[Infected myxoma as a cause of acute infective endocarditis]

Myxoma is the most frequent primary cardiac tumor. In the typical clinical picture mostly dominate signs of intracardial obstruction, embolisation or general signs of neoplastic process. The myxoma can mimic the course of acute endocarditis. Genuine proof of infection is rare. We report on a patient with familiar form of infected myxoma, who was treated succesfully with antiobiotic therapy and surgical extirpation of the tumor.

Decrease in plasma B-type natriuretic peptide early after initiation of cardiac resynchronization therapy predicts clinical improvement at 12 months

BACKGROUND

Decrease in neurohormonal activation during pharmacotherapy for chronic heart failure (CHF) is associated with haemodynamic and clinical improvement. We tested the hypothesis that changes in neurohormonal activation after initiation of cardiac resynchronization therapy (CRT) predict its long-term clinical effect.

METHODS

The study group included 43 patients with CHF (37 males, mean age 62+/-9 years, NYHA class 3.2+/-0.4, QRS duration 195+/-24 ms) who underwent successful implantation of a CRT system. Pharmacotherapy remained stable during the first 3 months of follow-up. Plasma levels of B-type natriuretic peptide (BNP) and big endothelin-1 (big ET-1) were evaluated before and 3 months after implantation. Clinical, echocardiographic and exercise parameters were monitored for a mean period of 25.8+/-6.7 months.

RESULTS

At 12 months of follow-up 13 non-responders were identified (no improvement in NYHA class (n=10), urgent heart transplantation (n=2) and death due to progressive heart failure (n=1)). CRT resulted in a significant reduction in neurohormone levels (BNP 345.4+/-346 vs. 267.7+/-320.8 pg/ml, p<0.01, big ET-1 3.11+/-1.50 vs. 2.50+/-1.56 fmol/ml p<0.05), especially in responders. Percentage change in BNP level was a stronger predictor of long-term clinical improvement than clinical, echocardiographic and exercise parameters at 3 months of follow-up.

CONCLUSIONS

Percentage change in plasma BNP levels from baseline to 3 months was the strongest predictor of long-term response to CRT and may have potential to predict outcome.

Optimization of right ventricular lead position in cardiac resynchronisation therapy

BACKGROUND

The benefit of biventricular pacing (BiV) may be substantially affected by optimal lead placement.

AIM

To evaluate the importance of right ventricular (RV) lead positioning on clinical outcome of BiV.

METHODS AND RESULTS

A total of 99 patients with symptomatic heart failure and implantation of BiV system were included. Position of the left-ventricular (LV) lead was selected based on timing of local endocardial signal within the terminal portion of the QRS complex. RV lead was preferably positioned at the midseptum (n=74, RVS group) where the earliest RV endocardial signal was recorded. A subgroup of patients had RV lead placed in the apex (n=25, RVA group). NYHA class, maximum oxygen-uptake (VO(2)max), LV end-diastolic diameter (LVEDD, mm) and ejection fraction were assessed every third month. A trend towards greater improvement in NYHA class and significant increase in VO(2)max was present in the RVS group. Moreover, a significant decrease in LVEDD (DeltaLVEDD) was observed in the RVS group only (-3.4+/-6.5 mm versus +1.7+/-6.4 mm in RVA group at 12 months, p=0.004). No significant correlation between the degree of DeltaLVEDD and QRS narrowing induced by BiV was found. LVEDD reduction was predominantly present in dilated cardiomyopathy.

CONCLUSIONS

Midseptal positioning of the RV lead appears to promote reverse LV remodelling during cardiac resynchronisation therapy.

Influence of Different Atrioventricular and Interventricular Delays on Cardiac Output During Cardiac Resynchronization Therapy

Restoration of the atrioventricular (AVD) and interventricular (VVD) delays increases the hemodynamic benefit conferred by biventricular (BiV) stimulation. This study compared the effects of different AVD and VVD on cardiac output (CO) during three stimulation modes: BiV-LV = left ventricle (LV) preceding right ventricle (RV) by 4 ms; BiV-RV = RV preceding LV by 4 ms; LVP = single-site LV pacing. We studied 19 patients with chronic heart failure due to ischemic or idiopathic dilated cardiomyopathy, QRS >/= 150 ms, mean LV end-diastolic diameter = 78 +/- 7 mm, and mean LV ejection fraction = 21 +/- 3%. CO was estimated by Doppler echocardiographic velocity time integral formula with sample volume placed in the LV outflow tract. Sets of sensed-AVDs (S-AVD) 90-160 ms, paced-AVDs (P-AVD) 120-160 ms, and VVDs 4-20 ms were used. BiV-RV resulted in lower CO than BiV-LV. S-AVD 120 ms and P-AVD 140 ms caused the most significant increase in CO for all three pacing modes. LVP produced a similar increase in CO as BiV stimulation; however, AV sequential pacing was associated with a nonsignificantly higher CO during LVP than with BiV stimulation. CO during BiV stimulation was the highest when LV preceded RV, and VVD ranged between 4 and 12 ms. The most negative effect on CO was observed when RV preceded LV by 4 ms. Hemodynamic improvement during BiV stimulation was dependent both on optimized AVD and VVD. LV preceding RV by 4-12 ms was the most optimal. Advancement of the RV was not beneficial in the majority of patients.

