction.

MATERIAL AND METHODS

We retrospectively examined all consecutive patients with isolated AVR who presented to our center from 2005 to 2018. The data of 1086 patients were analyzed. Severe PPM was defined as an indexed effective orifice area of 0.65 cm²/m² or less. As a result of the detailed assessment, 54 patients meeting the eligibility criteria were included in the study. Baseline data were collected and compared between the two groups of patients with severe PPM (n = 27) and those with normofunctional aortic prosthesis valve as a control group (n = 27). All patients underwent baseline echocardiography. Global longitudinal strain (GLS) and global circumferential strain (GCS) were evaluated by 2D-STE.

RESULTS

When compared with controls, patients with severe PPM had significantly decreased GLS (18.6 ± 2.9 vs. 21.4 ± 2.1; p < 0.01) and GCS (17.2 ± 3.6 vs. 21.7 ± 2.1; p < 0.01) values.

CONCLUSION

In addition to standard clinical and echocardiographic parameters, GLS and GCS suggest subclinical dysfunction and have incremental value in patients with severe PPM.

The Relationship Between β-Receptor Sensitivity and Nocturnal Blood Pressure and Heart Rate Recovery in Normotensive People

This study examined the relationship between nocturnal blood pressure (BP) dipping and chronotropic dose25 (CD25) as an indicator of β-adrenergic receptor functioning in normotensive people. In addition, the authors evaluated the influence of β-receptor functioning on heart rate recovery after exercise. The sample consisted of 41 participants (18 men, 23 women). Ambulatory BP monitoring took place in each patient's home. On a separate occasion, β-adrenergic receptor sensitivity was determined by response to isoproterenol infusion. Heart rate (HR) recovery was defined as the change from peak HR to that measured after 1 and 2 minutes of recovery. Relationships between dipping and CD25 were found such that participants with higher CD25 values had less nocturnal decline in systolic BP, diastolic BP, and mean arterial pressure ( r =–0.445, –0.533, –0.510, respectively; p<0.004, 0.001, 0.001, respectively). Heart rate recovery at 1 and 2 minutes after exercise was 28.8 ±5 and 49.9 ±6 beats/minute, respectively. Participants with higher CD25 values had more heart rate decline during the first 2 minutes of recovery ( r =0.407, p<0.008). In addition, heart rate recovery was inversely related to systolic, diastolic, and mean nocturnal blood pressure dipping ( r =–0.348, –0.432, –0.408, respectively, p<0.028, 0.005, 0.009, respectively). Normotensive people with an abnormal circadian pattern of blood pressure may have desensitized β-adrenergic receptors. This desensitization may contribute to blunted nocturnal blood pressure and increased heart rate recovery as measured at 2 minutes following exercise testing.

Severity of periodontitis in patients with isolated coronary artery ectasia

The concept that coronary artery ectasia (CAE) is an inflammatory-related disease has been increasingly recognized. Periodontitis induced low-grade chronic systemic inflammation has been shown to be associated with cardiovascular diseases. The aim of the present study was to evaluate the association between periodontitis and CAE.Thirty-two patients with isolated CAE, and 28 age, sex and smoking status-matched subjects with normal coronary arteries (NCA) underwent full dental examinations. Periodontal disease was evaluated using the following clinical parameters; number of remaining teeth, plaque index (PI), gingival index (GI), bleeding on probing (BOP), and pocket depth (PD).Cases and controls did not differ according to their baseline characteristics and prevalence of traditional cardiovascular risk factors. Patients with isolated CAE had higher periodontal indices when compared to subjects with NCA (PD: 3.6 ± 1.26 mm versus 2.3 ± 0.79 mm; GI: 2.29 ± 0.86 versus 1.43 ± 1.19; BOP (%): 52.18 ± 20.1 versus 27.8 ± 10.9, P < 0.001, P < 0.05 and P < 0.05, respectively). Moreover, in multivariate analysis higher values for PD were found to be significant predictors for the likelihood of having coronary ectasia.The results of the present study demonstrate for the first time that there is an association between periodontitis and isolated CAE.

Echocardiographic assessment of right ventricular function before and after surgery in patients with pectus excavatum and right ventricular compression

BACKGROUND

We aimed to evaluate the effect of surgical repair on right ventricular (RV) function in patients with pectus excavatum (PE) and RV compression by Doppler echocardiography.

