Lower Fractional Shortening Research Articles

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.

Cross-sectional relations of electrocardiographic QRS duration to left ventricular dimensions: The Framingham Heart Study

The goal of this study was to assess the relations of electrocardiographic QRS duration to left ventricular (LV) measurements in individuals without heart failure (HF) or prior myocardial infarction (MI). Increased electrocardiographic QRS duration (>/=120 ms) is a marker of ventricular dyssynchrony. We evaluated the relations of maximal electrocardiographic QRS duration to echocardiographic LV dimensions in 4,534 Framingham Heart study participants (mean age 54 years, 57% women) without prior HF or MI. QRS duration was analyzed as a continuous variable and as categories (<100, 100 to 119, and >/=120 ms). In linear regression models, LV mass, end-diastolic dimension, and septal and posterior wall thicknesses were positively related to log-QRS duration, whereas fractional shortening (FS) was inversely related (p < 0.001). There was a significant trend for increasing LV mass and dimensions, and decreasing FS across categories of QRS duration (p < 0.001). Left bundle branch block was associated with higher LV mass and lower FS compared with a normal QRS duration (p < 0.001). In our community-based sample of individuals free of HF and MI, increasing electrocardiographic QRS duration was positively related to LV mass and dimensions, and inversely associated with LV FS. Additional investigations are warranted to elucidate the mechanisms underlying the observed associations.

Effects of sarcoplasmic reticulum Ca2+-ATPase overexpression in postinfarction rat myocytes

Previous studies in adult myocytes isolated from rat hearts 3 wk after myocardial infarction (MI) demonstrated abnormal contractility and intracellular Ca(2+) concentration ([Ca(2+)](i)) homeostasis and decreased sarcoplasmic reticulum Ca(2+)-ATPase (SERCA2) expression and activity, but sarcoplasmic reticulum Ca(2+) leak was unchanged. In the present study, we investigated whether SERCA2 overexpression in MI myocytes would restore contraction and [Ca(2+)](i) transients to normal. Compared with sham-operated hearts, 3-wk MI hearts exhibited significantly higher left ventricular end-diastolic and end-systolic volumes but lower fractional shortening and ejection fraction, as measured by M-mode echocardiography. Seventy-two hours after adenovirus-mediated gene transfer, SERCA2 overexpression in 3-wk MI myocytes did not affect Na(+)-Ca(2+) exchanger expression but restored the depressed SERCA2 levels toward those measured in sham myocytes. In addition, the reduced sarcoplasmic reticulum Ca(2+) uptake in MI myocytes was improved to normal levels by SERCA2 overexpression. At extracellular Ca(2+) concentration of 5 mM, the subnormal contraction and [Ca(2+)](i) transient amplitudes in MI myocytes (compared with sham myocytes) were restored to normal by SERCA2 overexpression. However, at 0.6 mM extracellular Ca(2+) concentration, the supernormal contraction and [Ca(2+)](i) transient amplitudes in MI myocytes (compared with sham myocytes) were exacerbated by SERCA2 overexpression. We conclude that SERCA2 overexpression was only partially effective in ameliorating contraction and [Ca(2+)](i) transient abnormalities in our rat model of ischemic cardiomyopathy. We suggest that other Ca(2+) transport pathways, e.g., Na(+)-Ca(2+) exchanger, may also play an important role in contractile and [Ca(2+)](i) homeostatic abnormalities in MI myocytes.

Increased susceptibility to heart failure in response to volume overload in mice lacking natriuretic peptide receptor-A gene

Contribution of the natriuretic peptide system to the development of heart failure (HF) in vivo was examined using mice lacking or having decreased natriuretic peptide receptor-A (NPRA), a guanylyl cyclase-linked receptor. Volume-overloaded HF was produced by aortocaval fistula in mice with wild-type (+/+), heterozygous (+/-), and homozygous null mutants (-/-) of the NPRA gene. Severity of HF was assessed 4 weeks after operation on the basis of organ weight, hemodynamics, echocardiographic indices, urinary variables, neurohumoral factors, and myocardial gene expression. There were no significant differences in lung weight, kidney weight, left ventricular end-diastolic pressure (LVEDP), left ventricular systolic function, or urinary variables among the three sham-operated groups; however, sham-operated (-/-) mice had higher blood pressure and individual cardiac chamber weights than did (+/+) mice. In contrast, (-/-) mice with aortocaval fistula had higher LVEDP, left and right ventricular weights, lung weight, and left ventricular dimension, as well as lower fractional shortening and urinary sodium and cyclic guanosine monophosphate (cGMP) excretion than did (+/+) mice with aortocaval fistula. In addition, ventricular mRNA expression of natriuretic peptides and beta-myosin heavy chain increased markedly only in (-/-) mice. Plasma atrial natriuretic peptide, renin, and aldosterone, but not cGMP, showed greater responses to aortocaval fistula in (-/-) mice than in (+/+) mice. Both sham-operated and aortocaval fistula NPRA (+/-) mice almost consistently showed a phenotype intermediate between those of NPRA (-/-) and NPRA (+/+) mice. These results provide genetic evidence that NPRA signaling protects against HF induced by volume overload in mice.

