Left Ventricular Dysfunction Research Papers (original) (raw)

Acute bouts of ultraendurance exercise may result in the appearance of biomarkers of cardiac cell damage and a transient reduction in left ventricular function. The clinical significance of these changes is not fully understood. There seems to be two competing issues to be resolved. First, could prolonged endurance exercise produce a degree of cardiac stress and/or damage that results, during the short or long term, in deleterious consequences for cardiac health. Second, there is a clear need to educate those responsible for the medical care of endurance athletes about the possibility of a transient reduction in cardiac function and the appearance of cTnT/cTnI after an exercise. Minor elevations in cardiac troponins are commonplace after an endurance exercise in elite and recreational athletes and may occur alongside exercise-associated collapse. Misdiagnosis of myocardial injury and subsequent mismanagement can be unnecessarily expensive and psychologically damaging to the athlete. Diagnosis of myocardial injury after prolonged exercise should be made on the basis of all available information and not blood tests alone. The clinical significance of chronic exposure to endurance exercise is unknown. The development of myocardial fibrosis has been suggested as a long-term outcome to chronic exposure to repetitive bouts of endurance exercise and has been linked to an exercise-induced inflammatory process observed in an animal model. This hypothesis is supported by a limited number of studies reporting postmortem studies in athletes and an increased prevalence of complex arrhythmia in veteran athletes. Care is warranted in promoting this hypothesis without further detailed work, given the unequivocal link between exercise and mortality and morbidity. It would seem erroneous, however, to assume that a linear relationship exists between exercise volume and cardiac health.

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- Sports, Exercise, Fibrosis, Left Ventricular Dysfunction

Theaimof this studywasto assesswhethernitrateadministra tion improvesthe imagingcapabilitiesof @Â°â€˜Tc-MlBl tomogra phy in detectingviablemyocardiumin coronaryarterydisease (CAD). Methods: Thirty-one patients withangiographically proven CADand chronicLV dysfunction(ejectionfraction39% Â±9%) underwenttwo @Â°â€˜Tc-MlBl studieson separatedays:oneunder rest conditionsand the other after nitroglycerine(0.005mg/kg per Os)administration.Within1 wk, all patientsalso underwent rest-redistribution 2o1@fl imaging. Eightpatients werealsostud ied by echocardiography before and 5 Â±3 mo after coronary revascularization. Results: On resting 99mTc.MlBl im ages, 302 segmentshad normal uptake, 183 segmentshad moderatelyreduceduptakeand 197 had severelyreducedup take. Of the segmentswith severelyreduceduptake,54 (27%) had increased uptake after nitroglycerineand were viable on 201fl images. Of the 143 (73%) segmentswith severely reduced @Â°Tc-MlBl uptakeand no changeafternitroglycerine, 81% werenonvi...

- by Simone Maurea
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- Nuclear medicine, Echocardiography, Heart, Myocardial Revascularization

Although ischemic heart disease is the major cause of death in diabetic patients, diabetic cardiomyopathy (DCM) is increasingly recognized as a clinically relevant entity. Considering that it comprises a variety of mechanisms and effects on cardiac function, increasing the risk of heart failure and worsening the prognosis of this patient category, DCM represents an important complication of diabetes mellitus, with a silent development in its earlier stages, involving intricate pathophysiological mechanisms, including oxidative stress, defective calcium handling, altered mitochondrial function, remodeling of the extracellular matrix, and consequent deficient cardiomyocyte contractility. While DCM is common in diabetic asymptomatic patients, it is frequently underdiagnosed, due to few diagnostic possibilities in its early stages. Moreover, since a strategy for prevention and treatment in order to improve the prognosis of DCM has not been established, it is important to identify clear ...

- by Iris Bararu
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- Diabetes, Calcium, Magnetic Resonance Spectroscopy, Medicine

Mental health outcomes for survivors of critical congenital heart disease (CHD) remain under-investigated. We sought to examine psychiatric disorders and psychosocial functioning in adolescents with single ventricle CHD and to explore whether patient-related risk factors predict dysfunction. This cohort study recruited 156 adolescents with single ventricle CHD who underwent the Fontan procedure and 111 healthy referents. Participants underwent comprehensive psychiatric evaluation including a clinician-rated psychiatric interview and parent- and self-report ratings of anxiety, disruptive behavior, including attention-deficit/hyperactivity disorder (ADHD), and depressive symptoms. Risk factors for dysfunction included IQ, medical characteristics, and concurrent brain abnormalities. Adolescents with single ventricle CHD had higher rates of lifetime psychiatric diagnosis compared with referents (CHD: 65%, referent: 22%; P < .001). Specifically, they had higher rates of lifetime anxie...

- by Michael Rivkin
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- Pediatrics, Anxiety Disorders, Depression, Adolescent

Both resting tachycardia and irregular ventricular rhythm may contribute to impaired cardiac performance in atrial fibrillation (AF). This study assesses the relation between resting heart rate and beat-to-beat changes in left ventricular (LV) ejection and filling in patients with normal and impaired LV systolic function. Beat-to-beat variation in LV outflow and inflow velocity-time integral was measured using pulsed Doppler ultrasound in 39 patients with chronic AF and normal (n ‫؍‬ 22) or impaired (n ‫؍‬ 17) LV systolic function. Aortic velocity-time integral variability increased with mean heart rate (p ‫؍‬ 0.003) even though RR interval variability decreased (p <0.001). Aortic velocity-time integral was more sensitive to the duration of both the preceding (p <0.001) and prepreceding (p <0.001) RR intervals at higher heart rates. These relations were similar for patients with normal and impaired LV systolic function. The sensitivity of the filling velocity-time integral to RR interval variability also increased with heart rate (p <0.001). However, at higher heart rates the filling velocity-time integral (p ‫؍‬ 0.009 ) and filling time (p ‫؍‬ 0.005) were less sensitive to change in RR intervals in patients with impaired LV function. We conclude that beat-to-beat stroke volume variability in AF increases with heart rate. Stroke volume variability was not influenced by LV systolic function.

