Hypoalbuminemia in elderly patients with acute diastolic heart failure

OBJECTIVES: This study evaluated the relative contribution of serum colloid osmotic pressure (COP) lowering and pulmonary artery wedge pressure (PAWP) elevation in the pathogenesis of pulmonary edema in patients with systolic or isolated diastolic heart failure (DHF). BACKGROUND: The role of hypoalbuminemia and the resulting low COP have been shown in some patients with acute systolic heart failure (SHF).Colloid osmotic pressure and PAWP were determined in 100 patients with acute heart failure (HF) (56 with DHF and 44 with SHF; mean age, 78 +/- 12 years), in 35 patients with acute dyspnea from pulmonary origin, and in 15 normal controls. Pulmonary artery wedge pressure was estimated using transthoracic Doppler echocardiography. RESULTS: Colloid osmotic pressure was significantly lower in the DHF group (20.5 +/- 5 mm Hg) than in the SHF group (24.2 +/- 3.7 mm Hg, p < 0.001), pulmonary disease group (25.1 +/- 4.2 mm Hg, p < 0.001), or normal control group (24.7 +/- 3 mm Hg). Low COP resulted from hypoalbuminemia due to age, malnutrition, and sepsis. Pulmonary artery wedge pressure was significantly higher in patients with SHF (26 +/- 6.3 mm Hg) than in the patients with DHF (20.3 +/- 7 mm Hg, p < 0.001) and was significantly higher in the patients with DHF than in the patients with pulmonary disease (13 +/- 4.2 mm Hg, p < 0.001). The COP-PAWP gradient was similar in patients with SHF (-1.6 +/- 7.1 mm Hg) and patients with DHF (0.7 +/- 6 mm Hg). CONCLUSIONS: Frequent hypoalbuminemia resulting in low COP facilitates the onset of pulmonary edema in patients with DHF who usually have lower PAWP than patients with SHF.     

Percutaneous balloon valvuloplasty for congenital pulmonary valve stenosis in adults.

BACKGROUND: Although pulmonary valvular stenosis is not uncommon in adults, there are few reports of percutaneous pulmonary valvuloplasty in adults, despite the possibility of avoiding heart surgery. AIM: This report describes the experience in adult patients undergoing this procedure and evaluates its effectiveness and tolerance. METHODS: Over an 8-year period (1989-1997), pulmonary valvuloplasty was considered in 22 adult patients [8 men, 14 women; mean age 28.0 years +/- standard deviation (SD) 10.3; range 16-46 years] with congenital pulmonary valve stenosis. Sixteen patients were asymptomatic with pulmonary systolic murmurs, although 6 patients presented with dyspnea. Before the procedure, the mean transpulmonary valve gradient was 53.2 +/- 24.8 mmHg SD, with a mean right ventricular systolic pressure of 74.6 +/- 28.4 mmHg SD, and mean pulmonary artery pressure was 21.4 +/- 6.4/10.2 +/-3.9 mmHg. RESULTS: The procedure was successful in 19 patients (6 men, 13 women) and was well tolerated and free of complications. Following the procedure, the mean transvalvular gradient was 15.5 +/- 11.5 mmHg, with a mean right ventricular systolic pressure of 40.5 +/- 13.6 mmHg and a mean pulmonary systolic pressure of 24.3 +/- 7.4 mmHg. This represented mean fall in transpulmonary valve gradient of 42.4 +/- 22.0 mmHg (paired t-test, p < 0.0001). After a mean follow-up of 20.1 months (13.4 SD), most patients remained well and asymptomatic, although two patients required repeat valvuloplasty. CONCLUSION: Pulmonary valvuloplasty is a well tolerated and effective treatment for pulmonary valve stenosis in adults, with few complications and no need for surgery. This procedure should be considered as the primary treatment of adult patients with pulmonary valve stenosis.     

Doppler echocardiography reliably predicts pulmonary artery wedge pressure in patients with chronic heart failure even when atrial fibrillation is present