Left atrial function as a predictor of haemodynamic response in patients with mitral stenosis: a dobutamine stress echocardiographic study

Objective—The mechanisms of the different haemodynamic and clinical responses to dobutamine infusion in mitral stenosis (MS) are not clearly established. The aim of this study was to evaluate the relation between left atrial (LA) function and haemodynamic response in patiens with MS during dobutamine infusion.Methods and results — Forty-two consecutive moderately symptomatic patients (33 women, 9 men; mean age 46±9, range from 26 to 66), NewYork Heart Association (NYHA) class II with MS (mean mitral valve area 1.7±0.1cm2) were evaluated with dobutamine stress echocardiography. Haemodynamic measurements were obtained at rest and during peak dobutamine infusion. LA fractional shortening at rest was used as an index of global LA function. Group I consisting of patients with significantly elevated pulmonary artery pressure (>60 mm Hg) and mean transmitral gradient (>15 mm Hg) at peak dobutamine infusion were defined as haemodynamically serious MS. Group II consisted of the remaining 30 patients whose haemodynamic data were below these levels.While baseline haemodynamic parameters and mitral valve characteristics were not different between the two groups, LA fractional shortening was significantly lower (18.9±2.8 vs. 32.3±5.1%, p<0.0001) and left atrial dimension was significantly larger in group I (49.7±2.3mm vs 43.6±5.3 mm, p<0.0001). Left atrial fractional shortening was negatively correlated with the increase in mean transmitral gradient (r:-0.58, p<0.01). When the patients were divided using a LA fractional shortening level of 25% as the cut-off point, we observed that the patients with low LA fractional shortening had a greater increase in mean transmitral gradient (7.3±3.1 mm Hg vs. 4.6±1.4 mm Hg), p = 0.005) and pulmonary artery pressure (22.4±3.5 mm Hg vs. 16.1±8.5 mm Hg, p = 0.001) compared to the patients with high LA fractional shortening. Based on these haemodynamic results, management was changed in 12 patients (28%): 5 underwent percutaneous mitral balloon commissurotomy and 7 received intensive medical treatment.Conclusions—The present study demonstrates that haemodynamic response during dobutamine stress echocardiography correlates with LA fractional shortening in patients with MS. The evaluation of left atrial function at rest in patients with ambiguous symptoms and mild mitral stenosis may be useful in clinical decision making. Atrial dysfunction at rest may predict the haemodynamic response during stress echo in these patients.

Impact of a preoperative mitral regurgitation scoring system on outcome of surgical repair for mitral valve prolapse

The optimal timing of surgical correction of severe mitral regurgitation (MR) is important for improved morbidity and mortality. We utilized a scoring system to decide the timing of procedures. Based on clinical features and echocardiographic data, we hypothesized that preoperative semi-quantitation of MR using this scoring system may be useful for predicting prognosis after repair. The MR score was composed of 6 parameters associated with disease severity (i.e., history of heart failure, atrial fibrillation, pulmonary hypertension, left ventricular end-systolic dimension, fractional shortening, and left atrial dimension). The maximum score was 6. Of 267 patients who underwent mitral valve repair in the last 10 years, 191 patients with mitral valve prolapse were studied. Patients were categorized into 2 groups according to MR score (group low [L] : 0 to 2.5 and group high [H]: ≥3.0) irrespective of New York Heart Association functional class. A significant difference in postoperative event-free survival was observed between both groups (p = 0.0014); the adjusted risk ratio was 3.4 (95% confidence interval 1.6 to 7.2). Postoperative echocardiography showed larger left ventricular systolic dimensions (p <0.0001), lower fractional shortening (p = 0.0016), and larger left atrial dimensions (p <0.0001) in group H than group L. Thus, an MR score is a simple way to predict the prognosis of severe MR independently of subjective symptoms in patients undergoing mitral valve repair.

Left ventricular mass and systolic dysfunction in essential hypertension.

A relation between left ventricular (LV) hypertrophy and depressed midwall systolic function has been described in hypertensive subjects. However, a strong confounding factor in this relation is concentric geometry, which is both a powerful determinant of depressed midwall systolic function and a correlate of LV mass in hypertension. To evaluate the independent contribution of LV mass to depressed systolic function, 1827 patients with never-treated essential hypertension (age 48 +/- 12 years, men 58%) underwent M-mode echocardiography under two-dimensional guidance. Relative wall thickness was the strongest determinant of low midwall fractional shortening (r = -0.63, P < 0.0001). The significant inverse relation observed between LV mass and midwall fractional shortening (r = -0.43, P < 0.0001) persisted after taking into account the effect of relative wall thickness (partial r = -0.27, P < 0.0001). Within each sex-specific quintile of relative wall thickness, prevalence of subnormal afterload-corrected midwall systolic function was greater in subjects with, than in subjects without, LV hypertrophy (P < 0.05 for the first, third, fourth and fifth quintile). In a multiple linear regression analysis, both LV mass (P < 0.0001) and relative wall thickness (P < 0.0001) were independent predictors of a reduced midwall fractional shortening. In conclusion, the inverse association between LV mass and midwall systolic function is partly independent from the effect of relative wall thickness. LV hypertrophy is a determinant of subclinical LV dysfunction independently of the concomitant changes in chamber geometry.

