[Non-invasive evaluation of ventricular ejection force by Doppler echocardiography]

Left ventricular ejection force as been purpose as a new Doppler ejection phase index, to assess left ventricular performance. In order to evaluate its usefulness, 33 patients undergoing cardiac catheterization were prospectively study. We considered three groups based on angiographic ejection fraction: group A-- > or = 55% (11 patients), group B--35 to 55% (10 patients), and group C-- < or = 35% (10 patients). All patients were in sinus rhythm and mitral regurgitation > I/IV or aortic valve disease were exclusion criterion. The following parameters, derived from Pulsed Doppler aortic velocities curves, were analyzed: peak velocity (cm/s), acceleration time (s), velocity time integral over the acceleration time (VTI Ac-cm), mean acceleration (cm/s2) and ejection force (g.cm/s2). Ejection force as calculated using the mass-acceleration concept, ad: ejection force = mean acceleration x VTI Ac x CsA x 1.06 (CsA - 2D cross sectional area of the aortic annulus; 1.06 - mass density of blood, g/cm3). [table: see text]

CONCLUSIONS

The present study confirms that Doppler echocardiography can be used for the assessment of left ventricular performance based on noninvasive measurements and that Doppler derived ejection force is an accurate index for this purpose. However, ejection force evaluation, taking in account the results obtained for mean acceleration, a much less time consuming Doppler derived parameter, appears not to show any clinical advantage.

[The remote noninvasive assessment of left ventricular diastolic pressure by pulsed Doppler echography--the importance of the time of mitral protodiastolic deceleration]

To find a possible correlation between the transmitral diastolic flow, obtained by pulsed Doppler echocardiography, and left ventricular end-diastolic pressure (LVedP), we studied 95 patients (p) (58 +/- 9 years), with coronary artery disease (76 p) and dilated cardiomyopathy (19 p). P with atrial fibrillation, heart rate > 100 b/m or mitral regurgitation > 2+/4+ were excluded. We analyzed E and A wave peak velocities (v), time-velocity integrals (i) and diastolic filling intervals. Restriction to filling pattern was considered in the presence of an E wave deceleration time (DecT) < or = 120 ms (Group B- 22 p); the other 73 p (group A) ranged from abnormal relaxation to normal diastolic patterns, with DecT > 120 ms.

RESULTS

-LVedP ranged from 3 to 38 mmHg in group A and from 16 to 39 mmHg in group B. In group A, the Ai/Ei ratio showed a significant linear correlation with the LVedP (r = 0.83, y = 14 chi + 2); Ai/El ratio > 1.0 identified pts with LVedP > 18 mmHg with a sensitivity of 85% and a specificity of 98%. In group B, there was a correlation between LVedP and the inverse ratio of integrals (Ei/Ai) (r = 0.72), as well as Ev/Av ratio (r = 0.69).

CONCLUSIONS

In myocardial active relaxation abnormalities, Ai/Ei ratio increases proportionally to LVedP. A short DecT (< or = 120 ms) identifies a subgroup of p with predominant impairment of LV compliance and high filling pressures, in which the atrial contribution decreases as LVedP rises. Thus, whatever the prevailing mechanism of diastolic dysfunction, echo-Doppler transmitral diastolic flow can provide a noninvasive assessment of LVedP.

[The pulsed Doppler evaluation of patients with dilated cardiopathy]

OBJECTIVE

To evaluate, by 2D-Doppler echocardiography, the patterns of left ventricular filling in groups of patients with left ventricular systolic disfunction and different pulmonary wedge pressures.

STUDY DESIGN

perspective study of different indexes of left ventricular diastolic filling measured by Doppler echocardiography and compare them with a normal group.

SETTING

Patients studied in the Cardiology Department of the Santa Marta Hospital with a diagnosis of dilated cardiopathy and submitted to cardiac catheterisation.

PATIENTS

Twenty-four patients, aged 39 years old, submitted to hemodynamic study (group A) and nineteen subjects, aged 34 years old (group B). Pulmonary capillary wedge pressure (PWP) was determined in group A and the patients were divided in two groups: group A1 (with PWP < 16 mmHg) and group A2 (with PWP > or = 16 mmHg).

INTERVENTIONS

Every patient was submitted to cardiac catheterisation. The echocardiographic study showed global decrease of left ventricular systolic function. With pulsated Doppler left ventricular diastolic flow indexes were determined. The following parameters were studied: peak protodiastolic flow velocity (Vel E), peak telediastolic flow velocity (Vel A), E/A ratio, protodiastolic acceleration time (O-E) and diastolic flow time (O-C).

