Czynniki predykcyjne nadciśnienia płucnego u osób w podeszłym wieku z izolowaną rozkurczową niewydolnością serca

Background: Despite the growing recognition that pulmonary hypertension can develop in diastolic heart failure; its clinical significance remains poorly defined. Aim: We sought to explore the prevalence and predictors of pulmonary hypertension in elderly patients with isolated diastolic heart failure. Methods: We enrolled 100 consecutive elderly patients with isolated diastolic heart failure. All patients underwent transthoracic echocardiography to measure the pulmonary artery systolic pressure, diastolic function indices (mitral E peak deceleration time, isovolumetric relaxation time, early mitral annular diastolic velocity), left atrial diameter and left ventricular mass index. Pulmonary hypertension was defined as pulmonary artery systolic pressure &#8805; 37 mm Hg. We classified patients into two groups: one with diastolic heart failure and concomitant pulmonary hypertension, and one with diastolic heart failure but without concomitant pulmonary hypertension. Results: The mean age of the whole series was 65.4 &#177; 5.4 years, 49 (49%) being female. Patients with pulmonary hypertension (20% of the whole series) were more often females, hypertensive, more likely to have atrial fibrillation, pulmonary congestion symptoms, larger left atrial diameter, lower early mitral annular diastolic velocity, lower left ventricular ejection fraction, and more likely to have mitral regurgitation (p < 0.05 for all). Multivariate logistic regression analysis identified female gender, atrial fibrillation, and early mitral annular diastolic velocity (e&#8217;) as the independent predictors of the presence of pulmonary hypertension. Conclusions: Pulmonary hypertension is fairly prevalent in elderly patients with diastolic heart failure. Female gender, atrial fibrillation, and early mitral annular diastolic velocity (e&#8217;) were the independent predictors of the presence of pulmonary hypertension in this patient group. Kardiol Pol 2010; 68, 6: 655-661Wstęp: Mimo wzrostu świadomości, że nadciśnienie tętnicze może się przyczynić do rozwoju rozkurczowej niewydolności serca, jego znaczenie kliniczne nadal nie zostało ściśle określone. Cel: Celem niniejszej pracy było zbadanie częstości występowania czynników predykcyjnych nadciśnienia płucnego u osób w podeszłym wieku z izolowaną rozkurczową niewydolnością serca. Metody: Do badania włączono 100 kolejnych pacjentów w podeszłym wieku z izolowaną rozkurczową niewydolnością serca. U wszystkich chorych wykonano przezklatkowe badanie echokardiograficzne w celu określenia wartości ciśnienia skurczowego w tętnicy płucnej, wskaźników czynności rozkurczowej serca (czas deceleracji fali E, czas rozkurczu izowolumetrycznego, prędkość wczesnego napełniania lewej komory), wymiaru lewego przedsionka i wskaźnika masy lewej komory. Nadciśnienie płucne definiowano jako ciśnienie skurczowe w tętnicy płucnej &#8805; 37 mm Hg. Pacjentów podzielono na 2 grupy: grupę z rozkurczową niewydolnością serca i współistniejącym nadciśnieniem płucnym oraz grupę z rozkurczową niewydolnością serca bez nadciśnienia płucnego. Wyniki: Średni wiek badanych wynosił 65,4 &#177; 5,4 roku, 49% stanowili mężczyźni (n = 49). Nadciśnienie płucne (u 20% badanych) występowało częściej u kobiet i osób z nadciśnieniem tętniczym. U chorych z nadciśnieniem tętniczym częściej stwierdzano migotanie przedsionków, objawy zastoju płucnego, zwiększenie wymiaru lewego przedsionka, zmniejszenie prędkości wczesnego napełniania i frakcji wyrzutowej lewej komory oraz niewydolność zastawki mitralnej (p < 0,05 dla wszystkich porównań). W wieloczynnikowej analizie regresji wskazano, że płeć żeńska, migotanie przedsionków i prędkość wczesnego napełniania lewej komory (e&#8217;) są niezależnymi czynnikami predykcyjnymi nadciśnienia płucnego. Wnioski: Nadciśnienie płucne występuje stosunkowo często u osób w podeszłym wieku z rozkurczową niewydolnością serca. Płeć żeńska, migotanie przedsionków i zmniejszona prędkość wczesnego napełniania lewej komory (e&#8217;) są niezależnymi czynnikami predykcyjnymi obecności nadciśnienia płucnego w tej grupie pacjentów. Kardiol Pol 2010; 68, 6: 655-66

Powtórny zabieg przezskórnej walwuloplastyki mitralnej u chorych z nawrotem zwężenia zastawki - porównanie z pierwszorazowym zabiegiem u osób ze zwężeniem de novo