BACKGROUND AND AIMS: In patients with chronic congestive heart failure a high pulmonary artery wedge pressure (PAWP) is associated with poor prognosis, severe symptoms and low exercise tolerance. When atrial fibrillation is present the non-invasive prediction of PAWP by Doppler echocardiography is generally considered to be not reliable. METHODS: In 51 consecutive patients with chronic heart failure, due to either ischemic and non-ischemic dilated cardiomyopathy, and atrial fibrillation simultaneous Doppler echocardiographic and hemodynamic studies were used to estimate PAWP. The power of the obtained multivariate equation was compared with that of previously developed equations and was then prospectively tested in a group of 15 patients. RESULTS: The deceleration rate (DR) of early diastolic mitral flow, the left ventricular iso-volumic relaxation time (IVRT) and the systolic fraction of pulmonary venous flow (SF) were independent predictors of PAWP and the following multivariable equation was derived: PAWP=24.04 + 1.23 x DR- 0.089 x IVRT - 0.175 x SF. The correlation between invasive PAWP and the PAWP non-invasively estimated by this equation in the testing group was 0.91 (standard error of estimate=3.2 mmHg). The mean difference was 0.93 and the standard error of differences was 2.7 mmHg. CONCLUSION: In patients with chronic heart failure due to dilated cardiomyopathy who are in atrial fibrillation a relatively accurate estimation of PAWP can be obtained by Doppler echocardiography of mitral and pulmonary venous flow.     

Precipitating factors associated with diastolic heart failure in the elderly

BACKGROUND: Beside basal myocardial dysfunction, acute heart failure involves associated factors, which increase pulmonary capillary pressure or decrease colloid osmotic pressure. The aim of this study was to evaluate the prevalence of these precipitating factors in a population presenting with acute heart failure with preserved left ventricular systolic function. METHODS: Forty-eight patients (25 men, 78 +/- 10 years) presenting pulmonary edema with a left ventricular ejection fraction > 45% were included. All had a Doppler echocardiography at the time of intravenous loop diuretics initiation. Patients with severe valve disease or symptomatic coronary disease were excluded. RESULTS: A history of heart failure, coronary disease, hypertension and diabetes was present in 62%, 42%, 64% and 33% of patients, respectively. On admission, mean left ventricular ejection fraction was 61 +/- 9% and 79% of patients had critical elevation in Doppler filling pressures. Associated factors were renal failure (creatinine clearance < 30 ml/min) in 33% patients, silent myocardial ischemia (troponin I > 0.5 ng/ml) in 31%, atrial fibrillation in 29%, high systolic blood pressure (> or = 160 mmHg) in 27%, major sepsis in 25%, severe hypoalbuminemia (< or = 2.5 g/dl) in 23%, and severe anemia (< 10 g/dl) in 17%, respectively. Four patients had no aggravating factor, whereas 34 and 10 patients had 1-2 and 3-4 associated factors, respectively. CONCLUSION: Besides diastolic dysfunction, factors leading to a critical decrease in the oncotic pressure such as pulmonary capillary pressure gradient are found in most of the elderly patients presenting acute diastolic heart failure and must be checked systematically.     

Exercise hemodynamic findings in patients with exertional dyspnea

To determine whether upright bicycle exercise could provide useful information about disabling exertional dyspnea in the absence of severe abnormalities (as shown by traditional testing methods), we evaluated 13 such patients. There were 3 men and 10 women with a mean age of 49+/-15 (SD) years. We used pulmonary artery catheterization at rest and during upright bicycle exercise to evaluate these patients. All patients had normal left ventricular function except for 1, who had an ejection fraction of 45%. The mean duration to peak exercise was 9+/-6 minutes. Normal systolic pulmonary artery pressure was defined as 25+/-5 mmHg. Four patients had normal systolic pulmonary pressure, and 9 exhibited pulmonary hypertension with exercise. In those 9, the mean mixed pulmonary venous oxygen saturation at rest was 61%+/-9% and fell to 32%+/-9% at peak exercise. Six of the 9 patients also had some degree of resting pulmonary hypertension that worsened with exercise: their mean pulmonary artery systolic pressure at rest was 47+/-14 mmHg and rose to 75+/-25 mmHg at peak exertion (P = 0.01). The other 3 patients showed no pulmonary hypertension at rest; their mean pulmonary artery systolic pressure was 27+/-6 mmHg. However, this level rose to 53+/-4 mmHg at peak exertion (P = 0.04). In this pilot study of patients with dyspnea, 9 of 13 (69%) displayed marked pulmonary hypertension with exercise. The resting hemodynamic levels were normal in 3 (33%) of those with exercise pulmonary hypertension. We conclude that hemodynamic data from bicycle exercise tests can provide additional information regarding the mechanisms of exertional dyspnea.     

