[Show abstract][Hide abstract] ABSTRACT: Background: Transoesophageal echocardiography (TOE) is a widely used imaging modality in ambulatory patients, with a reportedly low complication
rate. TOE is frequently performed under conscious sedation. It is the imaging modality of choice for assessment of aortic
valve morphology and size prior to trans-catheter aortic valve implantation (TAVI). However, the population of patients undergoing
workup for TAVI differs from the general TOE population, as they have been turned down for conventional surgery due to high
operative risk. Therefore, we sought to establish whether the complication rate for patients undergoing TOE as part of TAVI
work-up is higher than the risk for the general TOE population.
Methods: We reviewed the registry of all patients who underwent TAVI work up at our institution and identified patients who underwent
TOE as part of TAVI work up. TOE was performed by a cardiologist assisted by a nurse and an echocardiographer. When sedation
was used, it was administered by the cardiologist. We calculated logistic Euroscore as a measure of patient risk and reviewed
the TOE records for sedation use and major complications (failed procedure, arrhythmia, desaturation, laryngospasm, reversal
of sedation, major upper GI bleeding or trauma, death). Minor complications such as sore throat were not recorded. Where there
was doubt as to outcome or a complication was documented, a full review of the medical record was performed.
Results: We identified 77 patients who underwent TOE during TAVI workup between November 2007 and May 2011. Mean patient age was 83.3
±6.6 years and 37 (48.1%) patients were aged ≥85y. Median Euroscore was 23.0% (Range 6-69%). Mean FEV1/FVC was 64±12.3%. 44
(57.1%) patients had moderate or severe COPD, defined as FEV1/FVC ratio <70%. 82% of patients underwent TOE under conscious
sedation. Median dose of Midazolam administered was 2mg. The TOE probe could not be inserted in 2 (2.6%) patients. No other
Conclusion: TOE may safely be performed under sedation in high risk patients undergoing TAVI work up.
Full-text · Article · Dec 2011 · European Heart Journal – Cardiovascular Imaging
[Show abstract][Hide abstract] ABSTRACT: Systemic hypertension is known to affect both left and right ventricular (RV) function. Little is known about the effect of the renin-angiotensin system (RAS) inhibition on global RV function in patients with essential hypertension.
Forty patients (17 male, mean age 47 ± 10 years) with mild hypertension free of cardiovascular disease were assessed by echocardiography at baseline and after nine months of antihypertensive treatment with RAS inhibitors. Tissue Doppler imaging derived myocardial performance index (MPI) of the left and right ventricle was used as an index of global ventricular function.
Both left ventricular (LV) and RV MPI were increased at baseline and were reduced after treatment (LV MPI reduced from 0.42 ± 0.06 to 0.39 ± 0.05, p < 0.001 and RV MPI was reduced from 0.34 ± 0.06 to 0.32 ± 0.05, p < 0.005). There was a positive correlation between mitral and tricuspid E/A ratio both at baseline and at month nine after treatment (r = 0.661, p < 0.001 and r = 0.503, p < 0.005 respectively). LV mass index and interventricular septum thickness were decreased after treatment. No correlation was found between MPI improvement and blood pressure reduction.
RAS inhibition in patients with mild hypertension results in an improvement of RV global function which is unrelated to the reduction in blood pressure.
Full-text · Article · Mar 2011 · Journal of Renin-Angiotensin-Aldosterone System
[Show abstract][Hide abstract] ABSTRACT: Coronary ostial stenosis is a rare but potentially serious sequela after aortic valve replacement. It occurs in the left main or right coronary artery after 1% to 5% of aortic valve replacement procedures. The clinical symptoms are usually severe and may appear from 1 to 6 months postoperatively. Although the typical treatment is coronary artery bypass grafting, patients have been successfully treated by means of percutaneous coronary intervention.Herein, we present the cases of 2 patients in whom coronary ostial stenosis developed after aortic valve replacement. In the 1st case, a 72-year-old man underwent aortic valve replacement and bypass grafting of the saphenous vein to the left anterior descending coronary artery. Six months later, he experienced a non-ST-segment-elevation myocardial infarction. Coronary angiography revealed a critical stenosis of the right coronary artery ostium. In the 2nd case, a 78-year-old woman underwent aortic valve replacement and grafting of the saphenous vein to an occluded right coronary artery. Four months later, she experienced unstable angina. Coronary angiography showed a critical left main coronary artery ostial stenosis and occlusion of the right coronary artery venous graft. In each patient, we performed percutaneous coronary intervention and deployed a drug-eluting stent. Both patients were asymptomatic on 6-to 12-month follow-up. We attribute the coronary ostial stenosis to the selective ostial administration of cardioplegic solution during surgery. We conclude that retrograde administration of cardioplegic solution through the coronary sinus may reduce the incidence of postoperative coronary ostial stenosis, and that stenting may be an efficient treatment option.
