Abstract: OBJECTIVE: The aim of the study was to evaluate left ventricular diastolic function and its relation to aortic wall stiffness in patients with type 1 diabetes mellitus without coronary artery disease or hypertension. PATIENTS: Sixty-six patients with type 1 diabetes mellitus were examined by echocardiography and divided into two groups according to the diastolic filling pattern determined by mitral annulus tissue Doppler velocities. Group A patients (n = 21) presented diastolic dysfunction with a peak early diastolic mitral annular velocity (Em)/peak late diastolic mitral annular velocity (Am) ratio <1 whereas in group B patients (n = 45) the Em/Am ratio was >1. Coronary artery disease was excluded based on normal thallium scintigraphy. Aortic stiffness index was calculated from aortic diameters measured by echocardiography, using accepted criteria. RESULTS: Aortic stiffness index differed significantly among the two groups. Significant correlations were found between parameters of left ventricular diastolic function (Em/Am, isovolumic relaxation time, deceleration time) and aortic stiffness index. Multiple stepwise linear regression analysis revealed aortic stiffness index (beta = -0.39, p = 0.001) and isovolumic relaxation time (beta = -0.46, p < 0.001) as the main predictors of Em/Am ratio. CONCLUSIONS: Aortic stiffness is increased in type 1 diabetic patients with left ventricular diastolic dysfunction. This impairment in aortic elastic properties seems to be related to parameters of diastolic function.
Abstract: Cardiovascular autonomic neuropathy (CAN) is one of the most serious complications of diabetes and has been weakly linked with left ventricular (LV) diastolic dysfunction. Previous studies that explored this association either suffer from inadequate definition of CAN or have mainly used conventional Doppler or nuclear techniques to investigate LV diastolic function. Tissue Doppler imaging (TDI) has evolved as a new quantitative tool for the assessment of cardiac systolic function, diastolic function, and the hemodynamics of LV filling. We sought to investigate conventional and TDI-derived indexes of LV systolic and diastolic function in type 1 diabetic patients with and without CAN and also in normal control subjects. Our findings suggest that the presence of CAN seems to have an additive effect on LV diastolic dysfunction in type 1 diabetes.
Abstract: Informed consent for emergency coronary artery bypass grafting (CABG) is routinely obtained from patients undergoing percutaneous coronary intervention (PCI) and diagnostic angiography. Given the recent technological and pharmacological advances as well as increasing operator experience, we sought to assess the contemporary incidence of emergency CABG following PCI in our centre. In a total of 7855 consecutive PCIs, the overall rate of emergency CABG was 0.11%, and the mortality risk was 0.67%. We believe that in the vast majority of patients undergoing PCI and diagnostic angiography, routine consent for emergency CABG is no longer appropriate.
Abstract: We hypothesised that apart from right ventricular (RV) dysfunction, patients with idiopathic pulmonary fibrosis (IPF) also exhibit left ventricular (LV) impairment, which may affect disease progression and prognosis.To evaluate LV performance in a cohort of IPF patients using conventional and tissue Doppler echocardiography.We studied 22 IPF patients (mean age 65+/-9 years) exhibiting mild to moderate pulmonary artery hypertension and 22 healthy individuals (mean age 61+/-6 years). We used conventional and tissue Doppler echocardiography for the evaluation of RV and LV systolic and diastolic function.Apart from the expected impairment in RV function, all patients showed a characteristic reversal of LV diastolic filling to late diastole compared to controls (E/A 0.7+/-0.2 vs. 1.5+/-0.1 respectively, p<0.001). Patients with IPF also exhibited lower peak myocardial velocities in early diastole (Em 5.7+/-1.1 vs. 10.3+/-1.6 respectively, p<0.001), higher in late diastole (Am 8.9+/-1.3 vs.5.5+/-0.8 respectively, p<0.001), lower Em/Am (0.6+/-0.1 vs.1.9+/-0.5 respectively, p<0.001) and higher E/Em ratio (10.8+/-3 vs. 6+/-0.6 respectively, p<0.001), all indicative of LV diastolic dysfunction. Moreover, LV propagation velocity was significantly lower in IPF patients (46+/-13 vs. 83+/-21 respectively, p<0.001).Physicians should be aware that patients with IPF exhibit early impairment of LV diastolic function.