Right ventricular myocardial infarction in patients with chronic lung disease: possible role of right ventricular hypertrophy

To determine the relation between right ventricular hypertrophy and right ventricular myocardial infarction in patients with chronic lung disease, the records of 28 patients with chronic lung disease, inferior myocardial infarction and significant coronary artery disease (group I) and 20 patients with right ventricular hypertrophy, chronic lung disease without inferior myocardial infarction or significant coronary artery disease (group II) were reviewed. Chronic lung disease was diagnosed by clinical criteria, chest radiographs and pulmonary function tests. All patients had postmortem examinations. Patients in group I were classified into two subgroups: group Ia (without right ventricular hypertrophy) and group Ib (with right ventricular hypertrophy). Right ventricular wall thickness was 3.3 mm +/- 0.5 in group Ia, 6.0 mm +/- 1.1 in group Ib and 8.8 mm +/- 2.4 in group II (group Ia versus Ib, p less than 0.001; group Ia versus II, p less than 0.001; group Ib versus II, p less than 0.001). Eleven patients (78.6%) in group Ib (chronic lung disease with both right ventricular hypertrophy and inferior myocardial infarction) had right ventricular myocardial infarction compared with only 3 patients (21.9%) in group Ia (chronic lung disease without right ventricular hypertrophy and with inferior myocardial infarction) (p less than 0.008). Isolated right ventricular myocardial infarction occurred in four patients (20%) in group II (chronic lung disease with right ventricular hypertrophy, but without evidence of infarction of the left ventricle or significant coronary artery disease). There was no significant difference in the extent of anatomic coronary disease in groups Ia and Ib.(ABSTRACT TRUNCATED AT 250 WORDS)     

Multicenter prospective investigation on efficacy and safety of carperitide as a first-line drug for acute heart failure syndrome with preserved blood pressure: COMPASS: Carperitide Effects Observed Through Monitoring Dyspnea in Acute Decompensated Heart Failure Study

BACKGROUND: Recently, vasodilators have been increasingly being recognized as useful for the treatment of acute heart failure syndromes (AHFS). Although carperitide (alpha-human atrial natriuretic peptide) has vasodilatory, diuretic and organ-protective effects, its efficacy and safety for the first-line drug treatment of AHFS have not been reported. METHODS AND RESULTS: A prospective observational study was performed in AHFS patients with preserved systolic blood pressure (SBP >or=120 mmHg), pulmonary congestion and dyspnea who were receiving carperitide monotherapy. The analysis was conducted in 1,832 patients (male: 52.7%; mean age: 75.1+/-12.7 years). The initial SBP was 151.1+/-25.7 mmHg; 62.0% were diagnosed as having acutely decompensated chronic heart failure and 78.8% were assessed as functional class III-IV according to New York Heart Association classification. Carperitide was administered at an initial dosage of 0.025-0.05 microg x kg(-1) x min(-1) in 50.4% of patients. In 1,524 patients (83.2%), carperitide monotherapy restored the acute phase and improved the degree of dyspnea as assessed using the modified Borg scale. The incidence of adverse drug reactions was 4.64%; the most frequently reported adverse reaction was hypotension (3.55%). CONCLUSION: In the present study, following carperitide monotherapy, 83.2% of AHFS patients recovered from the acute phase. Based on these findings, carperitide seems useful for the first-line drug treatment of AHFS in patients with pulmonary congestion and preserved blood pressure.     

Echocardiographic predictors of hemodynamic response and significance of dyspnea development in patients with mitral stenosis during dobutamine stress echocardiography

BACKGROUND AND AIM OF THE STUDY: In mitral stenosis (MS) patients, resting hemodynamic data do not always correlate with symptom severity. Stress tests may be carried out in these patients, but the mechanisms of different hemodynamic and clinical responses to stress are not clearly established. The study aim was to evaluate hemodynamic changes that correlate with dyspnea development during dobutamine infusion (DI) in patients with MS, and to assess determinants of transmitral gradient response. METHODS: Forty-five consecutive mild or moderately symptomatic patients (36 women, nine men; mean age 44 +/- 10 years; range: 26-66 years), in NYHA class II and with MS (mean mitral valve area (MVA) 1.6 +/- 0.1 cm2; range: 1.5-1.9 cm2) were evaluated with dobutamine stress echocardiography. RESULTS: During DI, dyspnea developed in 12 patients, and 33 patients remained asymptomatic. During infusion, both mean transmitral gradient (6 +/- 3 versus 11 +/- 6 mmHg, p = 0.01) and pulmonary artery systolic pressure (PASP) (13 +/- 4 versus 21 +/- 3 mmHg, p < 0.001) were significantly increased in patients who developed dyspnea compared to others. Hence, a subgroup of patients with more serious MS was identified using the hemodynamic response to dobutamine. Based on these clinical and hemodynamic results, management was changed in 12 patients (27%); five underwent percutaneous mitral balloon commissurotomy and seven received intensive medical treatment. In all patients, PASP at rest (p = 0.001), MVA (p < 0.0001) and subvalvular mitral score (p = 0.004), which is indicative of mitral valve damage, were significantly correlated with mean mitral valve gradient response. CONCLUSION: These results suggest that patients in whom dyspnea is provoked during DI show a greater increase in hemodynamic parameters than patients in whom provocation does not occur. The mean mitral valve gradient-response correlates with baseline pulmonary artery pressure, MVA and subvalvular echo score, and may be predicted by these parameters. Association between dyspnea and presence of severe mitral valve hemodynamics showed a high sensitivity and negative and positive predictive value. It is possible that dyspnea may be of value in identifying those patients with significant mitral valve obstruction.     