MATERIALS AND METHODS

Twenty-three patients who were admitted to our hospital for surgical correction of PE between 2009 and 2012 were included in the study. After transthoracic echocardiographic evaluation, 16 patients with RV compression were enrolled. All patients were males (100%) with a mean age of 20.5 ± 5.6 years. Transthoracic echocardiography was repeated 1 month after surgery. Echocardiographic evaluation included the assessment of RV diastolic diameter, tricuspid annular plane systolic excursion (TAPSE), pulsed tissue Doppler systolic velocity (S'), RV isovolumic acceleration (RV IVA), systolic pulmonary artery pressure, left ventricular (LV) ejection fraction, and myocardial performance indexes of both the right and the left ventricles (Tei index).

RESULTS

Following the surgery, the RV end-diastolic diameter, TAPSE, S', and RV IVA were found to be significantly increased in patients with PE. In addition, RV and LV Tei index significantly improved after surgical correction.

CONCLUSIONS

RV function significantly improved after corrective surgery. Quantitative echocardiographic examination provides accurate estimation when deciding for corrective surgery and also should be used in the assessment of postoperative improvement.

Evaluation of enalapril+losartan treatment with cardiopulmonary exercise test in patients with left ventricular dysfunction

The aim of this study was to evaluate the effects of the combination of enalapril and losartan in patients with left ventricular systolic dysfunction by means of cardiopulmonary exercise test (CPET). Patients with left-ventricular systolic dysfunction and ejection fractions of 40% or less were included to the study. All patients were under the treatment of enalapril 20 mg once daily. The study group consisted of 20 patients (18 men, 2 women; mean age +/- standard deviation: 62.4 +/-6.5 years) and the comparison group consisted of 10 (8 men, 2 women; mean age 59.3 +/-11.9 years). The dose of 50 mg of losartan once daily was given additionally to the study patients. Breath-by-breath CPET was performed before administration of losartan and then 6-8 weeks later in the study group and 2 times with an interval of 6-8 weeks in the control group without any change in the treatment protocol. In the study group the average exercise times were 361 +/-192 and 454 +/-205 seconds (p = 0.001) before and after the study. Peak oxygen consumption ( VO2) values were 1,209 +/-366 and 1,284 +/-398 mL/minute before and after the study (p = 0.01). Anaerobic threshold VO2 values were 785 +/-187 and 855 +/-217 mL/minute before and after the study, respectively (p = 0.01). Peak heart rates (HR) were 141 +/-28 and 143 +/-22/minute (p = 0.35); peak VO2/HR values were 9.02 +/-3.1 and 9.3 +/-3 mL/minute (p = 0.4) before and after the study, respectively. On the other hand, in the control group, average exercise times were 556 +/-250 and 528 +/-251 seconds (p = 0.8); peak VO2 values were 1,502 +/-537 and 1,450 +/-501 mL/minute (p = 0.2); and anaerobic threshold VO2 values were 1,005 +/-338 and 975 +/-319 mL/min (p = 0.7), before and after the study respectively. At the highest comparable exercise stage for both tests in the study group the expired volume/oxygen consumption ( VE/ VO2) ratio declined from 35.1 +/-6.2 to 32.4 +/-5.6 (p = 0.007). VE values declined from 37.5 +/-10.9 to 33.9 +/-10.1 L (p = 0.02); heart rate declined from 140 +/-27 to 132 +/-21/minute (p = 0.02). No significant change was observed in the mentioned values for the control group. Addition of losartan to the standard therapy in patients with left ventricular systolic dysfunction improved exercise capacity and caused lower heart rate and ventilation requirements for the same exercise level.

A Rare Case of Pulmonary Hypertension As a Result of Arteriovenous Fistula After Cardiac Surgery

A 19 year-old woman who underwent corrective surgery for an atrial septal defect (ASD) and ventricular septal defect (VSD) 12 years previously presented with pulmonary hypertension. Cardiac catheterization showed a fistula between the right subclavian artery and vena jugularis interna. In this case, a rare example of secondary pulmonary hypertension due to acquired arteriovenous fistula after cardiac surgery is presented.