Abstract: Tako-tsubo cardiomyopathy is a poorly understood syndrome. We report a case of a 76-year-old female patient with apical ballooning syndrome and features of left ventricular non-compaction that was followed up by Cardiovascular Magnetic Resonance (CMR) imaging.
Abstract: BACKGROUND: Left ventricular diastolic dysfunction represents the earliest preclinical manifestation of diabetic cardiomyopathy. Right ventricular function has not been studied in depth yet in diabetic patients, although the right ventricle has an important contribution to the overall cardiac function. This study was designed to assess diastolic and systolic ventricular function in both ventricles, in patients with type 1 diabetes, free from coronary artery disease and hypertension. METHODS: We studied 66 type 1 diabetic patients and 66 age- and sex-matched normal subjects by conventional and tissue Doppler echocardiography. A possible correlation was examined for age, diabetes duration and echocardiographic measurements of left ventricular and right ventricular functions with univariate analysis. RESULTS: Type 1 diabetic patients were found to have impaired diastolic function in both ventricles with either conventional or tissue Doppler echocardiography. On the contrary, systolic function in both ventricles was preserved in our diabetic population. The measured indexes showed an expected correlation with age and diabetes duration except from systolic velocity in tricuspid annulus determined by color tissue Doppler. Moreover, significant correlations were found among parameters of left and right ventricular function. CONCLUSIONS: Patients with type 1 diabetes mellitus have impaired diastolic function, and particularly relaxation, in both ventricles before the development of myocardial systolic dysfunction. These alterations in myocardial function may be attributed to ventricular interdependence as well as to the uniform effect of diabetes to cardiac function.
Abstract: OBJECTIVES: This study was designed to establish the diagnostic accuracy of cardiovascular magnetic resonance (CMR) perfusion imaging at 3-Tesla (T) in suspected coronary artery disease (CAD). BACKGROUND: Myocardial perfusion imaging is considered one of the most compelling applications for CMR at 3-T. The 3-T systems provide increased signal-to-noise ratio and contrast enhancement (compared with 1.5-T), which can potentially improve spatial resolution and image quality. METHODS: Sixty-one patients (age 64 +/- 8 years) referred for elective diagnostic coronary angiography (CA) for investigation of exertional chest pain were studied (before angiogram) with first-pass perfusion CMR at both 1.5- and 3-T and at stress (140 microg/kg/min intravenous adenosine, Adenoscan, Sanofi-Synthelabo, Guildford, United Kingdom) and rest. Four short-axis images were acquired during every heartbeat using a saturation recovery fast-gradient echo sequence and 0.04 mmol/kg Gd-DTPA bolus injection. Quantitative CA served as the reference standard. Perfusion deficits were interpreted visually by 2 blinded observers. We defined CAD angiographically as the presence of > or =1 stenosis of > or =50% diameter in any of the main epicardial coronary arteries or their branches with a diameter of > or =2 mm. RESULTS: The prevalence of CAD was 66%. All perfusion images were found to be visually interpretable for diagnosis. We found that 3-T CMR perfusion imaging provided a higher diagnostic accuracy (90% vs. 82%), sensitivity (98% vs. 90%), specificity (76% vs. 67%), positive predictive value (89% vs. 84%), and negative predictive value (94% vs. 78%) for detection of significant coronary stenoses compared with 1.5-T. The diagnostic performance of 3-T perfusion imaging was significantly greater than that of 1.5-T in identifying both single-vessel disease (area under receiver-operator characteristic [ROC] curve: 0.89 +/- 0.05 vs. 0.70 +/- 0.08; p < 0.05) and multivessel disease (area under ROC curve: 0.95 +/- 0.03 vs. 0.82 +/- 0.06; p < 0.05). There was no difference between field strengths for the overall detection of coronary disease (area under ROC curve: 0.87 +/- 0.05 vs. 0.78 +/- 0.06; p = 0.23). CONCLUSIONS: Our study showed that 3-T CMR perfusion imaging is superior to 1.5-T for prediction of significant single- and multi-vessel coronary disease, and 3-T may become the preferred CMR field strength for myocardial perfusion assessment in clinical practice.