Catheter-based fixation of the mitral valve after acute papillary muscle rupture: a new technique for temporary hemodynamic stabilization

We describe a new, catheter-based method for temporary management of hemodynamic instability after papillary muscle rupture in a patient with an acute myocardial infarction.

[Serum insulin levels affect body constitution, blood pressure, serum lipids and cardiac dimensions. Observations in clinically healthy offspring from hypertensive families]

BACKGROUND

According to some work hypertension is in a pathogenetic relationship with hyperinsulinaemia or is considered to be the consequence of insulin resistance. It is, however, also known that there exists a familial predisposition for hypertension; according to genetic investigations half the family relatives can suffer from hypertension. In conjunction with these views on the pathogenesis of hypertension and its familial character the authors outlined the following objectives of their investigation: to test clinically and metabolically the condition of the offspring of probands with essential hypertension requiring systematic treatment. The authors investigated in particular indicators of body composition, insulin concentration and its relationship to serum levels and some indicators of lean body mass. METHODS AND RESULTS. There were 48 offspring (25 men and 23 women) from families of 30 probands suffering from hypertension. The mean age of the offspring was 38.4 +/- 7.8 years. They were compared with a group of 72 controls, mean age 35.8 +/- 8.2 years (36 men and 36 women) without a family history of hypertension and diabetes (t-test). The basal insulin concentration (IRI O' = 20.5 +/- 12.8 microU/ml, and 14.3 +/- 7.3 microU/ml resp., p < 0.01) and basal C peptide (O' = 0.59 +/- 0.31 pmol/ml and 0.50 +/- 0.20 pmol/ml resp., p < 0.05) were elevated. The offspring of probands with hypertension had a higher body weight (BMI = 25.3 +/- 3.5 kg/m2 and 23.3 +/- 2.5 kg/m2 resp., p < 0.001) a higher ratio of waist hip circumferences (0.94 +/- 0.1 and 0.87 +/- 0.1 resp., p < 0.001) similarly as blood pressure (131.5 mmHg +/- 11.8 mmHg and 116 mmHg +/- 13.3 mmHg resp., p < 0.001) and blood sugar level (5.29 +/- 0.61 mmol/l and 4.93 +/- 0.39 mmol/resp., p < 0.01). The authors also found differences in the serum cholesterol levels (5.9 +/- 1.3 mmol/l and 5.1 +/- 0.6 mmol/l resp., p < 0.01), HDL cholesterol (1.45 +/- 0.50 mmol/l and 1.65 +/- 0.60 mmol/l resp., p < 0.01) and triacylglycerol trends (1.66 +/- 1.54 mmol/l and 1.37 +/- 0.96 mmol/l resp., p < 0.1). On echocardiographic examination the cardiac dimensions were not enlarged, however, significant relations (linear regression) were proved in offspring in particular as regards the dimensions of the left ventricle and insulin (IRI O-left atrium p < 0.05, IRI 30-left atrium, p < 0.01. C peptide O-left atrium, p < 0.05). Between the body mass index, cholesterol, uric acid HDL-cholesterol the waist/hip ratio on the one side, the dimensions of the left atrium, thickness of septum and posterior wall (p < 0.01-0.001), between insulin and C peptide (p < 0.001) on the other side even closer relations were found.

CONCLUSIONS

Elevated insulin concentrations may participate in the development of body composition, they influence the lipid transport and blood pressure in clinically healthy offspring of probands suffering from hypertension. The relationship between the insulin concentration and disposition towards enlargement of the left heart needs more detailed investigation.

[Pericardial puncture under echocardiographic control]

The authors summarize their hitherto assembled experience with pericardiocentesis under echocardiographic control. From May 1986 to December 1991 they made these punctures 55 times in 49 patients. In the majority therapeutic puncture was involved, only seven times puncture was used for diagnostic purposes. Echocardiography can evaluate not only the presence of an exudate and assess its haemodynamic impact but it is the optimal method for finding an optimal site for puncture and it is very suitable for checking the course of the operation. In smaller operations and in biopsies of pathological pericardial tissue it is advisable to use special instruments which make the procedure safe. The authors recorded a total of three failures, in one instance the exudate was removed with the assistance of a surgeon, in one instance the situation was coped with by repeated puncture and in one instance by a conservative procedure. None of the patients developed complications. A list of the latter is discussed. The method is nowadays part of therapeutic procedures of the cardiologist.

