Evidence Of Ventricular Dysfunction Research Articles

Left Atrial Mechanics Following Preeclamptic Pregnancy.

Preterm preeclampsia is a pregnancy complication associated with myocardial dysfunction and premature cardiovascular disease morbidity and mortality. Left atrial (LA) strain is a noninvasive index of left ventricular end diastolic pressure and an early marker of heart failure risk. This study aimed to evaluate LA strain during the postpartum period in participants with and without preterm preeclampsia and to assess whether this varied in the presence of hypertension, cardiac dysfunction or both. In this longitudinal cohort study, 321 women from 28 hospitals with preterm preeclampsia (cases) underwent cardiovascular assessment 6 months postpartum. This is a secondary analysis of the PHOEBE study (ISRCTN01879376). An uncomplicated pregnancy control group (n=30) was recruited from a single center for comparison. A full cross-sectional transthoracic echocardiogram was performed, and from these images, the myocardial strain of the left atrium, including reservoir, conduit, and contractile strain, as well as LA stiffness, were calculated. At 6 months postpartum, compared with controls, prior preeclampsia was associated with a significantly attenuated LA reservoir, conduit, and contractile strain, as well as increased LA stiffness (all P<0.001). LA strain was further reduced in preeclamptic women who had and had not developed hypertension, systolic, or diastolic dysfunction at 6 months postpartum (all P<0.05). LA mechanics were significantly attenuated at 6 months postpartum in participants with preterm preeclampsia, whether or not they remained hypertensive or had evidence of ventricular dysfunction. Further studies are needed to determine whether postnatal LA strain may identify women at greater risk for future cardiovascular disease.

Submassive pulmonary thromboembolism, post-COVID sequelae; with mechanical thrombus aspiration and accelerated thrombolysis by Ekos ultrasound with successful resolution

IntroductionAcute pulmonary thromboembolism is a pulmonary pathology that is becoming more frequent nowadays, the use of new mechanical and thrombolytic therapies has a significant impact on the cardiopulmonary prognosis.CaseA 41-year-old male, a retired military man, smoking, overweight, dyslipidemia, alcoholic liver disease, who attended the emergency department due to abrupt dyspnea, with tachycardia, chest pain, and syncope; the patient had tachycardia of 120 bpm, BP 90/60 mmHg and SO2 of 82%, with a history of COVID-19 infection, suspected of massive pulmonary embolism, it was decided to carry out computed tomography where a bilateral submassive pulmonary embolism was documented (Fig. 1A), it was proposed to perform systemic thrombolysis, however due to the risk of bleeding, it was decided to perform EKOS ultrasound directed thrombolysis. Baseline pulmonary angiography was performed with a large number of thrombi (Fig. 1B), distributed in both main right and left branches and deficient pulmonary filling of distal vessels, due to the large amount of thrombus, it was decided to perform manual thrombus aspiration, obtaining a large amount of thrombus (Fig. 1C), as well as thrombolysis in situ with Alteplase a dose of 1 mg/catheter/hour for 12 hours, with a total dose of 24 mg; Ultrasound probe was placed in both pulmonary arteries with the EKOS system (Fig. 1D).ResultsPulmonary angiography was performed 24 hours after the procedure, where no bleeding occurred and almost complete resolution of the thrombus was observed. The patient later with 92% SO2, without oxygen requirements, with HR 90 bpm, with no evidence of ventricular dysfunction, was discharged home with anticoagulation.ConclusionLow dose fibrinolysis and thromboaspiration are considered, as well as the use of EKOS endovascular ultrasound, a safe and effective procedure, in the context of a patient with high-risk of bleeding, with favorable results that condition clinical and prognostic improvement.

Severe Rhabdomyolysis in a Child With Multisystem Inflammatory Syndrome: An Autoimmune Mechanism?

Severe Rhabdomyolysis in a Child With Multisystem Inflammatory Syndrome: An Autoimmune Mechanism?