Effect of acute blood pressure reduction on oxygen uptake kinetics at the onset of exercise in hypertensive patients

The aim of the present study was to investigate the adverse effects of hypertension on the cardiovascular system in daily activities and the effect of acute blood pressure reduction on oxygen (O(2)) uptake kinetics. Twenty hypertensive patients were included in the study group. Patients performed treadmill exercise tests (2.5 km/hour and 5 inclines) twice, before and after blood pressure reduction with sublingual captopril. In the control group, ten hypertensive patients underwent two tests one hour apart without blood pressure reduction brought about by drug therapy. The changes in O(2) kinetic values (O(2) deficit and mean response time [MRT]) between the two tests were investigated. In the study group, the O(2) deficit and MRT values measured during the first exercise testing were found to be 547 +/- 183 mL and 40 +/- 9 seconds, while those in the second exercise testing were 401 +/- 127 mL and 34 +/- 7 seconds, respectively. In the control group, the O(2) deficit and MRT values measured during the first exercise test were 491 +/- 217 mL and 42 +/- 16 seconds and 515 +/- 159 mL and 41 +/- 13 seconds in the second exercise test. The differences in O(2) deficit and MRT in the study group were considered to be statistically significant (P = 0.008 and P = 0.004, respectively). Based on our findings, there was a significant improvement in O(2) kinetic values with an acute reduction in blood pressure in hypertensive patients, most likely as a result of an improved response in cardiac output.

Combined small and large bowel MR imaging in patients with Crohn's disease: a feasibility study

MRI of the small bowel is a new method for the assessment of inflammatory bowel diseases. However, inflammatory bowel disease can affect both the small and large bowel. Therefore, our goal was to assess the feasibility of displaying the small bowel and colon simultaneously by MR imaging. Eighteen patients with inflammatory bowel disease were studied. For small bowel distension, patients ingested a solution containing mannitol and locust bean gum. Furthermore, the colon was rectally filled with water. MR examinations were performed on a 1.5-T system. Before and after intravenous gadolinium administration, a T1w data set was collected. All patients underwent conventional colonoscopy as a standard of reference. The oral ingestion and the rectal application of water allowed an assessment of the small bowel and colon in all patients. By means of MRI (endoscopy), 19 (13) inflamed bowel segments in the colon and terminal ileum were detected. Furthermore, eight additional inflammatory lesions in the jejunum and proximal ileum that had not been endoscopically accessible were found by MRI. The simultaneous display of the small and large bowel by MRI is feasible. Major advantages of the proposed MR concept are related to its non-invasive character as well as to the potential to visualize parts of the small bowel that cannot be reached by endoscopy.

[Evaluation of success of mitral valvuloplasty in the early period with cardiopulmonary exercise test]

OBJECTIVE

It was shown that percutaneous balloon mitral valvuloplasty (PMBV) has provided symptomatic improvement in cases with mitral stenosis. The purpose of this study was to investigate the influences of successful PBMV on cardiopulmonary exercise test (CPET) in patients with mitral stenosis early after intervention.

METHODS

Twenty-nine patients with mitral stenosis were included in this study. Nineteen patients had undergone PBMV and ten patients were studied as control group. An incremental symptom limited CPET was carried out within the 24 hours before the PMVB procedure and within the five days thereafter. Breath by breath O2 uptake (VO2) and CO2 production (VCO2) were measured in these subjects.

RESULTS

The mean mitral valve area (MVA) in the PBMV group before the procedure was 1.2 +/- 0.7 cm2 and the mean pressure gradient (PG) through the mitral valve was 12.63 +/- 4.87 mmHg; after the procedure, the mean MVA was 1.9 +/- 0.3 cm2 and the mean PG was 4.9 +/- 2.3 mmHg. The mean MVA in the control group was 1.4 +/- 0.16 cm2 and the mean PG was 7.2 +/- 3.54 mmHg. In the PBMV group, exercise time was 12.1 +/- 6 min before the procedure and increased to 18.75 +/- 5.5 min after the procedure (p = 0.0001); peak VO2 value rised from 1035 +/- 392 ml/min to 1178 +/- 373 ml/min (p = 0.0001) and VO2 at the anaerobic threshold from 667 +/- 286 ml/min to 772 +/- 268 ml/min (p = 0.006). Peak VO2/HR rised from 10.97 +/- 6.10 ml/min to 12.24 +/- 7.36 ml/min (p = 0.001). No significant difference was observed in the control group.

CONCLUSIONS

The results of this study demonstrate that successful PBMV causes evident rise in exercise capacity, so that patients can manage the same exercise levels with lower heart rates and more economic ventilation.