Transthoracic echocardiography for the diagnosis of left ventricular thrombosis in the postoperative care unit

Introduction: Transthoracic echocardiography (TTE) is a reliable, noninvasive imaging method that is useful in the evaluation of cardiovascular thrombosis. We conducted a retrospective study of all the echocardiograms from patients in the postoperative care unit to assess the role of TTE in thrombus identification in the left ventricle. Methods: This retrospective database evaluation included all echocardiograms during a 14-month period. The echocardiographic examination protocol included the subcostal four-chamber view, the apical four-chamber view, the apical two-chamber view and the parasternal view, along the long and short axes in both spontaneously and mechanically ventilated patients. All echocardiograms were obtained within the 48 hours immediately following surgery. Results: In total, 160 postoperative echocardiograms were obtained from 160 patients and resulted in the detection of five cases of left ventricular thrombosis. Subgroup analysis showed that 21 and 35 of the 160 patients examined had either dilated or ischemic cardiomyopathy, respectively. In these patients, preoperative echocardiograms had been obtained recently prior to surgery and were negative for left ventricular thrombus. In three of 35 patients with ischemic cardiomyopathy and two of 21 patients with dilated cardiomyopathy, thrombus was identified in the left ventricle. The thrombi were mobile, uncalcified and pedunculated and were located in the apex of the left ventricle. In addition, no clinical consequences of the left ventricular thrombi were recorded. Conclusions: Low-flow conditions in heart chambers due to ischemic or dilated cardiomyopathy in conjunction with the hypercoagulability caused by perioperative prothrombotic factors may lead to thrombotic events in the left ventricle

Effects of darbepoetin-alpha on quality of life and emotional stress in anemic patients with chronic heart failure

Objective Anemia is a frequent comorbidity in chronic heart failure (CHF) adversely affecting patients’ prognosis. Erythropoietin seems to improve exercise capacity in CHF patients. This study investigates the effects of recombinant human erythropoietin analog darbepoetin-alpha on quality of life and emotional stress, evaluated by relevant questionnaires in patients with CHIF and anemia. Methods Forty-one CHF patients [New York Heart Association class: II-III; left ventricular (LV) ejection fraction (EF) < 40%; hemoglobin < 12.5 g/dl; serum creatinine < 2.5 mg/dl] were randomized (1 : 1) to receive either 3-month darbepoietin-alpha at 1.5 mu g/Kg every 20 days plus iron orally (n = 21) or placebo plus iron orally (n = 20). Echocardiographic LVEF, questionnaires addressing quality of life (Kansas City Cardiomyopathy Questionnaire, functional and overall, Duke’s Activity Status Index) and emotional stress [Zung self-rating depression scale (SDS), Beck Depression Inventory], as well as plasma b-type natriuretic peptide and 6-min walking distance (6MWT as a marker of exercise capacity) were assessed at baseline and posttreatment. Results A significant improvement in LVEF (32 +/- 6 from 26 +/- 6%, P < 0.001), 6MWT (274 +/- 97 from 201 +/- 113m, P < 0.01), hemoglobin (12.8 +/- 1.4 from 10.9 +/- 1.0g/dl, P < 0.001) and plasma b-type natriuretic peptide (517 +/- 579 from 829 +/- 858 pg/ml, P=0.002) was observed posttreatment only in darbepoetin-treated group. Kansas City Cardiomyopathy Questionnaire functional (78 +/- 14 from 57 +/- 24%, P < 0.01) and overall (68 +/- 20 from 47 +/- 22, P < 0.001), Duke’s Activity Status Index (19 +/- 11 from 14 +/- 9, P < 0.05), Zung SDS (38 +/- 10 from 47 +/- 11, P < 0.05) and Beck Depression Inventory (11 +/- 9 from 16 +/- 10, P < 0.05) scores also improved in darbepoeti n -treated patients, whereas they remain unchanged in the placebo group except for the Zung SDS which worsened (P < 0.05). A significant correlation between drug-induced percent changes in 6MWT and Zung SDS (r= - 0.627, P < 0.05) was also observed. Conclusions Darbepoetin-a improves quality of life and emotional stress in CHIF patients with anemia, with a parallel increase in exercise capacity