The value of recording the pulmonary insufficiency flow by continuous Doppler for the evaluation of systolic pulmonary artery pressure

Systolic, diastolic and mean pulmonary artery pressures can be evaluated by Doppler recordings of the maximal velocity of tricuspid regurgitation and early and late diastolic pulmonary regurgitant flow. The aim of this study was to assess the reliability of the calculation of systolic pulmonary artery pressure from pulmonary regurgitant flow by comparing the values with those obtained from the tricuspid regurgitant flow in the same patient. With this objective in mind, we investigated 70 patients with an average age of 45 +/- 34 years, in sinus rhythm, all of whom had tricuspid and pulmonary regurgitant jets which could be recorded with continuous wave Doppler. Systolic pulmonary artery pressure was calculated as follows: from tricuspid regurgitation: maximum pressure gradient + 10 mmHg; from pulmonary regurgitation: 3 x early diastolic gradient - 2 x late diastolic gradient + 10 mmHg. The systolic pulmonary artery pressures calculated from tricuspid and pulmonary regurgitation were: 42 +/- 16 mmHg and 43 +/- 17 mmHg respectively (r = 0.97) with an estimated standard error of 4.7 mmHg. These results show that the recording of pulmonary regurgitation by continuous wave Doppler allows accurate estimation of pulmonary artery pressures. The calculation by the two methods using tricuspid and pulmonary regurgitant jets increases the reliability of the results and provides a means of internal validation of the Doppler technique.     

Evaluation of the Incidence of Chronic Thromboembolic Pulmonary Hypertension 1 Year After First Episode of Acute Pulmonary Embolism: A Cohort Study

Purpose

Chronic thromboembolic pulmonary hypertension (CTEPH) is an important complication after acute pulmonary embolism (PE) with considerable morbidity and mortality. The aim of this study was to estimate the CTEPH incidence in a cohort after the first occurrence of PE.

Methods

We conducted a 1-year follow-up cohort study between 2015 and 2018 to assess the incidence of CTEPH in 474 patients with their first acute episode of PE. For the diagnosis of CTEPH, patients with unexplained persistent dyspnea during follow-up underwent transthoracic echocardiography, right heart catheterization, ventilation-perfusion lung scanning, and CT pulmonary angiography.

Results

Overall, 317 patients were included in the study. The mean age of the patients was 56.5 ± 16 years. One hundred and three patients (32%) had exertional dyspnea at the 1-year follow-up. Patients with evidence of pulmonary hypertension (PH) on echocardiography underwent right heart catheterization. Eleven patients (18%) had no PH (mPAP < 25 mmHg); 47 patients (81%) had mPAP > 25 mmHg. Fifteen patients had PAWP > 15 mmHg, including those with underlying left heart problems or valvular diseases. There were 32 patients with PAH (mPAP > 25 mmHg and PVR > 3 WU) undergoing CTEPH studies; 22 patients (6.9%) had multiple segmental defects suggesting CTEPH on a perfusion scan.

Conclusion

The incidence of CTEPH observed in this study 1 year after the first episode of acute PE was approximately 6.9%. This incidence seems to be high in our population, and diagnostic and therapeutic strategies for the early identification of CTEPH are needed.

     

Usefulness of Doppler echocardiography in the diagnosis of acute diastolic heart failure in the elderly

PURPOSE: To evaluate the clinical usefulness of the determination of Doppler mitral inflow pattern and new combined indices using colour M mode velocity flow propagation (Vp) in the diagnosis of acute diastolic heart failure in the elderly. METHODS: Total serum protein concentration (P, g/l) and E/A, E/Vp and 1000/(2 x IRT + Vp) Doppler indices (E and A: mitral inflow peak velocities; IRT: isovolumic relaxation time) were measured at the time of therapy initiation in 94 patients with left ventricular ejection fraction > 50% (78 +/- 13 years), 56 with pulmonary edema and 38 patients with acute respiratory disease. RESULTS: The feasibility was 73, 90 and 89% for E/A, E/Vp and 1000/(2 x IRT + Vp) respectively. The sensitivity, specificity and accuracy were 94-56-72%, 84-86-85% and 92-86-89% for E/A > or = 1, E/Vp > or = 2 and 1000/(2 x IRT + Vp) > or = 6 respectively in the diagnosis of pulmonary edema in patients with normal serum colloid osmotic pressure defined by P > or = 60 g/l, and 41-50-43%, 37-86-50% and 22-100-42% in patients with low colloid osmotic pressure (P < 60 g/l). CONCLUSIONS: The mitral inflow measurement is limited in most of cases of acute diastolic heart failure in the elderly by confounding factors such as atrial fibrillation and normalised pattern. New combined Doppler indices are useful in these patients, however, their value must be interpreted according to the serum colloid osmotic status estimated by total serum protein concentration.     