- by Ralph Stewart
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- Prospective studies, Doppler Ultrasound, Atrial Fibrillation, Heart rate

The aim of this prospective study was to evaluate the effect of the closed loop stimulation (CLS) on the ejection fraction in pediatric patients, affected by complete atrioventricular block (CAVB) or CAVB and sinus node dysfunction (SND), with a previously implanted pacemaker (PM) and ventricular dysfunction. The role of electrical therapy in the treatment of pediatric patients with congenital atrioventricular (AV) blocks has been shown. Conventional right ventricular pacing seems to affect ventricular function. Up to now, the feasibility and the long-term results of biventricular pacing in pediatric patients were not entirely clear. In eight pediatric patients with a previously implanted single or dual chamber PM, ventricular dysfunction, and CAVB or SND and CAVB, a dual chamber PM INOS(2+)-CLS (Biotronik GmbH, Berlin, Germany) was implanted. The effect of the physiological modulation of CLS pacing mode on the ejection fraction was evaluated by Echo-Doppler examination. Measurements were performed before the substitution of the old PM and for up to 2 years of follow-up. All patients showed correct electrical parameters at implantation and during follow-up. The mean value of the ejection fraction measured before the replacement of the old PM was 36 +/- 7%, while after 2 years it was 47 +/- 1% (P &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.003). No patient showed any worsening of the ejection fraction, while only one showed no improvement. DDD-CLS pacing seems to improve ventricular function in pediatric patients with CAVB and/SND in spite of the use of the apical right conventional stimulation.

- by Gabriele Rinelli and +1
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- Biomedical Engineering, Prospective studies, Child, Infant

Alterations in rotational mechanics can bring new aspects to the understanding of left ventricular (LV) dyssynchrony. The aims of this study were to investigate LV rotational mechanics in candidates for cardiac resynchronization therapy (CRT) and to assess the effect of CRT by speckle-tracking echocardiography. Fifty-four patients with heart failure and 33 healthy controls were studied. Thirty-three underwent CRT. Speckle tracking was applied to short-and long-axis views. Radial and longitudinal dyssynchrony were assessed as previously defined. Apical and basal rotations were measured as the average angular displacement about the LV central axis. LV twist and torsion were then calculated. Peak apical and basal rotation, peak LV twist and torsion, apical and basal rotation at aortic valve closure (AVC), and LV twist and torsion at AVC were significantly lower in patients than controls. Apical-basal rotation delay and AVC-to-peak LV twist interval were longer in patients and associated with decreased peak LV twist and LV twist at AVC, respectively. In patients, rotational indexes, particularly LV twist and torsion, were correlated strongly with radial dyssynchrony. LV torsion (cutoff 0.1°/cm) and twist (cutoff 1°) at AVC had the highest sensitivity (90%) and specificity (77%) to predict CRT responders among all other parameters, including radial and longitudinal dyssynchrony. In conclusion, LV dyssynchrony is associated with discoordinate rotation of the apical and basal regions, which in turn significantly decreases peak LV twist and torsion and LV twist and torsion at AVC. CRT significantly restored the altered rotational mechanics in responders. These parameters have potential for predicting responders to CRT.

- by Özlem Demir
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- Mechanics, Cardiology, Echocardiography, Left Ventricular Assist Device

Background: Myocardial infarction is a public health problem. Functional food is an alternative treatment for cardiovascular diseases. Objective: The objective was to analyze the functional and anatomopathological post-myocardial-infarction effects of soybean extract (SE) and isoflavone (IF). Methods: Myocardial infarction was induced in adult Wistar rats. After 5 days, an echocardiogram was performed to determine heart rate (HR), ejection fraction (EF), systolic volume (LVESV) and diastolic volume (LVEDV). Animals with ventricular dysfunction (EFb45%) were selected for study. The animals were divided into three groups: control (n=14), SE (n=15) and IF (n=12). The IF group received 120 mg/kg/day isolated IF, and the SE group received 12.52 g/day. After 30 days, a new echocardiogram was performed. A histological exam was carried out to determine the collagen. Activity of biochemical markers [arginase, lactate dehydrogenase (LDH) and malate dehydrogenase] was measured. Results: The animals of the control, IF and SE groups showed a reduction in EF after the infarction (P=.432, P=.017 and P=.320, respectively). An increase of LVESV and LVEDV was observed in all groups (P=.009, P=.001 and P=.140; and P=.003, P=.008 and P=.205, respectively). A reduction of HR was found in the SE group (P=.020). There was a greater activity of LDH in the SE group. A smaller quantity of mature collagen was found in the region proximal to the myocardial infarction in the SE group. Conclusion: A protective effect in the SE group was observed 30 days after the myocardial infarction.

- by Luiz Guarita-souza and +2
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- Nutrition and Dietetics, Echocardiography, Collagen, Left Ventricular Dysfunction

This study sought to develop and validate a method for the integrated analysis of systolic and diastolic ventricular function. B A C K G R O U N D An integrated approach to assess ventricular pump function, myocontractility (end-systolic pressure-volume relationship [ESPVR]), and diastolic compliance (end-diastolic pressurevolume relation [EDPVR]) is of high clinical value. Cardiac magnetic resonance (CMR) is well established

- by Boris Schmitt and +1
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- Integrated assessment, Magnetic Resonance, Left Ventricular Dysfunction, Clinical Sciences

Background: Cardiac transplant recipients have been regarded as not medically fit to fly an airplane. Recently, the Federal Aviation Administration decided to re-examine this policy and, in response, this study was undertaken to determine the risk of death from any cause and sudden-onset death in heart transplant recipients during the 12 months after an annual evaluation.

