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ABSTRACT: The assessment of pulmonary hypertension in patients with heart failure is of great clinical importance not only for diagnostic purposes but also for prognostication. The present study was undertaken on a consecutive basis with a group of patients with chronic heart failure. Patients were evaluated for their suitability for heart transplantation: (1) to explore the diagnostic accuracy of several echo Doppler parameters of pulmonary hemodynamics in predicting the presence of elevated pulmonary artery pressure (defined as pulmonary artery systolic pressure > or =35 mmHg and mean pulmonary artery pressure >20 mmHg); (2) to assess the diagnostic ability of the same parameters to identify patients with elevated pulmonary vascular resistance; and (3) to evaluate the influence of right ventricular function and degree of tricuspid regurgitation in modifying diagnostic accuracy.
Echo Doppler examination and right heart catheterization were performed consecutively within 24 hours in 86 patients. The optimal cut-off value for a series of echo Doppler parameters capable of identifying patients with pulmonary hypertension was obtained by dividing the entire sample into 2 groups; the optimal threshold (highest sensitivity and specificity) of the echo and Doppler parameters used to classify patients with and without pulmonary hypertension was determined in 67% of cases by means of the receiver operating characteristic (ROC) curve: this was the testing sample. The proportion of cases classified correctly according to the selected cut-off was computed. The remaining 33% of cases represented the validation sample: sensitivity, specificity and predictive values (and their 95% confidence intervals [CIs]) for identifying pulmonary hypertension were calculated from the proposed cut-offs in this second sample. Finally, the overall performance of the echo Doppler parameters was assessed over the whole sample by considering the extent of the area under the ROC curve (A-ROC) and its 95% CI, for the dichotomic measurement.
On right heart catheterization, a pulmonary artery systolic (PAPs) pressure > or =35 mmHg plus a mean pressure (mean PAP) >20 mmHg was documented in 49 of 86 cases (57%), for whom mean values were 56 +/- 17 and 38 +/- 11 mmHg, respectively. The proportion of cases identified correctly as having pulmonary hypertension was highest for PAPs (88%) and mean PAP (85%) in addition to acceleration time of pulmonary artery systolic flow (ACT) (79%) and pulmonary artery diastolic pressure obtained utilizing the early phase of the tricuspid regurgitation spectral flow (PAPd/TR) (75%). PAPd/TR performed better in the validating sample in terms of diagnostic ability, with high sensitivity and specificity (100% and 60%) and positive and negative predictive values (PPV 80%, NPV 100%). PAPs, mean PAP, ACT and PAPd/TR confirmed their prevailing diagnostic ability (A-ROC from 0.74 to 0.86) in identifying pulmonary hypertension with fair to high feasibility (67% to 91%) and an odds ratio (OR) indicative of strong association. ACT and PAPd/TR, the 2 parameters with the highest feasibility, allowed us to identify 46 of 49 (94%) hypertensive cases. The same parameters did not perform well in identifying patients with increased vascular resistance, with A-ROC ranging from 0.55 to 0.69. Heterogeneity of effect, due to right ventricular function or tricuspid regurgitation degree, could not be demonstrated in the ability of the echo Doppler measurements to identify pulmonary hypertension.
ACT, PAPd/TR, PAPs and mean PAP have been shown to accurately classify patients with chronic heart failure with or without pulmonary hypertension. In particular, ACT and PAPd/TR alone allowed reliable and accurate definition of pulmonary hypertension in 94% of patients, regardless of right ventricular function or degree of tricuspid regurgitation. Non-invasive pulmonary pressure assessment by the referred method might be useful in the evaluation of heart transplant candidates.
The Journal of Heart and Lung Transplantation 06/2005; 24(6):745-54. · 4.33 Impact Factor
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ABSTRACT: The study aimed at evaluating the prevalence of interventricular and intraventricular contractile dyssynchrony in heart failure patients with either normal or prolonged QRS duration.
Echocardiography and tissue Doppler imaging (TDI) were performed in 158 consecutive patients with advanced left ventricular dysfunction (LVEF<35%); 61 patients had a normal QRS duration (Group 1), 21 patients had left bundle branch block with a QRS duration between 120 and 150 ms (Group 2) and 76 patients had a QRS duration #10878;150 ms (Group 3). Interventricular dyssynchrony (defined by the presence of an interventricular mechanical delay greater than 40 ms) was found in 12.5%, 52.4% and 72% of patients in Group 1, 2 and 3, respectively (p < 0.001). Intraventricular dyssynchrony (defined by the presence of one or more differences greater than 50 ms among regional pre-ejection periods) was observed in 29.5%, 57.1% and 71% of patients in Group 1, 2 and 3, respectively (p < 0.001). No relationship was found between interventricular and intraventricular dyssynchrony.