Background: Percutaneous mitral valvuloplasty (PMV) has emerged as the procedure of choice in most patients with symptomatic mitral stenosis. However, very few reports have looked at redo PMV in patients with mitral restenosis. Aim: In a retrospective study, we explored the immediate results of redo PMV compared to primary PMV. Methods: We included 30 consecutive patients with de novo mitral stenosis and 40 consecutive patients with mitral restenosis after successful initial PMV. Echocardiographic assessment of the mitral valve was performed in all patients by transthoracic echocardiography (TTE), and trans-esophageal echocardiography excluded left atrial thrombosis. Percutaneous mitral valvuloplasty was performed by the antegrade trans-septal approach using either the standard Inoue technique or the multitrack technique. Patient assessment by TTE was repeated 48 hours after the procedure. Procedural success was defined as a 50% or more increase in mitral valve area, with a final mitral valve area &#8805; 1.5 cm2, without major complications. Results: The mean age of the study population was 33.7 &#177; 6 years, 18 (25.7%) patients being male. Procedural success was achieved in 28 (93.3%) patients undergoing first PMV, and in 37 (92.5%) patients undergoing redo PMV (NS). The two groups were similar in terms of the final mitral valve area, the gain of mitral valve area, the mean pressure gradient across the mitral valve, and the complication rate (NS for all). The final mitral valve area correlated negatively with the baseline mitral valve score in both groups. Conclusions: Redo PMV for mitral restenosis achieves immediate results that are comparable to initial PMV for de novo mitral stenosis. Kardiol Pol 2011; 69, 2: 125-131Wstęp: Przezskórna walwuloplastyka mitralna jest obecnie leczeniem z wyboru u większości chorych z objawowym zwężeniem zastawki mitralnej. Jednak opublikowano niewiele prac dotyczących powtórnych zabiegów walwuloplastyki u chorych z nawrotem zwężenia zastawki. Cel: W badaniu retrospektywnym oceniano bezpośrednie wyniki powtórnych zabiegów walwuloplastyki mitralnej w porównaniu z wynikami procedur pierwszorazowych. Metody: Do badania włączono 30 chorych ze zwężeniem de novo zastawki mitralnej (grupa A) oraz 40 kolejnych pacjentów z nawrotem zwężenia po wcześniejszej skutecznej walwuloplastyce przezskórnej (grupa B). Ocenę echokardiograficzną przeprowadzono za pomocą badania przezklatkowego, a badanie przezprzełykowe miało na celu wykluczenie skrzepliny w lewym przedsionku. Przezskórną walwuloplastykę mitralną wykonywano poprzez nakłucie przegrody międzyprzedsionkowej z zastosowaniem standardowej techniki Inoue&#8217;go lub techniki multi-track. Po 48 godzinach od zabiegu powtarzano badanie przezklatkowe. Procedurę definiowano jako skuteczną, gdy zwiększenie pola powierzchni zastawki po zabiegu wynosiło &#8805; 50%, a ostateczna wartość pola powierzchni była większa lub równa 1,5 cm2, bez poważnych powikłań. Wyniki: Średni wiek pacjentów włączonych do badania wynosił 33,7 &#177; 6 lat, 25,7% (18 osób) stanowili mężczyźni. Zabieg zakończył się powodzeniem u 28 (93,3%) pacjentów w grupie A i u 37 (92,5%) chorych w grupie B (p = NS). W obu grupach powierzchnia zastawki po zabiegu, przyrost powierzchni, średni gradient przez zastawkę i częstość powikłań były podobne. (p = NS dla wszystkich). Powierzchnia zastawki po zabiegu ujemnie korelowała z punktacją zastawki przed zabiegiem w obu grupach. Wnioski: Bezpośrednie wyniki powtórnego zabiegu przezskórnej walwuloplastyki mitralnej u chorych z nawrotem stenozy mitralnej są porównywalne z wynikami walwuloplastyki mitralnej wykonywanej z powodu zmian de novo. Kardiol Pol 2011; 69, 2: 125-13

Radius of proximal isovelocity surface area in the assessment of rheumatic mitral stenosis: Connecting flow to anatomy and hemodynamics

Background: Echocardiographic assessment of left atrial pressure (LAP) in mitral stenosis (MS) is controversial. We sought to examine the role of the radius of the proximal isovelocity surface area (PISA-r) in the assessment of the hemodynamic status of MS after fixing the aliasing velocity (Val). Methods and results: We studied 42 candidates of balloon mitral valvuloplasty (BMV), for whom pre-BMV echocardiography was done and LAP invasively measured before dilatation. PISA-r was calculated after fixing aliasing velocity to 33 cm/s. In addition, the ratio IVRT/Te’–E was also measured, where IVRT was isovolumic relaxation time, and Te’–E was the time difference between the onset of mitral flow E-wave and mitral annular early diastolic velocity. IVRT/Te’–E and PISA-r showed a strong correlation with LAP (r = −0.715 and −0.637, all p < 0.001) and with right-sided pressures. In addition, PISA-r correlated with mitral valve area by planimetry method (MVA) and with left ventricular outflow tract stroke volume (r = 0.66 and 0.71, all p < 0.001). Receiver operator characteristic curve (ROC-curve) showed that PISA-r was not inferior to IVRT/Te’–E in differentiating LAP ⩾25 from <25 mmHg. Conclusion: Provided that Val is set to a constant of 33 cm/s, PISA-r can assess the hemodynamic status of MS, and seems a simple alternative to the tedious IVRT/Te’–E for estimation of LAP