The effect of diabetes on heart rate and other determinants of myocardial oxygen demand in acute coronary syndromes.

AIMS: To compare major determinants of myocardial oxygen demand (heart rate, blood pressure and rate pressure product) in patients with and without diabetes admitted with acute coronary syndromes. METHODS: A cross-sectional study of the relation between diabetes and haemodynamic indices of myocardial oxygen demand in 2542 patients with acute coronary syndromes, of whom 1041 (41.0%) had acute myocardial infarction and 1501 (59.0%) unstable angina. RESULTS: Of the 2542 patients, 701 (27.6%) had diabetes. Major haemodynamic determinants of myocardial oxygen demand were higher in patients with than without diabetes: heart rate 80.0 +/- 20.4 vs. 75.2 +/- 19.2 beats/minute (P < 0.0001); systolic blood pressure 147.3 +/- 30.3 vs. 143.2 +/- 28.5 mmHg (P = 0.002); rate-pressure product 11533 +/- 4198 vs. 10541 +/- 3689 beats/minute x mmHg (P < 0.0001). Multiple regression analysis confirmed diabetes as a significant determinant of presenting heart rate [multiplicative coefficient (MC) 1.05; 95% confidence interval (CI) 1.03-1.07; P < 0.0001], rate pressure product (MC 1.09; CI 1.05-1.12; P < 0.0001) and systolic blood pressure, which was estimated to be 3.9 mmHg higher than in patients without diabetes (P=0.003). These effects of diabetes were independent of a range of baseline variables including acute left ventricular failure and mode of presentation (unstable angina or myocardial infarction). CONCLUSIONS: In acute coronary syndromes, heart rate and other determinants of myocardial oxygen demand are higher in patients with than without diabetes, providing a potential contributory mechanism of exaggerated regional ischaemia in this high-risk group.     

Immediate and mid-term results of percutaneous pulmonary valvotomy in adults. Apropos of 10 cases]

Percutaneous pulmonary valvulotomy (PPV) is the treatment of choice for isolated congenital pulmonary stenosis of infancy. However, experience with this technique in the adult is much more limited. From November 1983 to November 1990, PPV was performed in 10 adults in our Institute. The mean age was 40 +/- 19 years (range 21 to 71 years). Before PPV, 4 patients were in functional Class II and 6 in functional Class III of the NYHA classification. All procedures were successful with no complications. The right ventricular systolic pressure decreased from 98 +/- 35 to 57 +/- 30 mmHg (p less than 0.01) and the mean pulmonary gradient decreased from 57 +/- 30 to 23 +/- 15 mmHg (p less than 0.01). The cardiac output was unchanged: 5.3 +/- 2.8 and 5.9 +/- 2.6 l/mn (not significant). Pulmonary valve area increased from 0.59 +/- 0.3 to 1.15 +/- 0.5 cm2 (p less than 0.01). The post-dilatation infundibular gradient was less than 10 mmHg in all patients. After an mean follow-up period of 29 +/- 26 months all but one patient (Class II) were in functional Class I. Exercise capacity was 6.9 +/- 2 Mets. Doppler echocardiography indicated a stable mean pulmonary gradient of 16.5 +/- 6.8 mmHg after PPV and 15.0 +/- 7.0 mmHg during follow-up. Pulmonary regurgitation was less than Grade I in all cases. In conclusion, PPV is an effective treatment for adult pulmonary stenosis and carries a low risk. The mid term results are excellent.     

Stress echocardiography in the evaluation of exercise physiology in patients with severe arterial pulmonary hypertension. New methodology.