- by Barry Clemson
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- Adolescent, Multivariate Analysis, Aerospace Medicine, Risk factors

Aim: To estimate the prevalence of chronic heart failure (CHF) in mainland Portugal in 1998. Methods and population: A community-based epidemiological survey involving subjects attending primary care centres selected by a combined two-stage sampling and stratified procedure. General practitioners (GPs) randomly selected in proportion to the population of the District, evaluated subjects attending primary care centres aged over 25 years, recruited consecutively and stratified by age. CHF cases were identified according to the Guidelines of the European Society of Cardiology for CHF diagnosis. Results: 5434 eligible subjects were evaluated by 365 GPs; 551 patients with CHF were identified. The overall prevalence and 95% CI of CHF in mainland Portugal is 4.36% (3.69-5.02%), 4.33% in males (3.19-5.46%), and 4.38% in females (3.64-5.13%). Age-specific CHF prevalence was as follows: 1.36% in the 25-49 years-old group (0.39-2.33%), 2.93% in the 50-59 years-old group (5.58-9.37%), 7.63% in the 60-69 years-old group (5.58-9.37%), 12.67% in the 70-79 years-old group (10.73-14.6%), and 16.14% in group over 80 years old (13.81-18.47%). The prevalence of CHF due to systolic dysfunction was 1.3% and the prevalence of CHF with normal systolic function was 1.7%. Conclusions: The overall prevalence of CHF in Portugal was slightly higher than that of other European studies and increases sharply with age. The prevalence of CHF due to systolic dysfunction is very similar to that reported by other recent European studies. The differences found may correspond to differences in methodology rather than actual differences in the population. 4 See Appendix A. 5 three decades, it is likely that the number of CHF cases has increased as a result of general improvement in health care, leading to increased life expectancy and progressive ageing of the Western population w2-6x. Moreover, the effective treatment of chronic cardiovascular disorders, such as ischemic heart disease and hypertension, and other relevant diseases, such as diabetes mellitus, may actually postpone rather than prevent CHF w7x.

- by Fatima Ceia
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- Primary Care, Family Practice, Portugal, Heart Failure

Background Many patients with heart failure remain symptomatic and have a poor prognosis despite existing treatments. Decreases in myocardial contractility and shortening of ventricular systole are characteristic of systolic heart failure and might be improved by a new therapeutic class, cardiac myosin activators. We report the fi rst study of the cardiac myosin activator, omecamtiv mecarbil, in patients with systolic heart failure. Methods We undertook a double-blind, placebo-controlled, crossover, dose-ranging, phase 2 trial investigating the eff ects of omecamtiv mecarbil (formerly CK-1827452), given intravenously for 2, 24, or 72 h to patients with stable heart failure and left ventricular systolic dysfunction receiving guideline-indicated treatment. Clinical assessment (including vital signs, echocardiograms, and electrocardiographs) and testing of plasma drug concentrations took place during and after completion of each infusion. The primary aim was to assess safety and tolerability of omecamtiv mecarbil. This study is registered at ClinicalTrials.gov, NCT00624442. Findings 45 patients received 151 infusions of active drug or placebo. Placebo-corrected, concentration-dependent increases in left ventricular ejection time (up to an 80 ms increase from baseline) and stroke volume (up to 9•7 mL) were recorded, associated with a small reduction in heart rate (up to 2•7 beats per min; p<0•0001 for all three measures). Higher plasma concentrations were also associated with reductions in end-systolic (decrease of 15 mL at >500 ng/mL, p=0•0026) and end-diastolic volumes (16 mL, p=0•0096) that might have been more pronounced with increased duration of infusion. Cardiac ischaemia emerged at high plasma concentrations (two patients, plasma concentrations roughly 1750 ng/mL and 1350 ng/mL). For patients tolerant of all study drug infusions, no consistent pattern of adverse events with either dose or duration emerged. Interpretation Omecamtiv mecarbil improved cardiac function in patients with heart failure caused by left ventricular dysfunction and could be the fi rst in class of a new therapeutic agent. Funding Cytokinetics Inc. (S M Wasserman MD); ICON Development Solutions (a division of ICON plc), UK

- by Roxy Senior
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- Cardiology, Medicine, Echocardiography, Internal Medicine

Up to 15% of patients with NSTEMI present at admission with heart failure. Scientific evidence for its management is limited but much progress has been made during the last years. Our purpose was to review the last data concerning heart failure in NSTEMI and perform an update on the subject, with the following findings as main highlights. As Killip classes III and IV, Killip class II onset in the context of NSTEMI has also proven bad prognosis significance. Beta-blocker therapy has proven benefit to patients with Killip class II in observational studies and small trials. Angiotensin-converting enzyme inhibitor therapy shows stronger evidence of benefit in patients with heart failure than in patients without it. Eplerenone is indicated for patients with left ventricular dysfunction and heart failure or diabetes mellitus. Implantable cardioverter defibrillators improve survival in patients with severe ventricular dysfunction after a myocardial infarction. Cardiac resynchronization therapy indications must be carefully assessed due to the high rate of implants that do not fulfill guidelines indications. In conclusion, heart failure during a NSTEMI is a common and meaningful situation which warrants careful management and further investigation to reach stronger evidence for clinical recommendations.