A substantial proportion of heart failure patients with a slightly prolonged QRS or even with normal conduction may exhibit ventricular dyssynchrony. Both standard echocardiography and TDI are necessary to describe the entire spectrum of mechanical abnormalities due to dyssynchrony.
European Heart Journal 05/2004; 25(7):571-8. · 10.48 Impact Factor
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ABSTRACT: The aim of this study was to evaluate whether the use of contrast agent in addition to second harmonic imaging during dobutamine stress echocardiography can improve endocardial visualization and interobserver agreement in the evaluation of regional wall motion in patients with suboptimal or poor acoustic window.
Twenty-one patients with a poor or suboptimal acoustic window underwent dobutamine stress echocardiography. Echocardiographic images in parasternal long-axis and short-axis, apical 4-chamber and 2-chamber views were cine-looped at baseline and peak stress before and after injection of contrast medium (Levovist at a concentration of 400 mg/ml). Endocardial visualization and regional wall motion were evaluated by two blinded observers.
The contrast medium improved segment visualization both at baseline (complete visualization in 74% of segments with contrast vs 71% without, p = NS) and at peak stress (76 vs 64%, p < 0.001). Contrast medium improved significantly segment visualization in apical 4-chamber view both at baseline (complete visualization in 87% of segments with contrast vs 72% without, p < 0.01) and at peak (89 vs 66%, p < 0.001) and in apical 2-chamber view both at baseline (81 vs 61%, p < 0.001) and at peak (89 vs 55%, p < 0.001). When individual segments were analyzed, endocardial visualization improved significantly in all segments of the anterior wall and in the mid and distal segments of the lateral wall both at baseline and at peak stress. The use of contrast medium did not improve significantly interobserver agreement in the evaluation of regional wall motion at peak stress (k = 0.63 vs 0.67 without and with contrast, respectively).
The use of Levovist during dobutamine stress echocardiography improves significantly segment visualization in the apical views both at baseline and at peak stress and increases interobserver agreement in the evaluation of regional wall motion at peak stress.
Italian heart journal. Supplement: official journal of the Italian Federation of Cardiology 03/2003; 4(2):119-24.
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ABSTRACT: It has been suggested that an extensive contractile reserve identified recognised by means of dobutamine stress echocardiography may predict a better prognosis in patients with severe left ventricular dysfunction at rest. However, the clinical use of dobutamine stress echocardiography may be limited in patients with chronic heart failure by the substantial proportion of such patients treated with beta-blockers, since the inotropic response to adrenergic stimulation is known to be attenuated in patients receiving beta-adrenoceptor blockers. Enoximone is a positive inotropic agent that inhibits cyclic adenosine monophosphate-specific phosphosdiesterase. We therefore tested the hypothesis that enoximone may be an alternative to dobutamine in evaluating left ventricular contractile reserve in patients with systolic dysfunction on chronic beta-blocker therapy.
We studied 26 patients (21 males and five females) with a mean age of 58 PlusMinus; 10 years: 11 were not receiving beta-blockers (noBB group); 15 were receiving carvedilol at a mean dose of 34 mg/day (BB group). Dobutamine was infused at doses of 5 and 10 micrograms/kg/min, and enoximone at a dose of 1.5 mg/kg.
The ejection fraction in the noBB group increased by 9% with dobutamine and 8.73% with enoximone (p = 0.86); in the BB group, it increased by 6% with dobutamine and 8.94% with enoximone (p = 0.03). Regional peak systolic velocities were evaluated by means of tissue Doppler imaging in four basal and four medium level segments. In the noBB group, they increased more with dobutamine than with enoximone in three of the eight segments; no significant differences were found in the BB group. Dobutamine induced non-sustained ventricular tachycardia in three patients and supraventricular tachycardia in one, whereas enoximone did not induce any repetitive arrhythmias.
Enoximone might be preferable to low-dose dobutamine for evaluating left ventricular contractile reserve in chronically beta-blocked heart failure patients as it is slightly more potent and has a better safety profile.
Cardiovascular Ultrasound 02/2003; 1:13. · 1.26 Impact Factor
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ABSTRACT: Noninvasive estimation of pulmonary artery systolic and diastolic pressures usually requires the investigation of both tricuspid and pulmonary regurgitant jets and an estimate of right atrial pressure. A new, noninvasive method to obtain pulmonary diastolic pressure (based on the hemodynamic demonstration that right ventricular systolic pressure and pulmonary artery diastolic pressure are equal at the time of pulmonary valve opening) from the analysis of tricuspid regurgitation alone has been described in a small cohort of patients. We sought to verify the accuracy of this method in a large population of patients with heart failure.