Abstract: BACKGROUND: There are limited reports in the literature concerning right ventricular (RV) performance in patients with non end-stage idiopathic pulmonary fibrosis (IPF) who exhibit mild to moderate pulmonary hypertension (PH). We evaluated RV functional impairment in such a cohort using both conventional echocardiography and tissue Doppler imaging (TDI) and in addition we assessed the association of specific TDI indices with survival. METHODS: Twenty-two clinically stable patients with non-end stage IPF and mild to moderate PH were assessed. Twenty-two healthy individuals served as controls. We evaluated RV systolic and diastolic function and further estimated peak pulmonary artery systolic pressure (PASP). In addition, by combining TDI and Doppler echocardiography, we calculated the ratio of trans-tricuspid E-wave velocity to early diastolic tricuspid annulus velocity (RV E/Em). Patients were followed for a median period of 22 months and the incidence of death was recorded. RESULTS: Both echocardiographic modalities revealed impaired RV systolic and diastolic function in the IPF group compared to controls. A significant negative correlation was observed between RV E/Em and PASP (r = -0.5, p = 0.018). The probability of survival was 54.5% for those patients with RV E/Em < 4.7 versus 100% for those with an index > 4.7 (log-rank statistic 5.81, p = 0.016). CONCLUSIONS: TDI modality may serve as an alternative to conventional ultrasound technique for risk stratification and PH estimation in non end-stage IPF patients.
Abstract: N-Terminal-probrain natriuretic peptide (NT-proBNP) plasma levels are elevated in patients with congestive heart failure. Published data concerning the utility of NT-proBNP in hypertrophic cardiomyopathy (HCM) are lacking. Our aim was to evaluate the clinical significance of NT-proBNP in patients with HCM. A blood sample was collected for plasma NT-proBNP measurement from 43 consecutive patients with documented HCM. NT-proBNP was measured using a chemiluminescent immunoassay kit (Roche Diagnostics) on an Elecsys 2010 analyzer. Median value of NT-proBNP was 219 pg/ml (range 8-3 045 pg/ml) in NYHA class I patients, 698 pg/ml (125-2 463 pg/ml) in NYHA class II patients, and 2 683 pg/ml (131-11 542 pg/ml) in NYHA class III and IV patients. NT-proBNP plasma levels were significantly higher across the severity of functional limitation (i.e., NYHA class classification) (P = 0.002). NT-proBNP levels were significantly higher in female than male (P = 0.034), in referral vs nonreferral patients (P = 0.004), in symptomatic vs asymptomatic patients (P = 0.020), in patients with basal subaortic gradient >or=30 mmHg (P = 0.001) and in the patients who were on cardioactive medication (P = 0.010). In univariate analysis NT-proBNP was significantly correlated with age (P < 0.001), left ventricular maximum wall thickness (P = 0.001), left atrial size (P = 0.019), and subaortic gradient >or=30 mmHg (P < 0.001). In multivariate regression analysis, age (P < 0.001), maximum wall thickness (P = 0.007), and gradient >or=30 mmHg (P = 0.027) were independently associated with NT-proBNP levels. Our data support the idea that measurement of plasma NT-proBNP levels in HCM patients is useful to assess their clinical status, especially the severity of hypertrophy and the presence of obstruction, although age must be taken into account.
Abstract: BACKGROUND: Accurate and reproducible measurement of left ventricular (LV) mass and function is a significant strength of Cardiovascular Magnetic Resonance (CMR). Reproducibility and accuracy of these measurements is usually reported between experienced operators. However, an increasing number of inexperienced operators are now training in CMR and are involved in post-processing analysis. The aim of the study was to assess the interobserver variability of the manual planimetry of LV contours amongst two experienced and six inexperienced operators before and after a two months training period. METHODS: Ten healthy normal volunteers (5 men, mean age 34+/-14 years) comprised the study population. LV volumes, mass, and ejection fraction were manually evaluated using Argus software (Siemens Medical Solutions, Erlangen, Germany) for each subject, once by the two experienced and twice by the six inexperienced operators. The mean values of experienced operators were considered the reference values. The agreement between operators was evaluated by means of Bland-Altman analysis. Training involved standardized data acquisition, simulated off-line analysis and mentoring. RESULTS: The trainee operators demonstrated improvement in the measurement of all the parameters compared to the experienced operators. The mean ejection fraction variability improved from 7.2% before training to 3.7% after training (p=0.03). The parameter in which the trainees showed the least improvement was LV mass (from 7.7% to 6.7% after training). The basal slice selection and contour definition were the main sources of errors. CONCLUSIONS: An intensive two month training period significantly improved the accuracy of LV functional measurements. Adequate training of new CMR operators is of paramount importance in our aim to maintain the accuracy and high reproducibility of CMR in LV function analysis.