- by Eduardo Franco
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- IT Management, Treatment, Electrocardiography, Heart Failure

The addition of trimetazidine to standard treatment has been shown to improve left ventricular (LV) function in patients with heart failure. The aim of this study is to non-invasively assess, by means of in vivo 31 P-magnetic resonance spectroscopy (31 P-MRS), the effects of trimetazidine on LV cardiac phosphocreatine and adenosine triphosphate (PCr/ATP) ratio in patients with heart failure. Methods and results Twelve heart failure patients were randomized in a double-blind, cross-over study to placebo or trimetazidine (20 mg t.i.d.) for two periods of 90 days. At the end of each period, all patients underwent exercise testing, 2D echocardiography, and MRS. New York Heart Association (NYHA) class, ejection fraction (EF), maximal rate-pressure product, and metabolic equivalent system (METS) were evaluated. Relative concentrations of PCr and ATP were determined by cardiac 31 P-MRS. On trimetazidine, NYHA class decreased from 3.04 + 0.26 to 2.45 + 0.52 (P ¼ 0.005), whereas EF (34 + 10 vs. 39 + 10%, P ¼ 0.03) and METS (from 7.44 + 1.84 to 8.78 + 2.72, P ¼ 0.03) increased. The mean cardiac PCr/ATP ratio was 1.35 + 0.33 with placebo, but was increased by 33% to 1.80 + 0.50 (P ¼ 0.03) with trimetazidine. Conclusion Trimetazidine improves functional class and LV function in patients with heart failure. These effects are associated to the observed trimetazidine-induced increase in the PCr/ATP ratio, indicating preservation of the myocardial high-energy phosphate levels.

- by Gianluca Perseghin
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- Cardiology, Modulation, Echocardiography, Heart Failure

The purpose of this case report is to describe the responses of 4 patients with chronic heart failure (CHF) to a novel rehabilitation program: a group-based, high-intensity, interval-training program that includes aerobic, resistance,... more

- by May Risberg
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- Quality of life, Exercise therapy, Comorbidity, Physical Therapy

advanced decompensated heart failure; risk stratification; ADHF/NT-proBNP score; Seattle Heart Failure Model score BACKGROUND: The acute decompensated heart failure/N-terminal pro-B-type natriuretic peptide (ADHF/NT-proBNP) score is a validated risk scoring system that predicts mortality in hospitalized heart failure patients with a wide range of left ventricular ejection fractions (LVEFs). We sought to assess discrimination and calibration of the score when applied to patients with advanced decompensated heart failure (AHF). METHODS: We studied 445 patients hospitalized for AHF, defined by the presence of severe symptoms of worsening HF at admission, severely depressed LVEF, and the need for intravenous diuretic and/or inotropic drugs. The primary outcome was cumulative (in-hospital and post-discharge) mortality and post-discharge 1-year mortality. Separate analyses were performed for patients aged r 70 years. A Seattle Heart Failure Score (SHFS) was calculated for each patient discharged alive. RESULTS: During follow-up, 144 patients (32.4%) died, and 69 (15.5%) underwent heart transplantation (HT) or ventricular assist device (VAD) implantation. After accounting for the competing events (VAD/ HT), the ADHF/NT-proBNP score's C-statistic for cumulative mortality was 0.738 in the overall cohort and 0.771 in patients aged r 70 years. The C-statistic for post-discharge mortality was 0.741 and 0.751, respectively. Adding prior (r6 months) hospitalizations for HF to the score increased the C-statistic for post-discharge mortality to 0.759 in the overall cohort and to 0.774 in patients aged r 70 years. Predicted and observed mortality rates by quartiles of score were highly correlated. The SHFS demonstrated adequate discrimination but underestimated the risk. The ADHF/NT-proBNP risk calculator is available at

- by Filippo Mastropasqua and +1
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- Survival Analysis, Italy, Heart Failure, Diuretics

Cell therapy plus transmyocardial laser revascularization: a proposed alternative procedure for refractory angina Terapia celular associada à revascularização transmiocárdica laser como proposta no tratamento da angina refratária Artigo recebido em 19 de setembro de 2007 Artigo aprovado 7 de fevereiro de 2008 Resumo Objetivo: É descrita uma proposição cirúrgica para o tratamento de pacientes com doença arterial coronária (DAC) terminal, não mais passíveis de revascularização miocárdica convencional. Constitui-se na revascularização transmiocárdica com raios laser (RTML), associada ao emprego de células progenitoras hematopoiéticas autólogas (CPH). Métodos: Nove pacientes (oito homens), 65±5 anos, com as características supracitadas foram submetidos ao procedimento combinado. Além da avaliação clínica, o protocolo incluiu o estudo da perfusão miocárdica através da ressonância cardíaca (RMC) sob estresse farmacológico, antes e seis meses após a intervenção cirúrgica. Procedeuse à RMTL através de minitoracotomia esquerda e utilização de laser de CO 2 , com média de 11±3 tiros por paciente. As CPH foram obtidas por punção medular, seguindo-se sua injeção direta (1,9±0,3x10 8 células/paciente) em múltiplas áreas do miocárdio isquêmico. Resultados: Não ocorreram óbitos ou complicações imediatas decorrentes dos procedimentos. Um paciente faleceu no segundo ano de pós-operatório, de causa não cardíaca (choque séptico). O seguimento clínico pósoperatório desses pacientes revelou redução significativa DALLAN, LAO ET AL-Terapia celular associada à revascularização transmiocárdica laser como proposta no tratamento da angina refratária

- by Luís Henrique W. Gowdak
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- Magnetic Resonance Imaging, Treatment Outcome, Adolescent, Cell therapy