MEASUREMENTS AND RESULTS

There were no statistical differences between group A as a whole and group B. However in group A1, with a lower PWP there was a decrease of E flow velocity in relation to the control group (54.6 cm/sec +/- 14 vs 66.4 cm/seg +/- 12.8 p < 0.05) or to the group A2 (75.3 cm/sec +/- 29.9 p < 0.05). In the group A1 there was an increase of the flow velocity A in relation to group B (56.1 cm/sec +/- 15.9 vs 36.4 cm/sec +/- 7.3 p < 0.05) and to the group A2 (56.1 cm/sec +/- 15.5 vs 28.2 +/- 9.1 p < 0.05). The relation E/A in group A1 was deceased in relation to group B (1.0 +/- 0.4 m vs 1.8 +/- 0.6 p < 0.05) and in group A2 its increased in relation to B (2.6 +/- 0.9 vs 1.8 +/- 0.6 p < 0.05). The E-D time was increased in group A1 in relation to group B (162.1 +/- 8.7 cm/sec vs 140.5 +/- 42.0 cm/sec p < 0.05) and slightly reduced in group A2 (134.5 +/- 78 msec vs 140.5 +/- 42.0 msec NS). All the patients with mitral regurgitation belonged to group A2. There was only statistical difference in the velocity between the patients in group A with and without mitral regurgitation (29.6 +/- 17.4 cm/sec vs 26.4 +/- 8.5 cm/sec p < 0.05).

CONCLUSIONS

In spite of some limitations, Doppler echocardiography is useful in the evaluation of left ventricular filling of patients with dilated cardiomyopathy. It shows different patterns that vary according to the hemodynamic states of the patient.

[Dilated myocardiopathies: the relationship between the degree of cardiac dysfunction and ventricular arrhythmias. A clinical follow-up]

STUDY OBJECTIVE

Characterization of the arrhythmic profile of idiopathic dilated cardiomyopathy (DMC); Evaluation of the relation of complex ventricular ectopy and cardiac dysfunction; Clinical outcome.

PATIENTS

We studied 20 patients (P) with idiopathic DCM, 15 males P and 5 female P, mean age 51.3 +/- 17.4 years (between 17 and 75 years).

MATERIAL AND METHODS

24-hours Holter study and left cardiac catheterization with ventriculography were performed. Patients were followed at the consults.

RESULTS

We detected in the Holter study the presence of ventricular ectopy in 19 P (95%). Nine P had complex ventricular arrhythmias (45%), 10 P had simple ventricular arrhythmias (50%) and 1 P had no ventricular arrhythmia (5%). The mean left ventricular ejection fraction was 28.6 +/- 14.1% (12 to 44%). Two groups were defined based on the severity of left ventricular dysfunction: Group I with 12 P and Group II with 8 P. In Group I, 8 P had complex ventricular ectopy and, in Group II, 1 P had complex ventricular ectopy (p < 0.05). Comparing mean left ventricular ejection fraction in the two groups of arrhythmias (simple and complex), 33.9 +/- 12.5% and 22.1 +/- 13.8%, we found out a statistically significant difference (p < 0.05). After an eight to thirty six months of follow-up, a greater number of cardiac events (mortality, transplant) were detected in the groups of complex arrhythmia and of more severe cardiac dysfunction.

CONCLUSIONS

We conclude that there is a high frequency of ventricular arrhythmias in this group of patients with idiopathic DCM. Complex ventricular arrhythmias were more frequently associated to more severe left ventricular dysfunction. The number of cardiac events at follow-up was higher in patients with complex ventricular arrhythmias and in those with more depressed cardiac function.

[Pulmonary artery involvement in Takayasu arteritis. A case of right ventricular failure as presentation form]

Pulmonary involvement in Takayasu's artery disease has been reported since 1940 with an incidence of 14 to 56%. However, the development of severe pulmonary hypertension is an extremely rare event in the natural course of the disease. The authors report a case of a 62 year old male presenting with severe congestive heart failure of recent onset. The initial evaluation and routine exams suggested the presence of pulmonary hypertension of unknown etiology. The absence of left radial pulse in the physical examination led to the performance of a complete angiographic study which confirmed the diagnosis of Takayasu's arteritis with pulmonary involvement and severe pulmonary hypertension.

[Pulmonary stenosis in adults. Report of a clinical case]

The authors report a case of valvular pulmonary stenosis in a 60 years old patient, admitted to hospital with heart failure and angor pectoris. Four years previously a VVI pacemaker had been implanted for complete heart block. At the time of the admission he had two pacemakers leads in the right ventricle; one of them was retained and functionless since the changing of the generator which occurred 1 year before. The usual complications of endocardial pacemakers are discussed, as well as the natural course and surgery indications for valvular pulmonary stenosis in adults.