Full-text · Article · Aug 2010 · Texas Heart Institute journal / from the Texas Heart Institute of St. Luke's Episcopal Hospital, Texas Children's Hospital
[Show abstract][Hide abstract] ABSTRACT: A 57-year-old man with exertional chest pain underwent a positive study for myocardial ischemia on myocardial perfusion tomography. Coronary angiography revealed a long myocardial bridge in the midportion of the left anterior descending artery. The patient remained symptomatic with medical treatment. Surgical treatment was considered a better option because the diseased segment was a long, bare metal myocardial bridge stenting which has a higher restenosis rate compared with stenting of de novo atherosclerotic lesions, and data on drug-eluting myocardial bridge stenting is limited. The patient remained asymptomatic and had a normal myocardial perfusion tomography 12 months after surgery.
No preview · Article · Jun 2010 · Clinical nuclear medicine
[Show abstract][Hide abstract] ABSTRACT: It was hypothesised that, apart from right ventricular (RV) dysfunction, patients with idiopathic pulmonary fibrosis (IPF) also exhibit left ventricular (LV) impairment, which may affect disease progression and prognosis. The aim of the present study was to evaluate LV performance in a cohort of IPF patients using conventional and tissue Doppler ECG. IPF patients exhibiting mild-to-moderate pulmonary arterial hypertension (mean age 65+/-9 yrs; n = 22) and healthy individuals (mean age 61+/-6 yrs; n = 22) were studied. Conventional and tissue Doppler ECG were used for the evaluation of RV and LV systolic and diastolic function. In addition to the expected impairment in RV function, all patients showed a characteristic reversal of LV diastolic filling to late diastole compared with controls (early diastolic peak filling velocity (E)/late diastolic peak filling velocity 0.7+/-0.2 versus 1.5+/-0.1, respectively). Patients with IPF also exhibited lower peak myocardial velocities in early diastole (E(m); 5.7+/-1.1 versus 10.3+/-1.6 cm x s(-1), respectively), higher in late diastole (A(m); 8.9+/-1.3 versus 5.5+/-0.8 cm x s(-1), respectively), lower E(m)/A(m) ratio (0.6+/-0.1 versus 1.9+/-0.5, respectively) and higher E/E(m) ratio (10.8+/-3 versus 6+/-0.6, respectively), all indicative of LV diastolic dysfunction. Moreover, LV propagation velocity was significantly lower in IPF patients (46+/-13 versus 83+/-21 cm x s(-1), respectively). Physicians should be aware that patients with idiopathic pulmonary fibrosis exhibit early impairment of left ventricular diastolic function.
Full-text · Article · May 2008 · European Respiratory Journal
[Show abstract][Hide abstract] ABSTRACT: The aim of the study was to evaluate left ventricular diastolic function and its relation to aortic wall stiffness in patients with type 1 diabetes mellitus without coronary artery disease or hypertension.
Sixty-six patients with type 1 diabetes mellitus were examined by echocardiography and divided into two groups according to the diastolic filling pattern determined by mitral annulus tissue Doppler velocities. Group A patients (n = 21) presented diastolic dysfunction with a peak early diastolic mitral annular velocity (Em)/peak late diastolic mitral annular velocity (Am) ratio <1 whereas in group B patients (n = 45) the Em/Am ratio was >1. Coronary artery disease was excluded based on normal thallium scintigraphy. Aortic stiffness index was calculated from aortic diameters measured by echocardiography, using accepted criteria.
Aortic stiffness index differed significantly among the two groups. Significant correlations were found between parameters of left ventricular diastolic function (Em/Am, isovolumic relaxation time, deceleration time) and aortic stiffness index. Multiple stepwise linear regression analysis revealed aortic stiffness index (beta = -0.39, p = 0.001) and isovolumic relaxation time (beta = -0.46, p < 0.001) as the main predictors of Em/Am ratio.
Aortic stiffness is increased in type 1 diabetic patients with left ventricular diastolic dysfunction. This impairment in aortic elastic properties seems to be related to parameters of diastolic function.