F or normal cardiac performance, the left ventricle (LV) must be able to eject an adequate stroke volume at arterial pressure (systolic function) and fill without requiring an elevated left atrial (LA) pressure (diastolic function). These... more

- by Shailesh Sharma
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- Nepal, Echocardiography, Left Ventricular Dysfunction, Clinical Sciences

OBJECTIVES This study sought to ascertain whether left ventricular systolic dysfunction (LVSD) is more common among clinic patients with rheumatoid disease (RD) compared with the general population, and to assess the diagnostic utility of brain natriuretic peptide (BNP). BACKGROUND Patients with RD are at increased risk of ischemic heart disease. However, there are few large echocardiographic studies identifying cardiac dysfunction in RD. We hypothesized that LVSD would be more prevalent in RD patients than in the general population. METHODS A total of 226 hospital outpatients with RD (65% women) underwent clinical evaluation, electrocardiography (ECG), echocardiography, and plasma BNP assay (218 patients). Prevalence of LVSD was compared with local population estimates. RESULTS Definite LVSD (left ventricular ejection fraction Ͻ40%) occurred in 5.3% of the RD group: standardized prevalence ratio, 3.20; 95% confidence interval, 1.65 to 5.59. Median BNP values were higher in patients with LVSD compared with those without: 16.6 pmol/l versus 8.5 pmol/l, p Ͻ 0.005, although values between the two groups overlapped. One in nine patients with an abnormal ECG had definite LVSD. CONCLUSIONS Definite LVSD was three times more common in RD patients than in the general population. Given the prognostic benefits of treating LVSD, echocardiographic screening of RD patients with an abnormal ECG may be worthwhile.

- by Karlis Grindulis
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- Electrocardiography, Heart Failure, Left Ventricular Dysfunction, Heart Disease

Left ventricular (LV) diastolic function is important because the enhanced systolic function that underpins high levels of cardio-respiratory fitness has to be matched by changes in LV filling, and LV diastolic dysfunction plays a key early role in the development and progression of a myriad of cardiovascular diseases. This review serves to detail knowledge in relation to: (1) the definition of diastole and the mechanical processes that occur during the diastolic period, (2) the quantitative assessment of diastolic function, predominantly focusing on non-invasive echocardiographic imaging modes such as tissue Doppler imaging and deformation analysis, (3) the impact of acute aerobic exercise on diastolic function, from the augmentation of function necessary to meet the demand for an increased cardiac output at exercise onset, to current concerns related to the impact of prolonged or ultraendurance activity on diastolic function during recovery, (4) the adaptation in diastolic function observed with chronic aerobic exercise training in athletes and sedentary individuals who undergo training programmes, and (5) directions for future research.

- by Gregory Whyte
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- Cardiovascular, Cardiovascular disease, Swimming, Echocardiography

We nd that intervals between successive drops from a leaky faucet display scale-invariant, longrange anticorrelations characterized by the same exponents of heart beat-to-beat intervals of healthy subjects. This behavior is also con rmed by numerical simulations on lattice and it is faucetwidth-and ow-rate-independent. The histogram for the drop intervals is also well described by a L evy distribution with the same index for both histograms of healthy and diseased subjects. This additional result corroborates the evidence for similarities between leaky faucets and healthy hearts underlying dynamics.

- by Reynaldo D Pinto
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- Electrocardiography, Heart Failure, Hemodynamics, Physical sciences

Background: Left ventricular remodeling (LVr) is still common after ST-segment elevation myocardial infarction (STEMI). Early predictors of remodeling are being investigated. The aims of this study were to evaluate the prognostic value of speckle-tracking echocardiography for the prediction of LVr 3 months after primary percutaneous coronary intervention in patients with STEMI and to analyze the relationship between values of peak longitudinal strain of particular LV segments and relative changes of their subvolumes.

- by Krystian Wita
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- Treatment Outcome, Left Ventricular Assist Device, OR, Left Ventricular Dysfunction

Toff WD, Camm AJ, Skehan JD, et al. N Engl J Med 2005;353:145-55. Study Question: Does dual-chamber pacing (DCP) improve outcomes relative to single-chamber pacing (SCP) in elderly patients with atrioventricular block (AVB)? Methods: In this multicenter trial, 2021 patients Ն70 years of age (mean age 80 years) with high-grade AVB were randomly assigned to undergo either DCP (nϭ1012) or SCP (nϭ1009). The primary end point was death from any cause. The minimum duration of follow-up was 3 years. Results: There was no significant difference in annual mortality between the DCP (7.4%) and SCP (7.2%) groups. Likewise, no significant differences existed between the DCP and SCP groups in the annual incidence of atrial fibrillation (2.8% and 3%, respectively), heart failure (3.3% and 3.2%, respectively) or a composite of stroke, transient ischemic attack or thromboembolism (1.7% and 2.1%, respectively). At a median of 3 years of follow-up, the crossover rate from SCP to DCP was 3.1%. Conclusions: In elderly patients with high-grade AVB, the incidence of death or significant cardiovascular events is no higher with SCP than with DCP. Perspective: The subjects of this study were very elderly and were followed for only 3 years. It is conceivable that DCP does improve outcomes compared to SCP, but that the magnitude of the effect is small, such that the clinical advantages become manifest only after Ͼ10 years of followup. Also of note is that the crossover rate from SCP to DCP probably would be considerably higher than 3.1% in younger patients, who in general are more physically active than 80-year-olds and therefore more likely to experience deleterious effects of nonphysiologic SCP on exercise tolerance. Fred Morady

- by Alain Bernheim and +2
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- Algorithms, Electrocardiography, Heart Failure, Left Ventricular Dysfunction