Inflammatory status in patients with rheumatic mitral stenosis: Guilty before and after balloon mitral valvuloplasty

Aim: We studied the inflammatory status, suggested by high sensitivity C-reactive protein (hsCRP) in patients with rheumatic mitral stenosis (MS) before, immediately after, and 1-month after balloon mitral valvuloplasty (BMV). Methods and results: We studied 31 BMV candidates [35.6 ± 12.8 years, 20 (65%) females, and 9 (29%) had atrial fibrillation rhythm]. Mitral valve area (MVA) and hsCRP were measured before, immediately after BMV, and 1 month after BMV in 13 patients. In addition, hsCRP was measured in 15 controls. hsCRP was significantly higher in MS patients than control, significantly increased after BMV, and dropped 1 month after BMV to values comparable to basal but still higher than normal. hsCRP showed a trend for correlation with MVA after BMV (r = 0.384, p = 0.07), and the absolute increase in MVA (d-MVA) correlated significantly with the absolute increase in hsCRP (d-CRP) (r = 0.523, p = 0.01). 21 patients had successful BMV and 10 patients had unsuccessful BMV. The increase in hsCRP post compared to pre-BMV was attenuated in patients with unsuccessful BMV, and receiver operator characteristic curve suggested that hsCRP >3.6 before BMV and d-CRP <2.25 mg/dL can detect patients with unsuccessful BMV with good sensitivities and specificities. Conclusion: Inflammatory pathogenesis of rheumatic fever, suggested by hsCRP, seems fixed both before, and after BMV. A basal increase in hsCRP before BMV is related to BMV success and an acute increase immediately after BMV seems related to trauma of balloon dilatations

Atrial Fibrillation in Heart Failure with Preserved Left Ventricular Systolic Function: Distinct Elevated Risk for Cardiovascular Outcomes in Women Compared to Men

Background: Heart failure with preserved ejection fraction (HFpEF) is prevalent in women and is associated with atrial fibrillation (AF). However, sex associations in AF-related HFpEF are not well explored. Aim: We studied differences between men and women with and without AF-related HFpEF symptoms on left ventricular (LV) geometry and diastolic dysfunction (DD) and their effect on cardiovascular events. Methods: Retrospectively, HFpEF patients with and without a history of AF referred for echocardiography were studied. Echocardiographic assessments were focused on LV geometry and diastolic functions. Patients were followed for the occurrence of cardiac events defined as death and cardiac hospitalization. Results: We studied 556 patients [age: 66.7 &plusmn; 17 years, 320 (58%) women, 91 (16%) AF]. Compared to HFpEF without AF (HFpEF-AF), HFpEF with AF patients (HFpEF+AF) were older (76 &plusmn; 13.8 vs. 64.9 &plusmn; 17.3 years, p &lt; 0.001), had more risk factors, comorbidities, left ventricular hypertrophy (32 vs. 13%, p &lt; 0.001), higher relative wall thickness (0.50 &plusmn; 0.14 vs. 0.44 &plusmn; 0.15, p &lt; 0.001), and DD (56 vs. 30%, all p &lt; 0.001). HFpEF+AF women had the worst clinical, LV geometric, and diastolic functional profiles and highest rates of cardiovascular outcomes compared to HFpEF+AF men and were the only group to predict outcomes (HR: 2.7, 95%CI: 1.4&ndash;5.1), while HFpEF-AF women were a low-risk group; HFpEF+AF and HFpEF-AF men had intermediate cardiovascular outcomes which were confirmed after propensity score matching. Conclusions: Among patients with HFpEF, women with AF had more abnormal LV geometry and diastolic function and had an increased risk of adverse cardiovascular outcomes independent of traditional risk factors, comorbidities, and baseline diastolic function

Worsening of left ventricular twist mechanics in isolated rheumatic mitral stenosis immediately after balloon mitral valvuloplasty

Background: Reportedly, left ventricular (LV) mechanics are worsened in patients with mitral stenosis (MS) compared to controls. The immediate effect of balloon mitral valvuloplasty (BMV) on LV mechanics is, however, not known. Aim: To assess the immediate effect of balloon mitral valvuloplasty on the left ventricular twist mechanics. Methods and results: We studied 39 candidates for BMV. Pressures were measured invasively before and after BMV. Speckle tracking echocardiography (STE) was done for twist mechanics (basal rotation, apical rotation, and torsion) before and immediately after BMV. Twist mechanics were also measured by STE in 15 normal subjects as control group. Mean age was 30.4 ± 7.2 years, mean BMI was 24.7 ± 3.1 and 28 patients (72%) were females. All twist mechanics apical rotation and torsion were lower post-BMV compared to pre-BMV. Left ventricular end diastolic pressure was significantly higher post compared to pre-BMV while left atrial pressure (LAP) was similar between both groups. Importantly, patients who showed an increased LVEDP post compared to pre-BMV had worse LV twist mechanics than those whose LVEDP post-BMV was similar to or lower than pre-BMV. Conclusion: LV twist mechanics are worsened in MS with a further worsening, immediately after BMV probably because of failure of the LV to adapt to the sudden increased preload