Effects of darbepoetin-alpha on plasma pro-inflammatory cytokines, anti-inflammatory cytokine interleukin-10 and soluble Fas/Fas ligand system in anemic patients with chronic heart failure

Pro-inflammatory cytokine over-expression may be implicated to the pathogenesis of anemia in chronic heart failure (CHF) through the suppression of bone marrow erythropoiesis. Erythropoietin administration has anti-inflammatory and anti-apoptotic properties in experimental CHF models and improves exercise capacity in anemic CHF patients. The present study investigates the effects of recombinant human erythropoietin analogue darbepoetin-alpha on circulating pro-inflammatory cytokines and soluble Fas/soluble Fas ligand system in patients with CHF and anemia. Forty-one CHF patients (NYHA class: II-III; left ventricular (LV) ejection fraction (EF) <40%; hemoglobin <12.5 g/dl; serum creatinine <2.5 mg/dl) were randomized to receive either 3-month darbepoietin-alpha at 1.5 mu g/kg every 20 days plus iron orally (n = 21) or placebo plus iron orally (n = 20). LV systolic function, plasma B-type natriuretic peptide (BNP), inflammatory markers (TNF-alpha, IL-6, CRP), anti-inflammatory cytokine IL-10, endothelial adhesion molecules (soluble ICAM-1 and VCAM-1) and soluble apoptosis mediators (soluble Fas, soluble Fas ligand), and 6-min walking distance were assessed at baseline and 3 months post-treatment. In darbepoetin-alpha treated patients, plasma BNP (451 (62-2770) from 802 (476-4440) pg/ml,p = 0.002), IL-6 (6.5 +/- 4.7 from 10.5 +/- 7.8 pg/ml, p, = 0.013) and soluble Fas ligand (53.2 +/- 16.6 from 59.2 +/- 17.9 pg/ml, p = 0.023) decreased significantly, while LVEF (32 +/- 6 from 26 +/- 6%, p < 0.001), hemoglobin (12.8 +/- 1.4 from 10.9 +/- 1.0 g/dl, p < 0.001) and 6-min walked distance (274 +/- 97 from 201 +/- 113 m, p < 0.01) increased significantly. No significant changes were observed in the placebo arm, except for a worsening in 6-min walked distance (p = 0.044). In conclusion, darbepoetin-alpha reduces circulating pro-inflammatory cytokine IL-6 and apoptotic mediator soluble Fas ligand in CHF patients with anemia, with a parallel improvement of cardiac performance and exercise capacity. (C) 2007 Elsevier Ireland Ltd. All rights reserved

Effects of darbepoetin alpha on right and left ventricular systolic and diastolic function in anemic patients with chronic heart failure secondary to ischemic or idiopathic dilated cardiomyopathy

Background Anemia is a frequent condition in chronic heart failure (CHF) that affects adversely long-term cardiac outcomes. We sought to investigate the effects of recombinant human erythropoietin analogue darbepoetin alpha on left (LV) and right ventricular (RV) function and neurohormonal activation in patients with CHF and anemia. Methods Thirty-two CHF patients (New York Heart Association class II-III, LV ejection fraction [EF] <40%, hemoglobin level < 12.5 9/dL, serum creatinine level <2.5 mg/dL) were randomized (2: 1) to receive either a 3-month darbepoetin alpha regimen at 1.5 mu g/kg every 20 days plus oral iron (n = 2 1) or placebo plus oral iron (n = 11). Echocardiographic indices of LV systolic and diastolic function and RV function, plasma B-type natriuretic peptide (BNP) and 6-minute walked distance were assessed at baseline and posttreatment. Results Regarding LV function, only treatment with darbepoetin a caused a significant improvement in LVEF (F = 22.001, P<.001), end-systolic wall stress (F = 4.934, P =.03A), mitral annulus systolic displacement (F = 6.710, P<.015), isovolumic relaxation time (F = 4.909, P =.035), and E/e ratio (F = 7.833, P =.009). The RV systolic pressure (F = 7.715, P =.009) as well as tricuspid annulus systolic displacement and RVEF (F = 9.264, P =.005) were significantly improved only in the darbepoetin a group. Darbepoetin a had also a beneficial effect on New York Heart Association class (F = 14,586, P =.001), plasma BNP (F = 14.781, P =.001), and 6-minute walk test (F = 19.926, P <.001), whereas these parameters did not significantly change in the placebo-treated patients. Conclusion Darbepoetin a improves both LV and RV performance and exercise capacity and counteracts neurohormonal activation in CHF patients with anemia. The drug effects on LV diastolic function, RV function, and LV end-systolic wall stress, in particular, are novel findings, with a potential important contribution to patients’ symptomatic improvement