Background: Real time three-dimensional (3D) echocardiography allows the assessment of left ventricular (LV) mechanical dyssynchrony and may be useful in predicting response to cardiac resynchronization therapy. However, reproducibility of 3D dyssynchrony in past reports varied widely. We evaluated intraand interobserver reproducibility of parameters of LV mechanical dyssynchrony by 3D echocardiography and explored the impact of image quality as a possible source of variability. Methods: LV volumes and ejection fraction (LV EF) were measured by 3D echocardiography in 90 subjects. LV mechanical dyssynchrony was calculated as the standard deviation of the time-to-minimum segmental volume (Tmsv) over 16 (SDI16) and 12 (SDI12) segments and as the maximum time-difference in Tmsv over 16 (Dif16), 12 (Dif12), and 2 (DifS-L) segments. Opposing wall delay in peak myocardial systolic velocity (S-L delay) by tissue Doppler imaging (TDI) was also evaluated. Results: Feasibility of 3D measurements was 88.9%. Intra-and interobserver intraclass correlation coefficients were excellent for LV volumes, LV EF, and S-L delay (all ≥0.90), very good for SDI16 (0.83 and 0.85), moderate to good for SDI12, Dif16, Dif12, and DifS-L (0.51-0.81). No systematic bias was present between readings for 3D dyssynchrony, but limits of agreement resulted fairly large for most parameters with the exception of SDI16, which showed reproducibility slightly lower than TDI. Suboptimal image quality was a significant source of variability in 3D-dyssynchrony assessment. Conclusions: The 3D assessment of LV volumes and dyssynchrony was feasible in our community-based cohort. SDI16 was the most reproducible among 3D-dyssynchrony parameters and the least affected by image quality. (Echocardiography 2012;29:598-607)

- by Cesare Russo
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- Treatment Outcome, Echocardiography, Computer Systems, Feasibility Studies

We report a novel palliative treatment to improve refractory cardiogenic shock due to right ventricular ischemia. We performed percutaneous atrial septostomy to create an atrial septal defect, which resulted in immediate right ventricular decompression and increased left ventricular filling associated with prompt and dramatic hemodynamic and clinical improvement. Cathet Cardiovasc Intervent 2003;59:44 -48.

- by James Goldstein
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- Palliative Care, Stents, Catheterization, Fluoroscopy

Aim We sought to verify which changes in right ventricular pressures occur before acute heart failure (HF) in patients with advanced systolic left ventricular (LV) dysfunction. In patients with chronic HF, continuous hemodynamic... more

Background. Ischemic left ventricular (LV) dysfunction may occur after exercise but is regarded as uncommon after vasodilator stress. We evaluated the prevalence of LV dysfunction after adenosine stress in relation to reversible perfusion... more

- by Nathaniel Reichek
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- Risk assessment, Comorbidity, Los Angeles, California
- by John Meletis
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- Adolescent, Pulmonary Hypertension, Echocardiography, Heart Failure
- by Olav Petersen
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- Obstetrics, Ultrasound, Twins, Pregnancy

Our aim was to determine the feasibility and value of a protocol-driven approach to patients with cardiac resynchronization therapy (CRT) who did not exhibit a positive response long after implant. Up to one-third of patients with advanced heart failure do not exhibit a positive response to CRT. A total of 75 consecutive ambulatory patients with persistent advanced heart failure symptoms and/or adverse reverse remodeling and CRT implanted &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;gt;6 months underwent a comprehensive protocol-driven evaluation to determine the potential reasons for a suboptimal response. Recommendations were made to maximize the potential of CRT, and adverse events were documented. All patients (mean left ventricular [LV] ejection fraction 23 +/- 9%, LV end-diastolic volume 275 +/- 127 ml) underwent evaluation. Eighty-eight percent of patients had significantly better echocardiographic indexes of LV filling and LV ejection with optimal setting of their CRT compared with a temporary VVI back-up setting. Most patients had identifiable reasons for suboptimal response, including inadequate device settings (47%), suboptimal medical treatment (32%), arrhythmias (32%), inappropriate lead position (21%), or lack of baseline dyssynchrony (9%). Multidisciplinary recommendations led to changes in device settings and/or other therapy modifications in 74% of patients and were associated with fewer adverse events (13% vs. 50%, odds ratio: 0.2 [95% confidence interval: 0.07 to 0.56], p = 0.002) compared with those in which no recommendation could be made. Routine protocol-driven approach to evaluate ambulatory CRT patients who did not exhibit a positive response is feasible, and changes in device settings and/or other therapies after multidisciplinary evaluation may be associated with fewer adverse events.

- by Bruce Wilkoff
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- Treatment Outcome, Heart Failure, Feasibility Studies, The

Groups did not differ in age, gender or EF. Group III patients had larger LAD (4.6 + − 1.0 cm) compared with both Group I (3.7 ± 0.6) and Group II (3.7 ± 0.5 cm) (p < 0.0001). A markedly enlarged (arbitrarily defined as LAD higher or... more

- by John Nguyen
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- Cardiology, Echocardiography, Heart Failure, Chronic Disease