INTRODUCTION: Doppler echocardiography is usually performed when assessing a patient with severe pulmonary hypertension (PHT), since it enables accurate determination of the severity of the hypertension through evaluation of several morphologic and hemodynamic variables. Echocardiograms are usually performed in left lateral decubitus (LLD). However, symptoms often arise only in a standing position and particularly during exercise. OBJECTIVE: To evaluate a group of patients with severe PHT using Doppler echocardiography during treadmill exercise testing. METHODS: We studied 8 patients (group A), mean age 43.88 +/- 14 years, 7 women; three had idiopathic pulmonary hypertension, 2 pulmonary thromboembolic disease, 2 Eisenmenger syndrome, and one pulmonary hypertension associated with celiac disease. We also studied an 8-patient control group (group B) with similar demographic characteristics, who had tricuspid regurgitation but no known cardiac disease, including pulmonary hypertension (excluded by echocardiogram). In addition to the ergometric variables of stress test duration using the modified Bruce protocol, resting heart rate, peak heart rate (PHR), resting systolic blood pressure (RSBP) and peak systolic blood pressure (PSBP), we evaluated the following echocardiographic variables: pressure gradient between right ventricle and right atrium (RV/RAg) and systolic volume (SV) in left lateral decubitus, in a standing position (SP) and at peak workload (PW). Stress testing was stopped in cases of fatigue and/or dyspnea. RESULTS: In group A, the RV/RAg in LLD was 100 +/- 20 mmHg, 98 +/- 20 mmHg in SP (p = NS) and 129 +/- 27 mmHg at PW (p = 0.003 vs. SP). In group B, the RV/RAg in LLD was 19.8 +/- 3.5 mmHg, 14.6 +/- 2.1 mmHg in SP (p = 0.0005) and 29.5 +/- 3.3 mmHg at PW (p < 0.0001 vs. SP). In group A, SV was 38 +/- 11 ml in LLD, 35 +/- 10 ml in SP and 32 +/- 9 ml at PW (p = NS); in group B, it was 63 +/- 5 ml in LLD, 55 +/- 5 ml in SP and 64 +/- 7 ml at PW (p < 0.0001). PHR was 114 +/- 10 bpm in group A and 145 +/- 8 (p < 0.0001) in group B. RSBP was 113 +/- 13 mmHg and PSBP 112 +/- 21 mmHg (p = NS) in group A, and 116 +/- 18 mmHg and 161 +/- 25 mmHg respectively (p < 0.0001) in group B. In four patients from group A, symptomatic falls in systolic blood pressure and SV occurred at PW. During a mean follow-up of 27 months (between 6 and 44 months), two of these four patients died and one is awaiting lung transplantation. CONCLUSIONS: 1. RV/RAg did not diminish in the standing position and rose significantly with orthostatic isotonic exercise during exercise testing in patients with severe PHT, with pulmonary artery systolic pressure reaching suprasystemic values. 2. Systolic volume and systolic blood pressure did not rise during exercise in patients with severe PHT, and patients with a decrease in systolic volume had worse clinical evolution. 3. Patients with severe PHT appeared to have chronotropic incompetence during exercise compared to the control group.     

Effect of Inoue balloon mitral valvotomy on severe pulmonary arterial hypertension in 315 patients with rheumatic mitral stenosis: immediate and long-term results

BACKGROUND AND AIMS OF THE STUDY: Despite advances in surgical techniques, mitral valve surgery in patients with severe pulmonary arterial hypertension (PAH) causes considerable mortality and morbidity. Balloon mitral valvotomy (BMV) is an established alternative to treat high-risk surgical patients with mitral stenosis (MS). The study aims were to evaluate immediate and long-term efficacy of BMV in patients with MS and severe PAH, compared to those with mild/moderate PAH. METHODS: Among 1,125 patients who underwent Inoue BMV, 315 had severe PAH (mean pulmonary artery (PA) pressure > or = 50 mmHg (group I; 79 of these patients had suprasystemic PAH). Results from this group were compared with those of patients with mild/moderate PAH (group II). RESULTS: Group I patients were younger and more symptomatic (mean PA pressure 62 +/- 10.6 mmHg versus 32.6 +/- 8.2 mmHg in group II). Before BMV, mean transmitral gradient (17.8 +/- 6.5 versus 14.4 +/- 5.4 mmHg) and pulmonary capillary wedge pressure (PCWP) (31.6 +/- 6.1 versus 22.8 +/- 6.2 mmHg) were significantly higher, while mitral valve area (MVA) (0.66 +/- 0.2 versus 0.85 +/- 0.2 cm2) was significantly lower in group I. After BMV, PA mean pressure was significantly reduced (34.8 +/- 11.2 and 21.1 +/- 8.4 mmHg), transmitral gradient (8.0 +/- 3.9 and 6.9 +/- 3.2 mmHg) and mean PCWP (12.8 +/- 5.8 and 11.0 +/- 5.1 mmHg) in groups I and II, respectively, with a comparable increase in MVA (1.77 +/- 0.4 and 1.84 +/- 0.5 cm2). Group I patients had worse baseline hemodynamic parameters than group II, but the former had a higher absolute gain in hemodynamic parameters. Residual severe PAH after BMV was seen in 9.8% of patients, with PA pressures normalized in 9.5%. Among 79 patients with suprasystemic PA pressure (mean PA systolic pressure 116.6 +/- 28.2 mmHg), 16.5% normalized their PA pressures and 25.3% had residual severe PAH. At mean follow up of 33 months, 80.4% were in NYHA class I. Mean PA systolic pressure in 161 patients was 39.0 +/- 14.2 mmHg compared with a post-BMV value of 55.0 +/- 16.9 mmHg; thus, a sustained fall in pressure was demonstrated at follow up. CONCLUSION: Inoue BMV is safe and effective in patients with MS and severe PAH. Although these patients have worse clinical and hemodynamic parameters before BMV, they achieve a greater absolute gain in terms of improvement in all hemodynamic parameters.     