An estimate of pulmonary artery diastolic pressure was obtained by transposing the pulmonary opening time (from the onset of the R wave on the electrocardiographic tracing to the beginning of pulmonic forward flow on Doppler examination) onto the tricuspid regurgitant velocity curve and calculating the pulmonary artery diastolic pressure value as the pressure gradient between the right ventricle and right atrium at this time. The study group included 86 consecutive patients (64 men, aged 52 +/- 11 years) with heart failure (New York Heart Association class > or =II, 94%) who were in stable clinical condition with a chiefly idiopathic (57%), ischemic (24%), or other form (13%) of dilated cardiomyopathy. Noninvasive, right-sided pressures were compared with invasive measurements obtained during right heart catheterization performed within 24 hours. The Bland and Altman graphic method was used together with the calculation of the Lin concordance correlation coefficient and its 95% CI to assess the agreement between hemodynamic and echocardiographic measurements.
Catheter-derived pulmonary artery systolic pressure ranged from 8 to 119 mm Hg (mean 42 +/- 21 mm Hg), pulmonary artery diastolic pressure from 1 to 59 mm Hg (mean 20 +/- 11 mm Hg), and right atrial pressure from -5 to 20 mm Hg (mean 6 +/- 5 mm Hg). Tricuspid regurgitation was detected in 75 of 86 patients (87%). Pulmonary artery systolic pressure ranged from 13 to 110 mm Hg (mean 44 +/- 21 mm Hg); the pressure gradient between the right ventricle and right atrium at time t of the pulmonary valve opening on the tricuspid regurgitation velocity curve was measurable in 70 of 75 (93%) cases and ranged from 3.5 to 64 mm Hg (mean 22 +/- 11 mm Hg). Good agreement was observed not only for pulmonary artery systolic pressure but also for pulmonary artery diastolic pressure, based on the analysis of the tricuspid regurgitation velocity jet, with a slight difference between measurements (-1.8 and 0.1, respectively), no evident pattern of point scattering, and a high concordance correlation coefficient that was elicited by the virtually total overlapping of lines on the graph. Overall results were not significantly different whether patients with depressed right ventricular function (right ventricular ejection fraction < or =35%), with a tricuspid regurgitation grade > or =2 and atrial fibrillation were included in the analysis.
The narrow paired difference for the estimate of pulmonary artery systolic pressure and the even better difference for pulmonary artery diastolic pressure using the tricuspid regurgitation velocity curve analysis indicates that this new method reliably estimates invasive right-sided pressures over a wide range of pressure values in patients with heart failure. The overall good correlation with invasive values indicates that Doppler examination of tricuspid regurgitation alone may provide a simple and comprehensive new method for the noninvasive evaluation of right ventricular and pulmonary hemodynamics in patients with heart failure.
American heart journal 12/2002; 144(6):1087-94. · 4.65 Impact Factor
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Alessandra Repetto,
Alessandra Serio,
Michele Pasotti, Alessandra Fontana,
Alessandra Bertoletti,
Laura Scelsi,
Giulia Magrini,
Lorenzo Monti,
Carlo Campana,
Stefano Ghio,
Luigi Tavazzi,
Eloisa Arbustini
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ABSTRACT: Objectives To test the diagnostic impact of the non-invasive rescreening of relatives of index patients consecutively diagnosed as having dilated cardiomyopathy. Background The aim of rescreening asymptomatic healthy relatives of DCM patients is to diagnose newly affected subjects and evaluate the predictive significance of the instrumental abnormalities found at the first screening. Methods and results Two hundred and three healthy relatives of 73 consecutive index patients with DCM (18 with familial disease at first screening) underwent rescreening involving a clinical examination, electro- and echocardiography, and biochemical tests a median of 29.3 months after the first screening. Seven relatives had developed the diagnostic criteria for DCM during the screening–rescreening interval. Of the 24 healthy relatives with left ventricular end-diastolic diameter enlargement and normal function at the first screening, nine had normalised, seven showed persistent enlargement, three had worsened, and five had developed the disease criteria at rescreening. Of the three relatives with atrioventricular block at the first screening, one had developed DCM. Finally, one of the relatives with normal echocardiographic and electrocardiographic results at the first screening, had developed the disease. Three of the newly diagnosed subjects came from families with evidence-based familial DCM, and four from families with what was defined as sporadic DCM at the first screening. Conclusions Medium-term rescreening of the relatives of DCM patients can identify a significant number of newly affected patients (3.5%).