[Show abstract][Hide abstract] ABSTRACT: There are limited reports in the literature concerning right ventricular (RV) performance in patients with non end-stage idiopathic pulmonary fibrosis (IPF) who exhibit mild to moderate pulmonary hypertension (PH). We evaluated RV functional impairment in such a cohort using both conventional echocardiography and tissue Doppler imaging (TDI) and in addition we assessed the association of specific TDI indices with survival.
Twenty-two clinically stable patients with non-end stage IPF and mild to moderate PH were assessed. Twenty-two healthy individuals served as controls. We evaluated RV systolic and diastolic function and further estimated peak pulmonary artery systolic pressure (PASP). In addition, by combining TDI and Doppler echocardiography, we calculated the ratio of trans-tricuspid E-wave velocity to early diastolic tricuspid annulus velocity (RV E/Em). Patients were followed for a median period of 22 months and the incidence of death was recorded.
Both echocardiographic modalities revealed impaired RV systolic and diastolic function in the IPF group compared to controls. A significant negative correlation was observed between RV E/Em and PASP (r = -0.5, p = 0.018). The probability of survival was 54.5% for those patients with RV E/Em < 4.7 versus 100% for those with an index > 4.7 (log-rank statistic 5.81, p = 0.016).
TDI modality may serve as an alternative to conventional ultrasound technique for risk stratification and PH estimation in non end-stage IPF patients.
Full-text · Article · May 2007 · Hellenic journal of cardiology: HJC = Hellēnikē kardiologikē epitheōrēsē
[Show abstract][Hide abstract] ABSTRACT: Left ventricular diastolic dysfunction represents the earliest preclinical manifestation of diabetic cardiomyopathy. Right ventricular function has not been studied in depth yet in diabetic patients, although the right ventricle has an important contribution to the overall cardiac function. This study was designed to assess diastolic and systolic ventricular function in both ventricles, in patients with type 1 diabetes, free from coronary artery disease and hypertension.
We studied 66 type 1 diabetic patients and 66 age- and sex-matched normal subjects by conventional and tissue Doppler echocardiography. A possible correlation was examined for age, diabetes duration and echocardiographic measurements of left ventricular and right ventricular functions with univariate analysis.
Type 1 diabetic patients were found to have impaired diastolic function in both ventricles with either conventional or tissue Doppler echocardiography. On the contrary, systolic function in both ventricles was preserved in our diabetic population. The measured indexes showed an expected correlation with age and diabetes duration except from systolic velocity in tricuspid annulus determined by color tissue Doppler. Moreover, significant correlations were found among parameters of left and right ventricular function.
Patients with type 1 diabetes mellitus have impaired diastolic function, and particularly relaxation, in both ventricles before the development of myocardial systolic dysfunction. These alterations in myocardial function may be attributed to ventricular interdependence as well as to the uniform effect of diabetes to cardiac function.
No preview · Article · Feb 2007 · International journal of cardiology
[Show abstract][Hide abstract] ABSTRACT: Hypertrophic cardiomyopathy (HC) may transition to a phase characterized by systolic impairment resembling dilated cardiomyopathy. This study retrospectively assessed the incidence of left ventricular (LV) systolic impairment at initial clinical evaluation in 248 consecutive patients with HC (mean age 53 +/- 16 years). HC with systolic impairment was diagnosed if the LV ejection fraction was <50%, calculated by echocardiography. Twenty patients (8%) had HC with LV systolic impairment at initial evaluation. Patients with systolic impairment had a greater incidence of family histories of sudden cardiac death (SCD) than patients with preserved systolic function (25% vs 5.3%, p = 0.006) and more severe functional limitations (New York Heart Association class >or=III, p <0.001). All-cause mortality and cardiovascular mortality did not differ between the 2 groups. The incidence of SCD was 1.7% in patients with normal LV ejection fractions, and no SCD was observed in patients with systolic impairment. The latter group had more frequent major cardiac events (SCD, ventricular fibrillation, aborted cardiac arrest, and first implantable cardioverter-defibrillator discharge; p = 0.03). During follow-up, 2 patients progressed to HC with systolic impairment (annual incidence 0.85%). In conclusion, systolic impairment is not exceptional in patients with HC at initial evaluation and is associated with functional deterioration and major cardiac events.
No preview · Article · Dec 2006 · The American Journal of Cardiology