Short-term course under beta blockers of clinical and echocardiographic parameters in mitral stenosis in sinus rhythm

The purpose of this study is to evaluate the short-term benefit of a beta-blocker (atenolol) on clinical and echocardiographic parameters of patients presenting isolated or predominant mitral stenosis in sinus rhythm. It is a prospective study performed on 26 patients who have had a clinical and echocardiographic assessment before and 15 days after treatment by atenolol. After 15 days of beta-blocker treatment, there is a significant improvement of dyspnea (57.6% in class III or IV before beta-blockade versus 15.3% with atenolol; P = 0.001) and a significant decrease of the heart rate (83.3 +/- 15.2 versus 68.9 +/- 13.9; P = 0.001) and the diastolic blood pressure (8 mmHg +/- 1.3 versus 7.2 mmHg +/- 0.9; P = 0.01). The Doppler echocardiography shows a significant increase of the stroke volume calculated by the Doppler method (28.7 +/- 6.2 versus 38.6 +/- 9.7 mL; P = 0.04). There is an insignificant trend to an improvement of the left ventricular systolic function, an increase of cardiac output and the decrease of the mean transmitral gradient. The factors associated with the failure of beta-blocker treatment are: the right heart failure (P = 0.04) and the low diastolic blood pressure (P = 0.01). The beta-blockers could be a logical and effective treatment of patients with mitral stenosis waiting for balloon commissurotomy or surgery.     

Impact of cigarette smoking on response to interferon therapy in chronic hepatitis C Egyptian patients

AIM: Smoking may affect adversely the response rate to interferon-α. Our objective was to verify this issue among chronic hepatitis C patients. METHODS: Over the year 1998, 138 chronic hepatitis C male Egyptian patients presenting to Cairo Liver Center, were divided on the basis of smoking habit into: group I which comprised 38 smoker patients (&gt;30 cigarettes/d) and group II which included 84 non-smoker patients. Irregular and mild smokers (16 patients) were excluded. Non eligible patients for interferon-~ therapy were excluded from the study and comprised 3/38 (normal ALT) in group I and 22/84 in group II (normal ALT, advanced cirrhosis and thrombocytopenia). Group I was randomly allocated into 2 sub-groups: group Ia comprised 18 patients who were subjected to therapeutic phlebotomy while sub-group Ib consisted of 17 patients who had no phlebotomy. In sub-group Ia, 3 patients with normal ALT after repeated phlebotomies were excluded from the study. Interferon-α2b 3 MU/TIW was given for 6 mo to 15 patients in group Ia, 17 patients in group Ib and 62 patients in group II. Biochemical, virological end-of- treatment and sustained responses were evaluated.RESULTS: At the end of interferon-α treatment, ALT was normalized in 3/15 patients (20%) in group Ia and 2/17 patients (11.8%) in group Ib compared to17/62 patients (27.4%) in group II (P=0.1). Whereas 2/15 patients (13.3%) in group Ia. and 2/17 patients (11.8%) in group Ib lost viraemia compared to 13/62 patients (26%) in group II(P=0.3). Six months later, ALT was persistently normal in 2/15 patients (13.3%) in group la and 1/17 patients (5.9%) in group Ib compared to 9/62 patients (14.5%) in group Ⅱ (P= 0.47). Viraemia was eliminated in 1/15 patients (6.7%) in group Ia and 1/17 patients (5.9%) in group Ib compared to 7/62 patients (11.3%) in group Ⅱ, but the results did not mount to statistical significance (P = 0.4). CONCLUSION: Smokers suffering from chronic hepatitis C tend to have a lower response rate to interferon-α compared to non-smokers. Therapeutic phlebotomy improves the response rate to interferon-α therapy among this group.     