[Floating thrombus in the left atrium. Apropos of a clinical case]

The authors report a case of floating left atrial thrombus, detected by transthoracic echocardiography, in a 63 years old patient with moderate mitral stenosis and atrial fibrillation. He was admitted to hospital, with supraventricular tachyarrhythmia and pulmonary edema. There was no previous syncope or thromboembolism episodes. Apparently the anticoagulant therapy wasn't interrupted. The diagnosis of the free floating left atrial thrombus was made by two-dimensional echocardiography. Predisposing factors, clinical course and echocardiographic diagnosis are discussed. The risk of prolonged engagement of the thrombus in the mitral orifice, causing syncope or sudden death, justifies urgent surgery associating thrombectomy and treatment of mitral stenosis.

[Changes in coronary angiography in young patients with myocardial infarction]

OBJECTIVE

To assess the coronariographic changes and left ventricular function of a group of young patients (pts) (less than 40 years) with myocardial infarction.

DESIGN

Retrospective analysis on clinical data and cineangiography.

SETTING

Patients studied in the Cardiology Department and Cardiothoracic Department of the Santa Marta Hospital in Lisbon.

PATIENTS AND INTERVENTIONS

Sequential sample of 40 pts 39 male and one female submitted to coronariography after an acute myocardial infarction (mean age--34 +/- 3 years).

MEASUREMENTS AND RESULTS

Twenty one pts had one vessel disease, 6 pts two vessel disease, 3 pts three vessel disease, 1 left main disease (2.5%) and 9 normal coronary arteries. More than a half (22) had a lesion on the left anterior descending artery (proximal in 12-30%), 13 a lesion on the right coronary artery (proximal in 3) and 8 on the circunflex coronary artery. There were 22 (55%) total occlusions (3 of the circunflex, 9 of the left anterior descending artery and 10 of the right coronary artery). Of these 8 were proximal. We divided the pts according to the regional contractility score in three groups. Most of them had a moderate decrease in contractility. Three pts had an apical aneurysm and 8 pts had apical discinesia. Three of these 11 pts had no significant coronary lesions, six had one vessel disease and 6 had a proximal lesion of the left anterior descending artery. The mean ejection was 53% and none was less than 30%. There was a statistical difference of score and ejection fraction between anterior and inferior myocardial infarctions (6.5 +/- 1.8 versus 7.8 +/- 1.6 e 48 +/- 11.6 versus 55.4 +/- 10.8), p less than 0.05 and between those with and without a proximal lesion of the anterior descending coronary artery (5.5 +/- 1.5 versus 7.9 +/- 1.5 and 41.4 +/- 7.9 versus 56.3 +/- 9.9), p less than 0.0005. Neverthless, when we tried to separate the pts with or without atherosclerotic lesions (6.9 +/- 1.7 versus 7.9 +/- 2.2 and 50.4 +/- 11 versus 54.8 +/- 14.3) or with and without multivessel disease (7.2 +/- 1.8 versus 6.7 +/- 1.9 and 52.9 +/- 12.2 versus 46.6 +/- 8.7), no statistical difference of score and ejection fraction was found.

CONCLUSION

Young patients with myocardial infarction are predominantly males; - There is an important number of one vessel disease and in many patients no coronary significant lesions were found; - The functional changes depended more on the proximal location than on the number of diseased vessels.

[Arrhythmic profiles evaluated by Holter's technique in sick sinus syndrome]

OBJECTIVES

The aim of this study was to evaluate in a group of patients with sick sinus syndrome: 1) Characteristics of arrhythmia on Holter monitoring. 2) Value of Holter monitoring to select patients for pacemaker implantation.

SETTING

Department of Cardiology in a Central Hospital.

METHODS

In 40 patients (27 men and 13 women, aged 37 to 83 years) Holter monitoring during a 24-hour period was performed. According to the arrhythmia profiles four groups of patients were considered: group A--with severe sinus bradycardia; group B--with sinus bradycardia associated to sinoatrial exit block or to sinus pauses; group C--characterized by the bradycardia-tachycardia syndrome and group D--defined by the finding of atrial fibrillation with a slow ventricular response. Symptoms and the presence of structural heart disease were evaluated.

RESULTS

In this patients population, 24 patients had coronary artery disease and/or hypertensive heart disease. A severe sinus bradycardia was found in 14 patients (group A) and in other 11 patients it was accompanied by sinoatrial exist block of sinus pauses (group B); 12 patients had the bradycardia-tachycardia syndrome (group C) and periods of atrial fibrillation with a slow ventricular response were found in 3 other patients (Group D). Nonspecific clinical pattern was observed in this population.

CONCLUSIONS

Holter monitoring was important to the diagnosis of sick sinus syndrome and for posterior definitive pacemaker implantation. Coronary artery disease and/or hypertensive heart disease were the main pathologies found in this study, being the severe sinus bradycardia and the bradycardia-tachycardia syndrome the principal manifestations of the sick sinus syndrome.