Effects of levosimendan on right ventricular function in patients with advanced heart failure

Right ventricular (RV) dysfunction frequently complicates advanced left ventricular heart failure and contributes to an unfavorable prognosis. Levosimendan is a novel inodilator that beneficially affects hemodynamics and left ventricular systolic and diastolic function in patients with advanced heart failure. However, its effects on RV function have not yet been properly assessed in these patients. In this randomized trial, the impact of levosimendan or placebo on various echocardiographic parameters of RV systolic and diastolic function was investigated in 54 patients with advanced heart failure due to left ventricular systolic dysfunction. Tissue Doppler imaging maximal, systolic tricuspid annular velocity (S wave) increased significantly only in the levosimendan group (8.2 +/- 3.2 vs 9.0 +/- 3.0 cm/s, p < 0.03). Tissue Doppler imaging RV early diastolic velocity (E wave) and the, ratio of early to late diastolic velocities (E/A) also increased significantly after levosimendan administration (p < 0.01 and p < 0.05, respectively). Systolic pulmonary arterial pressure decreased significantly (54 +/- 11 vs 43 +/- 11 mm Hg, p < 0.01) in the levosimendan-treated patients. Levosimendan beneficially modulated neurohormonal and inflammatory status by decreasing B-type natriuretic peptide levels (p < 0.05) and by altering the ratio of interleukin-6 to interleukin-10 in favor of the latter (p < 0.05). In conclusion, levosimendan could offer further therapeutic advantages in patients with advanced heart failure by improving systolic and diastolic RV function. (c) 2006 Elsevier Inc. All rights reserved

Diastolic stress echocardiography detects coronary artery disease in patients with asymptomatic type II diabetes

Objectives Diabetes mellitus is considered as an equivalent of coronary artery disease (CAD). Aim of the study was to investigate whether in asymptomatic patients with type II diabetes, diastolic stress echocardiography may represent an alternative tool for the detection of CAD. Methods The study population consisted of 105 patients with diabetes mellitus (age 61 +/- 9 years, 26% female, duration of diabetes 37 +/- 14 months). We performed an exercise stress test, followed by an echo-study and a single-positron emission tomography. Coronary angiography was performed within 1 month. Results Coronary angiography revealed a coronary artery stenosis of at least 70% in 72 patients (69%, CAD group), while the remaining formed the non-CAD group. Exercise induced an increase of both E/E’ lateral and septal ratios as well as their average in the CAD group and on the contrary a decrease of these ratios in the non-CAD group. Receiver operating curve analysis for discrimination between patients with and without obstructive CAD showed an optimal cut-off value of - 0.0708 for the exercise-induced change of E/E’ average (area under curve 0.892, P < 0.001). Sensitivities of scintigraphy and of diastolic stress echocardiography for detection of CAD were 75.0 and 93.1%, respectively; specificity was 78.8% for both methods. In asymptomatic patients, sensitivities of scintigraphy and diastolic stress echocardiography were 76.9 and 92.3%; specificity of both was 80%. Conclusion In patients with type II diabetes, diastolic stress echocardiography, by means of E/E’ ratio exercise-induced changes, can be used for the diagnosis and severity of CAD and for the detection of occult myocardial ischemia. Coron Artery Dis 21:104-112 (C) 2010 Wolters Kluwer Health vertical bar Lippincott Williams & Wilkins