Abstract: In the cardiovascular system, parathyroid hormone-related peptide (PTHrP) is expressed in various cells such as cardiac vascular smooth muscle cells, coronary endothelial cells and cardiomyocytes and acts as an autocrine/paracrine substance. We compared PTHrP levels in 35 consecutive patients with severe CHF (33 male, mean age 66.2 +/- 8.9 years) with 26 normal controls (24 male, mean age 63.1 +/- 8.6 years). PTHrP levels were reduced in severe CHF patients (11.10 +/- 1.37 fmol/ml) compared with the controls (20.62 +/- 3.30 fmol/ml, p = 0.005). PTHrP values decreased as a function of New York Heart Association classification. These results suggest that PTHrP levels decrease in proportion to the severity of heart failure and could potentially be used to monitor progression of disease non-invasively.
Abstract: AIMS: Diabetes mellitus (DM) is associated with macrovascular disease and impaired aortic function. We hypothesized that the change in aortic elastic properties could be investigated with colour tissue Doppler imaging (CTDI) in Type 1 diabetic patients and that these findings could be related to the aortic stiffness index. METHODS: We examined by echocardiography 66 patients with Type 1 DM (mean age 35 +/- 10 years, mean duration of disease 20 +/- 9 years) without a history of arterial hypertension or coronary artery disease (negative thallium-201 stress test) and 66 age- and sex-matched normal subjects. Arterial pressure was measured before echocardiography was performed. Internal aortic systolic and diastolic diameters by M-mode echocardiography and aortic systolic upper wall tissue velocity (Sao, cm/s) by CTDI were measured 3 cm above the aortic valve. Aortic distensibility and aortic stiffness index were calculated using accepted formulae. RESULTS: Aortic stiffness, distensibility and Sao velocity differed significantly between the studied groups. In the diabetic group, duration of diabetes correlated with aortic stiffness (r = 0.53, P < 0.001), distensibility (r = -0.61, P < 0.001) and Sao velocity (r = -0.48, P < 0.001). There was a negative correlation between aortic stiffness and Sao velocity (r = -0.49, P < 0.001). Multiple stepwise linear regression analysis in the diabetic group revealed that aortic S velocity (beta = 0.30, P = 0.005) and duration of diabetes (beta = -0.49, P = 0.001) were the main predictors of aortic distensibility (overall R(2) = 0.48). CONCLUSIONS: Aortic elastic properties can be directly assessed by measuring the movements in the upper aortic wall. Reduced aortic S velocity is associated with increased aortic stiffness in Type 1 diabetic patients.
Abstract: BACKGROUND: Functional mitral valve regurgitation attenuation after cardiac resynchronization therapy (CRT) in patients with severe heart failure has been attributed to both the increased rate of left ventricular systolic pressure increase and to papillary muscle (PM) recoordinated contraction. We hypothesized that an increase in systolic deformation of the PMs or the adjacent myocardial wall may in part account for this effect, by preventing their outward displacement during systole. METHODS: We studied by echocardiography 22 patients with moderate/severe functional mitral valve regurgitation and a mean ejection fraction of 18 +/- 4% at baseline and after implantation of a CRT system. RESULTS: CRT induced a significant reduction of the effective regurgitant orifice area (0.18 +/- 0.11 vs 0.35 +/- 0.17 mm2, P < .001). Strain improved in both PMs and their adjacent walls, although this improvement was significant only in anterolateral PM (-16 +/- 4.7 vs -11 +/- 4.3%, P = .02) and posteromedial PM adjacent wall (-16 +/- 10 vs -8 +/- 4.6%, P = .01). CONCLUSIONS: CRT acutely reduces the severity of functional mitral valve regurgitation in patients with heart failure and this effect may be in part attributed to improved strain of PM or adjacent wall.