This trial evaluated the effects of epoprostenol on patients with severe left ventricular failure. Patients with class IIIB/IV congestive heart failure and decreased left ventricular ejection fraction were eligible for enrollment if angiography documented severely compromised hemodynamics while the patient was receiving a regimen of digoxin, diuretics, and an angiotensinconverting enzyme inhibitor. We randomly assigned 471 patients to epoprostenol infusion or standard care. The primary end point was survival; secondary end points were clinical events, congestive heart failure symptoms, distance walked in 6 minutes, and quality-of-life measures. The median dose of epoprostenol was 4.0 ng/kg/min, resulting in a significant increase in cardiac index (1.81 to 2.61 L/min/m2), a decrease in pulmonary capillary wedge pressure (24.5 to 20.0 mm Hg), and a decrease in systemic vascular resistance (20.76 to 12.33 units). The trial was terminated early because of a strong trend toward decreased survival in the patients treated with epoprostenol. Chronic intravenous epoprostenol therapy is not associated with improvement in distance walked, quality of life, or morbid events and is associated with an increased risk of death. (Am Heart J 1997;134:44-54) Congestive heart failure is an increasing cause of morbidity and mortality as the world's population continues to age. The advent of cardiac transplantation and of medical regimens--including angiotensin-converting enzyme inhibitors, 1 nitrates, and hydralazine2--and digitalis 3 have allowed practitioners to substantially affect the mortality rates and quality of life of patients with symptomatic heart failure. Nevertheless, heart failure inevitably progresses to an increasingly symptomatic stage, often in circumstances that preclude transplantation because of age, comorbidity, or lack of organ availability. Even with maximal conventional medical therapy, the 1-year mortality rate of patients with class IV heart failure is >25%. 4

- by Frank Harrell
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- Quality of life, Heart Failure, Walking, Left Ventricular Assist Device

Congestive heart failure may be caused by late left ventricular (LV) dilation following anterior infarction. Early reperfusion prevents transmural necrosis, and makes the infarcted segment akinetic rather than dyskinetic. Surgical ventricular restoration (SVR) reduces LV volume and creates a more elliptical chamber by excluding scar in either akinetic or dyskinetic segments.

- by Lorenzo Menicanti
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- Survival Analysis, Treatment Outcome, Heart Failure, Congestive Heart Failure

Background. Small-molecule tyrosine kinase inhibitors (TKIs) may provide an effective therapeutic option in patients with hematologicmalignanciesandsolidtumors.However,cardiovascular (CV) events, including hypertension, heart failure, left ventricular systolic dysfunction, and QT prolongation, have emerged as potential adverse events (AEs) with TKI therapy. Purpose. We review what is known about the mechanism of action of CV AEs associated with TKI use and discuss therapeutic interventions that may prevent and manage these events in clinical practice. Methods. References for this review were identified through searches of PubMed and Medline databases, and only papers published in English were considered. Search terms included "cardiac," "cardiovascular," "cancer," and "kinase inhibitor." Related links in the databases were reviewed, along with relevant published guidelines.

- by Daniel Lenihan
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- Heart Failure, Hypertension, Left Ventricular Dysfunction, Neoplasms

its, and hospitalizations within the 6 months before EECP therapy were compared with those at 6-month follow-up. Despite the unfavorable risk profile, refractory angina patients with LV dysfunction achieved a substantial reduction in all-cause ED visits and hospitalization rates at 6-month follow-up. EECP therapy appears to offer an effective adjunctive treatment option for this group of patients. (CHF. 2007;13:36-40)

- by Sheryl Kelsey
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- Treatment Outcome, Prospective studies, Congestive Heart Failure, Hospitalization
- by Lynne Stevenson and +1
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- Survival Analysis, Adolescent, Child, Left Ventricular Assist Device

Background: Recent studies have shown that real-time three-dimensional (3D) echocardiography (RT3DE) gives more accurate and reproducible left ventricular (LV) volume and ejection fraction (EF) measurements than traditional two-dimensional methods. A new semi-automated tool (4DLVQ) for volume measurements in RT3DE has been developed. We sought to evaluate the accuracy and repeatability of this method compared to a 3D echo standard. Methods: LV end-diastolic volumes (EDV), end-systolic volumes (ESV), and EF measured using 4DLVQ were compared with a commercially available semi-automated analysis tool (TomTec 4D LV-Analysis ver. 2.2) in 35 patients. Repeated measurements were performed to investigate interand intra-observer variability. Results: Average analysis time of the new tool was 141s, significantly shorter than 261s using TomTec (p < 0.001). Bland Altman analysis revealed high agreement of measured EDV, ESV, and EF compared to TomTec (p = NS), with bias and 95% limits of agreement of 2.1 ± 21 ml,-0.88 ± 17 ml, and 1.6 ± 11% for EDV, ESV, and EF respectively. Intra-observer variability of 4DLVQ vs. TomTec was 7.5 ± 6.2 ml vs. 7.7 ± 7.3 ml for EDV, 5.5 ± 5.6 ml vs. 5.0 ± 5.9 ml for ESV, and 3.0 ± 2.7% vs. 2.1 ± 2.0% for EF (p = NS). The inter-observer variability of 4DLVQ vs. TomTec was 9.0 ± 5.9 ml vs. 17 ± 6.3 ml for EDV (p < 0.05), 5.0 ± 3.6 ml vs. 12 ± 7.7 ml for ESV (p < 0.05), and 2.7 ± 2.8% vs. 3.0 ± 2.1% for EF (p = NS). Conclusion: In conclusion, the new analysis tool gives rapid and reproducible measurements of LV volumes and EF, with good agreement compared to another RT3DE volume quantification tool.