Abstract 17118: Myocarditis in Multisystem Inflammatory Syndrome in Children (MIS-C) Temporally Related to COVID-19

Background: Little is know about the pathophysiology of Multisystem Inflammatory syndrome in Children (MIS-C) temporally associated with COVID-19 Hypothesis: Patients with MIS-C may present with myocarditis. Cardiac magnetic resonance (CMR) may help in its diagnosis. Methods: Nine children and adolescents were identified to have clinically suspected myocarditis based on their clinical presentation, abnormal cardiac enzymes and evidence of ventricular dysfunction on echocardiogram. 5 patients underwent CMR. Results: All patients had evidence of current/recent SARS-COV-2 infection. Five were PCR+, 7 were IgG+. On echocardiogram at presentation, all the patients had mild-severe left ventricular dysfunction (EF: 25%-53%). Three had left ventricular dilation, 7 had evidence of valvulitis presenting as mitral regurgitation, 4 had pericardial effusion with no evidence of tamponade and 3 patients had associated coronary dilation. Seven patients presented in cardiogenic shock requiring inotropic support. Out of the 5 patients who underwent CMR, 2 had evidence of early and late gadolinium enhancement. Small focal area of late gadolinium enhancement was noted in the inferolateral segment of the subepicardial region of the left ventricle. There was evidence of myocardial edema in the other 3 patients. Conclusions: Children with Multi system Inflammatory Syndrome in Children can present as myocarditis. Cardiac magnetic resonance has a role in its diagnosis, prognosis, better understanding of this disease and may be useful for the long term follow up of these children. Table 1: Patient characteristics, labs, imaging findingsAbbreviations:-BNP: Brain natriuretic peptide, CRP:C-reactive protein, LV EF: Left ventricular ejection fraction, CAs: Coronary abnormalities, Valvar R: valvar regurgitation, EGE: Early gadolinium enhancement, LGE: Late gadolinium enhancement

Right ventricular longitudinal strain measured using feature-tracking cardiac magnetic resonance is an independent predictor of all cause mortality in patients with severe tricuspid regurgitation

Abstract Introduction Tricuspid regurgitation imposes a volume overload on the right ventricle (RV) that can lead to progressive RV dilation and dysfunction. Overt RV dysfunction is associated with poor prognosis and increased operative risk. Abnormalities of myocardial strain may provide the earliest evidence of ventricular dysfunction. CMR feature-tracking techniques now allow assessment of strain from routine cine-images, without specialized pulse sequences. Whether abnormalities of RV strain measured using CMR feature-tracking have prognostic value in patients with tricuspid regurgitation is unknown Purpose To evaluate the prognostic value of CMR feature-tracking derived RV free wall longitudinal strain (RVFWLS) in a large multicenter population of patients with severe tricuspid regurgitation. Methods Consecutive patients with severe tricuspid regurgitation undergoing CMR at four US medical centers were included in this study. Feature-tracking RVFWLS was calculated from 4 chamber cine-views (Figure-left panel). The primary endpoint was all-cause death. Cox proportional hazards regression modeling was used to examine the independent association between RVFWLS and death. The incremental prognostic value of RVFWLS was assessed in nested models. Results Of the 406 patients in this study,115 died during a median follow-up of 8.8 years. By Kaplan-Meier-analysis, patients with RVFWLS ≥median (−16%) had significantly reduced event free survival compared to those with RVFWLS &amp;lt; median (log-rank p&amp;lt;0.001) (Figure-right panel). By Cox multivariable regression modeling, each 1% worsening in RVFWLS was associated with a 13% increased risk-of-death after adjustement for clinical and imaging risk factors (HR=1.13 per %; p&amp;lt;0.001). Addition of RVFWLS in this model resulted in significant-improvement in the global-chi-square (26 to 65; p&amp;lt;0.0001). Conclusions CMR feature-tracking derived RVFWLS is an independent predictor of mortality in patients with severe tricuspid regurgitation, incremental to common clinical and imaging risk factors. Funding Acknowledgement Type of funding source: None

Advances in Neonatal Cardiac Surgery

After completing this article, readers should be able to: 1. Describe the developments that have allowed advances in neonatal cardiac surgery. 2. Describe the diagnostic approach to hypoplastic left heart syndrome (HLHS). 3. Delineate the preoperative management of the neonate who has HLHS. 4. Describe the original Norwood procedure and subsequent modifications. 5. Delineate the optimal therapy in the postoperative period for neonates who have a single ventricle. Advances in the surgical and medical management of children who have congenital heart disease (CHD) have led to a dramatic improvement in overall survival and reduced the long-term sequelae of open-heart surgery. With improved survival and decreased morbidity over the past 2 decades, the early complete repair of complex congenital heart problems in preterm and low-birthweight neonates has gained wider acceptance. Cardiologists and cardiothoracic surgeons now consider and perform complete neonatal repair more frequently than palliative surgery in this patient population. The treatment of hypoplastic left heart syndrome (HLHS) best illustrates the evolution of management strategies to improve survival and long-term outcome. A recent modification of the Norwood operation that involves a right ventricle-to-pulmonary artery conduit has led to much improved early postoperative stability and, in many centers, improved survival to a stage II superior cavopulmonary connection. A multidisciplinary team approach is required to provide the necessary care for this complex patient population. In 1938, Robert Gross at Children’s Hospital in Boston successfully ligated a patent ductus arteriosus, and this procedure—performed against the wishes of surgeon-in-chief William Ladd—opened the era of surgery for CHD. (1) Gross and Hufnagel performed detailed animal experiments to develop a technique for treatment of coarctation of the aorta that involves excision and end-to-end anastomosis. (2) Clarence Craaford of Stockholm, Sweden, had visited Gross to observe his experimental work, and in October 1944, Craaford and Nylin were the first to repair aortic …