[Echocardiographic findings in cerebrovascular accidents]

The authors present a review on the frequency and causes of cardiogenic systemic embolism and on the influence of damage of the central nervous system on the heart muscle. 10-20% of ischaemic cerebrovascular attacks are of cardioembolic origin. In patients with chronic atrial fibrillation the risk of a cerebrovascular attack is six times higher than in the corresponding population with a sinus rhythm. Views on the preventive administration of anticoagulants differ so far. In extensive myocardial infarctions of the anterior wall thrombi in the left ventricle are present in 30-40%. Thrombolytic treatment affects their formation; so far it is not clear whether it reduces the risk of embolization. With technical advances in echocardiography, and in particular transoesophageal echocardiography, attention is focused on abnormal findings in patients with cerebrovascular attacks without manifest heart disease. Most frequently in these patients a prolapse of the mitral valve is found, a foramen ovale patents, an aneurysm of the atrial septum, sometimes thrombi in the left auricula atrialis of an otherwise quite normal heart. A rare finding are cardiac tumours, systemic embolism being frequently their first clinical manifestation. An indicator of high risk of thromboembolism is probably a spontaneous echo contrast in the left atrium, detected reliably only from an oesophageal approach. In the second part the authors summarize contemporary knowledge on the effect of damage of the central nervous system on cardiac action. Cerebral injury or haemorrhage accompany kinetic disorders of the left ventricle of varying impact. Myocardial damage is caused by a high catecholamine level and can be prevented by administration of beta blockers.(ABSTRACT TRUNCATED AT 250 WORDS)

[Evaluation of diastolic left ventricular function using pulsed Doppler echocardiography]

The authors give an account of the evaluation of diastolic functions by means of pulsed Doppler echocardiography. It is a relatively new method which is still seeking its position in the pattern of examinations. However, some authors have already demonstrated that it is valuable and can contribute towards a more accurate description of the functional state of the myocardium and help to detect initial stages of disease. As it is non-invasive, it can be repeated, as required without damaging the patient and thus can be used to follow up the effect of therapy.

[Pseudoaneurysm of the heart. Report on 4 patients]

A cardiac pseudoaneurysm (PA) is a rare complication of myocardial infarction. It may occur isolated, after cardiosurgery or after an accident. Echocardiography is of fundamental importance in its diagnosis. Coronarography provides important data on the state of the coronary arteries which is essential for planning further, in particular surgical treatment of the condition. The authors describe from four patients with PA.

Heart and vessel hypertrophy in hypertension: possibilities of regression

Fifty-two middle-aged hypertensive males with left ventricular hypertrophy, diagnosed by echocardiography, were divided into two groups; 30 of them were treated with beta-blockers and 22 with methyldopa. Where blood pressure was insufficiently controlled, diuretics and, eventually vasodilating agents, were added to both treatment regimes. During 2 years of follow-up, blood pressure decreased significantly. The greatest decrease was observed during the first 3 months. Echocardiography revealed the greatest decrease in posterior wall and interventricular septal thickness also during the first 3 months. Posterior wall hypertrophy was reversed completely in the next 3 months, while further regression of interventricular septal hypertrophy was continuous during the remaining follow-up period. Left ventricular hypertrophy was reversed completely in 27 (51.9%) probands and remained unchanged in two patients. The regression was incomplete in 23 (44.2%) patients who were more obese and whose left ventricular hypertrophy was initially more pronounced. Regression of hypertrophy was not associated with a deterioration in left ventricular function and was achieved even after the addition of vasodilating drugs. No differences were observed between the treatment groups. The pathogenesis of left ventricular hypertrophy still remains unclear. After 2 years, no changes in peripheral vascular resistance in the forearm were observed at reactive hyperaemia. These results indicate that there might be a delay in the regression of vessel hypertrophy compared with that of the left ventricle.

Prediction of pulmonary hypertension from postural changes of pulmonary transfer factor

The differences between lung transfer factor values measured in supine and standing positions were correlated with pulmonary artery pressures in 61 patients with chronic obstructive lung disease and in 34 patients with recurrent pulmonary embolism. No significant correlation was found. The postural change of transfer factor cannot be used as a noninvasive indicator of pulmonary artery pressure in these diseases.