Clinical, hemodynamic and morphologic findings in dilated cardiomyopathy

45 patients (39 men, six women), mean 41 (19-63) years of age with clinical, angiographic and morphologic diagnosis of dilated cardiomyopathy were evaluated in respect of three morphologic classes. Two groups of patients without signs of previous myocarditis were formed, with one-to-two mitochondria per two sarcomeres (group Ia, n = 19), or with more than two mitochondria per two sarcomeres, respectively (group Ib, n = 14); and one group with signs of previous myocarditis (group II, n = 12). The mean relative mitochondrial volume fraction in relation to myofibril volume fraction was significantly lower in group Ia (33 +/- 4/67 +/- 4%) compared to group Ib (39 +/- 5/61 +/- 5%) (p less than 0.01). Mean values of group II (36 +/- 6/64 +/- 6%) were in between the two other groups. Left ventricular enddiastolic pressure (18 +/- 11, 18 +/- 8, 16 +/- 10 mm Hg), pulmonary vascular resistance (473 +/- 414, 406 +/- 205, 458 +/- 495 dyn x s x cm-5), ejection fraction (36 +/- 21, 32 +/- 16, 28 +/- 16%), endsystolic volume index (131 +/- 82, 127 +/- 66, 132 +/- 60 ml/m2), enddiastolic volume index (187 +/- 81, 176 +/- 62, 181 +/- 63 ml/m2), dp/dt max (1951 +/- 875, 1737 +/- 575, 1741 +/- 478 mmHg x s-1) and mean VCF (0.76 +/- 0.58, 0.44 +/- 0.32, 0.54 +/- 0.39 s-1) showed no significant differences between the three groups. Follow-up of the patients in the three groups to median 19, 22, 24 months, respectively, after biopsy, showed an improvement of the clinical findings, especially concerning the groups with one-to-two mitochondria only and with signs of previous myocarditis, but no difference in survival within the three groups. For the individual case our morphologic parameters seem to be without predictive value.     

Comparative study of 2 mechanical mitral valves]

We present the long term follow-up of two groups of patients under 16 years of age in whom two different types of mitral valve prostheses were used for the treatment of mitral valve disease. Group I was formed by 74 patients with Starr-Edwards (6120) prosthesis and group II by 36 cases with Bjork-Shiley prosthesis. Group I was followed for a mean period of 11 years and group II for a mean period of 7.5 years. The clinical evolution of both groups assessed according to the New York Heart Association criteria showed improvement of the functional class (p less than 0.006). Twenty seven cases of group I and 21 of group II underwent cardiac catheterization for the evaluation of surgical results. In group I, the mean pulmonary arterial systolic pressure (PASP) decreased from 57 mmHg to 33 mmHg (p less than 0.001) and the mean pulmonary arterial wedge pressure (PAWP) from 20.8 mmHg to 12.1 mmHg (p less than 0.05). In group II, the mean PASP decreased from 59.2 mmHg to 28.5 mmHg (p less than 0.001) and the mean PAWP from 24.6 mmHg to 8.5 mmHg (p less than 0.001). There was statistically significant difference for a greater incidence of thromboembolism in group I (p = 0.037). No differences were found for bacterial endocarditis, dysfunction and death.     

Haemodynamically unstable pulmonary embolism in the RIETE Registry: systolic blood pressure or shock index?

Patients with acute pulmonary embolism (PE) presenting with haemodynamic instability have the worst prognosis. However, what is understood by haemodynamic instability has not been clearly defined. The Registro Informatizado de la Enfermedad Tromboembólica (RIETE) is an ongoing registry of consecutive patients with symptomatic, objectively confirmed, acute deep vein thrombosis or PE. The present authors compared the predictive value of a systolic blood pressure (SBP) value of <100 mmHg and <90 mmHg and the shock index (cardiac frequency divided by SBP) on 30-day mortality in consecutive patients with PE. As of May 2006, 6,599 patients with PE were enrolled in the study. Of these, 417 (6.3%) died within 30 days: 153 of the initial PE, 29 of recurrent PE and 235 due to other causes. Of the 417 individuals who died, 127 (30%) had a positive shock index, 60 (14%) had SBP <100 mmHg and 33 (7.9%) had SBP <90 mmHg. On multivariate analysis any of the three parameters were independently associated with an increased mortality. The shock index had a higher sensitivity (30.5 versus 14.4 and 7.9% for SBP <100 mmHg and <90 mmHg, respectively) but lower specificity (86.3 versus 93.0 and 96.6). All three measures of haemodynamic instability are independent predictors of 30-day mortality. However, while the shock index had the highest sensitivity, a systolic blood pressure value <90 mmHg had the highest specificity.