Phase I Study of Depsipeptide in Pediatric Patients With Refractory Solid Tumors: A Children's Oncology Group Report

To determine the maximum-tolerated dose (MTD), dose-limiting toxicities (DLT), pharmacokinetic profile, and pharmacodynamics of the histone deacetylase inhibitor, depsipeptide, in children with refractory or recurrent solid tumors. Depsipeptide was administered as a 4-hour infusion weekly for 3 consecutive weeks every 28 days at dose levels of 10 mg/m2, 13 mg/m2, 17 mg/m2, and 22 mg/m2. Pharmacokinetics and histone acetylation studies were performed in the first course. The levels of H3 histone and acetyl-H3 histone were evaluated in peripheral blood mononuclear cells (PBMC) using immunofluorescence techniques. There were 24 patients, and 18 who were assessable were enrolled. DLTs included reversible, asymptomatic T-wave inversions, without any associated changes in troponin levels or evidence of ventricular dysfunction, in the inferior leads in two patients at 22 mg/m2 and in the lateral leads in one patient at 13 mg/m2 (n = 1), and transient asymptomatic sick sinus syndrome and hypocalcemia in one patient at 17 mg/m2. At the MTD (17 mg/m2), the median depsipeptide clearance was 6.8 L/h/m(2) with an area under the plasma depsipeptide concentration-time curve from 0 to infinity of 2,414 ng/mL/h, similar to adults. Accumulation of acetylated H3 histones was seen in all patients in a dose independent manner, with maximal accumulation at a median of 4 hours, (range, 0 hours to 20 hours) after the end of the infusion. No objective tumor responses were observed. Depsipeptide is well tolerated in children with recurrent or refractory solid tumors when administered weekly for 3 consecutive weeks every 28 days and inhibits histone deacetylase activity in PBMC in a dose-independent manner. The recommended phase II dose in children with solid tumors is 17 mg/m2.

Fetal Rhabdomyoma Causing Postnatal Critical Left Ventricular Outflow Tract Obstruction

Fetal Rhabdomyoma Causing Postnatal Critical Left Ventricular Outflow Tract Obstruction

Early detection of cardiac dysfunction in thalassemic patients by radionuclide angiography and heart rate variability analysis

Cardiac dysfunction remains the major cause of death in beta-thalassemia. Aim of this study was to assess early myocardial damage in thalassemic patients with no symptoms or echocardiographic evidence of dysfunction at routine monitoring. Twenty patients (seven females; median 25 yr [first quartile 22,third quartile 28]) with beta-thalassemia underwent radionuclide angiography (RNA) at rest and during low-dose dobutamine infusion (5-10 gamma/kg/min). Right and left ventricular ejection fractions (EF) were determined by first-pass method and gated equilibrium acquisition, respectively. Twenty-four-hour Holter monitoring with time-domain heart rate variability (HRV) assessment and echocardiographic follow-up (21 months [5,27]) were performed. Eleven patients showed regional wall motion abnormalities at RNA; left ventricular EF, HR and diastolic measurements significantly increased after dobutamine infusion. Patients with abnormal RNA right ventricular EF (n = 8, <0.45) showed lower echocardiographic left ventricular EF at the enrollment (0.54 [0.50,0.61] vs. 0.62 [0.56,0.67], P = 0.02) than those with a normal right ventricular EF. Patients with reduced standard deviation of the averages of RR intervals in all 5-minute periods of entire recording (SDANN) (n = 6, <100 ms), a measure of HRV, had lower echocardiographic left ventricular EF (0.53 [0.49,0.62] vs. 0.62 [0.56,0.66], P = 0.03) and lower fractional shortening (0.28 [0.25,0.32] vs. 0.36 [0.30,0.39], P = 0.003) at the enrollment than those with normal SDANN. No significant association was found between RNA and HRV measurements and follow-up left ventricular function. Right ventricular dysfunction and abnormal HRV may represent the early features of cardiac disease in thalassemic patients with no evidence of ventricular dysfunction at routine evaluation.