- by Oronzo Catalano
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- Cardiovascular, Young Adult, Left Ventricular Dysfunction, Real Time

Background: The purpose of this multicenter study was to determine the reliability of visual assessments of segmental wall motion (WM) abnormalities and global left ventricular function among highly experienced echocardiographers using... more

- by David Blondheim
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- Israel, Variability, Reliability, Left Ventricular Dysfunction

Background: Amiodarone use has been rarely associated with the development of acute respiratory distress syndrome (ARDS), usually in association with surgery or pulmonary angiography. In patients with preexisting left ventricular dysfunction, the diagnosis may be overlooked. Case Report: A 92-year-old woman with a history of atrial fibrillation who was on low-dose amiodarone presented to the Emergency Department with sudden onset of shortness of breath. The patient was started on treatment for acute heart failure based on the physical examination and the elevated brain natriuretic peptide level. Despite adequate diuresis, the patient showed no improvement. A chest computed tomography scan revealed acute interstitial pneumonitis. The patient received corticosteroids due to suspected amiodarone-induced acute interstitial pneumonitis resulting in ARDS. She returned to her baseline activity within 2 weeks of the therapy. Conclusion: Although rare, clinicians should be vigilant for amiodarone-induced acute interstitial pneumonitis resulting in ARDS, as delay in treatment may result in a high risk of mortality. In addition, the development of ARDS occurred in our patient in the absence of precipitating factors such as surgery or pulmonary angiography. Ó

- by Sebastian Sarvari and +1
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- Cardiology, Cancer, Dispersion, Mutation
- by Patrice Delafontaine
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- Risk assessment, Multivariate Analysis, Heart Failure, Prospective studies

Echocardiographic assessment prior to valve surgery is crucial for clinical decision making, timing of surgery, planning the adequate surgical therapy and predicting the patient's outcome. Description of transvalvular velocities is not enough for sending a patient to the operating room. There are specific functional and morphological characteristics of each valve dysfunction that have to be addressed by the echocardiographer prior to surgery. Evaluation of the aortic valve, annulus, root, ascending aorta, left ventricular outflow tract and left ventricular function are important. In knowing these characteristics the surgeon may choose the appropriate valve and operation techniques and assess the need for additional surgical procedures. A detailed evaluation of valve morphology and function in context with cardiac hemodynamics should be achieved during echocardiography. This step-by-step evaluation allows the correct diagnosis and classification of patient's outcome. In conclusion, an echohemodynamic approach enables the cardiac surgeon to plan and perform the adequate surgical procedure.

- by Andreas Mügge
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- Cardiology, Surgery, Treatment, Echocardiography

Severe right ventricular dysfunction independent of left ventricular ejection fraction increased the risk of heart failure (HF) and death after myocardial infarction (MI). The association between right ventricular function and other clinical outcomes after MI was less clear. Two-dimensional echocardiograms were obtained in 605 patients with left ventricular dysfunction and/or clinical/radiologic evidence of HF from the VALIANT echocardiographic substudy (mean 5.0 ؎ 2.5 days after MI). Clinical outcomes included all-cause mortality, cardiovascular (CV) death, sudden death, HF, and stroke. Baseline right ventricular function was measured in 522 patients using right ventricular fractional area change (RVFAC) and was related to clinical outcomes. Mean RVFAC was 41.9 ؎ 4.3% (range 19.2% to 53.1%). The incidence of clinical events increased with decreasing RVFAC. After adjusting for 11 covariates, including age, ejection fraction, and Killip's classification, decreased RVFAC was independently associated with increased risk of all-cause mortality (hazard ratio [HR] 1.61, 95% confidence interval [CI] 1.31 to 1.98), CV death (HR 1.62, 95% CI 1.30 to 2.01), sudden death (HR 1.79, 95% CI 1.26 to 2.54), HF (HR 1.48, 95% CI 1.17 to 1.86), and stroke (HR 2.95, 95% CI 1.76 to 4.95), but not recurrent MI. Each 5% decrease in baseline RVFAC was associated with a 1.53 (95% CI 1.24 to 1.88) increased risk of fatal and nonfatal CV outcomes. In conclusion, decreased right ventricular systolic function is a major risk factor for death, sudden death, HF, and stroke after MI.

- by jalal chambar
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- Heart Failure, Sudden Death, Stroke, Follow-up studies

Objective: Controversy still exists regarding the optimal surgical technique for postinfarction left ventricular (LV) aneurysm repair. We analyze the efficacy of two established techniques, linear vs. patch remodeling, for repair of dyskinetic LV aneurysms. Methods: Between May 1988 and December 2001, 110 consecutive patients underwent repair of LV aneurysms. These represent 2.0% of a total group of 5429 patients who underwent isolated CABG during the period. Seventy-six (69.1%) patients were submitted to linear repair and 34 (30.9%) to patch remodelling. There were 94 (84.5%) men and 17 women, with a mean age of 59.2G9.2 years. Coronary surgery was performed in all patients (mean no. of grafts/patient, 2.7G0.8) and 14 (12.7%) had associated coronary endarterectomy. Forty-four (40.0%) patients had angina CCS class III/IV (linear 43.4%, patch 32.4%, NS) and the majority was in NYHA class I/II (88.2% in both groups). Left ventricular dysfunction (EFO40%) was present in 72 (65.5%) patients (linear 61.8%, patch 73.5%, NS). Results: There was no perioperative mortality, and major morbidity was not significantly different between linear repair and patch repair groups. During a mean follow-up of 7.3G3.4 years (range 4-182 months) 14 patients (14.3%) had died, 12 (85.7%) of possible cardiac-related cause. Actual global survival rate was 85.7%. Actuarial survival rates at 5, 10 and 15 years were 91.3, 81.4 and 74%, respectively. There was no significant difference in late survival between the patch and the linear groups. At late follow-up the mean angina and NYHA class were, 1.3 (preoperative 2.4, P!0.001) and 1.5 (preoperative 1.7, NS), respectively, with no difference between the groups. There was no significant difference in hospital readmissions for cardiac causes (linear 22.8% and patch 37.0%). Conclusions: The technique of repair of postinfarction dyskinetic LV aneurysms should be adapted in each patient to the cavity size and shape, and the dimension of the scar. Both techniques achieved good results with respect to perioperative mortality, late functional status and survival. q