MRL mice fail to heal the heart in response to ischemia-reperfusion injury

The MRL/MpJ mouse strain has been reported to recover after right ventricular cryoinjury without scar formation or evidence of ventricular dysfunction, suggesting that this mouse strain harbors genetic traits that confer the capacity for adult myocardium to regenerate. We therefore sought to assess the capacity of adult MRL myocardium to regenerate in a left ventricular ischemia-reperfusion model of myocardial infarction, which more closely recapitulates injury that occurs in human disease. MRL (n = 13) and control C57/Bl6 (n = 12) mice underwent transient occlusion of the left anterior descending coronary artery. After 10 weeks, MRL and C57Bl/6 mice were euthanized and the extent of infarcted myocardium quantified with (2,3,5)-triphenyltetrazolium chloride and trichrome staining. There was no evidence of resistance to cardiac injury or of reduced scar formation in the MRL mice compared to C57/Bl6 controls. Myocardial infarct size (percentage of total heart weight +/- SEM) did not significantly differ between MRL and C57/Bl6 controls (18.9 +/- 1.8% for MRL vs. 15.7 + 1.3% for C57/Bl6, p = 0.20). Thickness of the infarcted anterior LV wall at the mid-papillary level normalized to body weight was not significantly different between the two groups (0.017 + 0.003 mm/mg for MRL and 0.017 + 0.002 mm/mg for C57/BL6, p = 0.91). Trichrome staining showed intense scar formation in both C57/BL6 and MRL hearts. We conclude that there appears to be no effect of the MRL genetic background on resistance to myocardial infarction in mice.

Determinação do peptídeo natriurético cerebral humano em portadores da doença de Chagas

To measure the serum levels of brain natriuretic peptide (BNP) in patients with chronic chagasic heart disease and in individuals with positive serology for Chagas' disease and no heart impairment, and to correlate the serum BNP levels with the degree of cardiac impairment, cardiac dimensions, presence of a pacemaker, and ejection fraction. Serum BNP concentrations were determined by use of the Triage-BNP Test produced by BIOSITE. Serum BNP was assessed in 25 patients from the Chagas' disease outpatient clinic of the Hospital Universitario Oswaldo Cruz, who were divided into 2 groups as follows: 1) G1--comprising 13 asymptomatic patients with positive serology for Chagas' disease and no heart disease detectable on electrocardiography, chest X-ray, and echocardiography; and 2) G2--comprising 12 patients with Chagas' disease and heart impairment. Significantly more elevated BNP levels were detected in the chagasic patients with cardiac impairment: (G1=4.4 +/-4.4 pg/ml, G2=293.0+/-460.2 pg/ml); (P<0.01). In the 2 groups, the serum levels of BNP correlated neither with age nor with sex. The levels were directly proportional to functional class and cardiac area on chest X-ray. Although a trend towards an increment in systolic function impairment was observed, no linear correlation with the ejection fraction on echocardiography occurred. The presence of definitive pacemaker and electrocardiographic alterations did not change the serum BNP levels. Asymptomatic individuals with a positive serology for Chagas' disease and no evidence of ventricular dysfunction have serum BNP levels similar to those of the general population.

Early treatment of acute myocardlal infarction with anglotensin-convertlng enzyme inhibition: Safety considerations

The use of angtotensln-converting enzyme (ACE) Inhibitors In acute myocardial infarction (AMI) Is based on their capacity to limit ventricular enlargement and dysfunction. To date, the safety profile of administration of ACE inhibitors early in the course of AMI has not been established. Inhospital and long-term consequences of treatment with the ACE inhibitor zofenopril initiated within 24 hours of the onset of symptoms were compared with those of standard treatment in an open-label trial involving 204 patients with AMI who were not undergoing thrombolytic treatment. Zofenopril promptly blocked ACE activation. Blockade was almost complete (91 ± 6%) after 72 hours and paralleled decreases in systolic Mood pressure. Systemic blood pressure was acutely reduced by zofenopril, and severe but reversible hypotension occurred in 15% of hospitalized patients and in 3% of those treated over the long term. No adverse clinical or biochemical events were reported during the course of zofenopril therapy. Overall cardiovascular mortality was not significantly reduced by early zofenopril compared with placebo therapy (7.8% vs 10.7% [difference not significant]). The inhospttal incidence of acute left ventricular failure and ventricular arrhythmias decreased by 63% and 39%, respectively, among zofenopril-treated patients, who also reported fewer anginal episodes both acutely (68% reduction) and over the long term (56% reduction) and did not require as much drug treatment (i.e., diuretics, digoxin, and/or anti-ischemic agents) during the follow-up phase. Left ventricular size decreased and ejection fraction (EF) increased in patients who received zofenopril, and the Improvement was greater among patients with poorer ventricular function (EF < 40%). Early administration of ACE inhibitors may therefore constitute a safe form of therapy for patients with AMI, particularly when the event is complicated by clinical signs or evidence of ventricular dysfunction.

Midterm results after the arterial switch operation for transposition of the great arteries with intact ventricular septum: clinical, hemodynamic, echocardiographic, and electrophysiologic data.

Although the short-term results of atrial level repair of transposition of the great arteries (TGA) are satisfactory, longer follow-up has disclosed a significant incidence of systemic right ventricular dysfunction and rhythm disturbances. The arterial switch operation (ASO) may represent a major improvement by restoring the left ventricle as the systemic ventricle and avoiding extensive atrial surgery. We have prospectively evaluated 49 consecutive survivors of ASO for TGA with intact ventricular septum (IVS) by clinical examination, echocardiography, cardiac catheterization, ambulatory electrocardiographic monitoring, and invasive electrophysiologic studies. The mean length of follow-up has been 29 +/- 14 (SD) months after surgery. All children are currently asymptomatic and on no medications. Severe supravalvular pulmonary stenosis (greater than 60 mm Hg) was present in five children, all of whom have undergone reoperation. No patient has severe supravalvular aortic obstruction. Mild degrees of supravalvular pulmonary or aortic obstruction have not progressed. Seven children (14%) have trivial or mild aortic regurgitation. Two children have proximal occlusion of the left anterior descending coronary artery with adequate retrograde collateral perfusion. One child had an electrocardiographic pattern of inferior myocardial infarction without evidence of ventricular dysfunction. Systemic (left) ventricular function is normal as measured by end-diastolic pressure (mean 7 +/- 6 mm Hg), ejection fraction (mean 68 +/- 6%), end-diastolic volume (mean 101 +/- 22% of predicted normal), and cardiac index (mean 4.7 +/- 1.3 liters/min/m2). Only one patient has sinus node dysfunction. There have been no late deaths. These early results are encouraging. We conclude that the arterial switch operation is currently the procedure of choice for neonates with TGA and IVS.

Assessment of Cardiac Function in Patients with the Acquired Immunodeficiency Syndrome

We have assessed right and left ventricular function by multigated radionuclide ventriculography in 12 consecutive patients with acquired immunodeficiency syndrome (AIDS) grouped according to the CDC classification system for HIV infection. Results were correlated with clinical, electrocardiographic and echocardiographic findings. Clinical examination and chest x-ray films showed no evidence of acute cardiac or pulmonary pathology. Five patients had evidence of ventricular dysfunction by radionuclide ventriculography along with significant ECG abnormalities. Three patients had abnormal ECG findings with normal ejection fractions. Echocardiography showed no evidence of significant valvulopathy or pericardial disease except for one patient with fibrinous strands associated with the pericardium. Decreased ejection fractions did not correlate with disease classification, risk group or survival. This study suggests that a major percentage of AIDS patients have some evidence of cardiac abnormalities. We conclude that abnormal ECG findings in an AIDS patient should alert the clinician to possible underlying ventricular dysfunction.

Value of Serial Apexcardiograms during and after Myocardial Infarction

Apexcardiograms were systematically recorded serially in 40 patients after acute myocardial infarction, in an additional 21 patients with proven aneurysms, and in 18 patients with good ventricular performance following myocardial infarction. Abnormalities of the "A" wave and systolic waves of the apexcardiogram correlated well with akinesia or dyskinesia proven by cinefluoroscopic and cineangiographic studies. Third and fourth heart sounds and apical systolic murmurs also correlated well with evidence of ventricular dysfunction. This study indicates that the apexcardiogram is a good qualitative tool for serially assessing patients following acute myocardial infarction and that the results on invasive study may be predicted in most patients.