Metallothionein: localization in human transplant endomyocardium, relation to cytokines and allograft function

Background: The aim of this study was to investigate the role of metallothionein in cardiac transplants in relation to cytokines and allograft function. Recent studies have revealed an association of allograft dysfunction with elevated proinflammatory cytokines independent of cellular rejection. In animal experiments, cytokines induced overexpression of metallothionein, a low–molecular-weight protein implicated in cellular stress response. Methods In 105 consecutive biopsies from 15 patients during the first 3 months after heart transplantation, metallothionein expression was investigated immunohistochemically. Its relation to serum interleukin-6, tumor necrosis factor-α, interleukin-2 (IL-2), soluble interleukin-2 receptor rejection, and echocardiographic parameters was determined. Forty-three biopsies of 12 patients with idiopathic ventricular tachycardia served as controls. Results Metallothionein expression was demonstrated in small vessels, cardiomyocytes, fibrocytes, and interstitial round cells. A positive relation between interleukin-6 levels and the number of metallothionein-positive small vessels ( p < 0.028) was observed. Patients with lower serum IL-2 levels showed significantly higher numbers of metallothionein-positive small vessels ( p < 0.043). Grafts with prolonged ischemic time (>150 minutes) showed a significantly higher myocardial metallothionein score ( p < 0.021). Metallothionein expression was associated with lower fractional shortening, larger left ventricular end-systolic diameter, and lower mean arterial pressure but not with acute cellular rejection. Conclusions Metallothionein expression is associated with elevated interleukin-6 and decreased interleukin-2 serum levels and left ventricular allograft dysfunction in the absence of rejection.

Valve Replacement in Rheumatic Mitral Incompetence: Total versus Posterior Chordal Preservation

Several studies have shown that mitral valve replacement with total chordal preservation (MVR-TCP) improves left ventricular function when compared with total chordal transection. Few clinical studies, however, have compared this technique to that involving only posterior chordal preservation (MVR-PCP). This study was intended to cover this aspect. A total of 36 consecutive patients with chronic rheumatic mitral incompetence were operated upon by one surgeon and benefited from MVR-TCP (group I). During the same period and along similar selection criteria, 60 patients underwent MVR-PCP (group II) in our department. With the exception of a statistically significant higher preoperative left ventricular ejection fraction (LVEF) percentage and lower fractional shortening (LVFS) percentage in group II patients; both groups were comparable as regarding age, sex distribution New York Heart Association (NYHA) functional class (FC). preoperative left atrial diameter (LAD), left ventricular end-diastolic dimension (LVEDD), left ventricular end-systolic dimension (LVESD) as well as aortic cross-clamp and cardiopulmonary bypass times. The means of the differences, between the pre- and postoperative values of NYHA FC and echocardiographic data were compared between both groups. As compared with group II, group I patients showed lower: hospital mortality rate (0 versus 8.3%; P &gt; 0.05); need for positive inotropic support (11.1 versus 20.8%; P &gt; 0.05) and total ICU stay (2.9 ± 0.17 versus 2.2 ± 0.13 days; P &lt; 0.01). In addition, group 1 patients showed a better NYHA FC improvement (−2.08 ± 0.15 versus −1.93 ± 0.11; P &gt; 0.05) as well as a statistically significant ( P &lt; 0.00001) higher decrease in the LAD (−18.19 ± 0.97 versus −11.59 ± 0.58 mm). LVEDD (−14.44 ± 0.91 versus −6.17 ± 0.05 mm). LVESD (−6.17 ± 0.77 versus −3.23 ± 0.01 mm), LVFS percentage (−0.06 ± 0.01 versus −0.01 ± 0.001%) and a higher increase in the LVEF percentage (8.1 ± 0.9 versus 1.48 ± 0.02%). The smaller mean diameter of the implanted St Jude prosthesis, in group I patients (26.77 ± 0.22 versus 27.43 ± 0.21 mm; P = 0.046), was neither associated with the use of a smaller prosthesis than that predicted for the patient size nor a significantly higher mean transprosthetic pressure gradient. These data suggest that in rheumatic patients with chronic mitral incompetence, MVR-TCP is always feasible: it is associated with lower hospital mortality and morbidity rates and better preservation of the postoperative left ventricular systolic functions when compared with MVR-PCP.

Valve replacement in rheumatic mitral incompetence: total versus posterior chordal preservation

Several studies have shown that mitral valve replacement with total chordal preservation (MVR-TCP) improves left ventricular function when compared with total chordal transection. Few clinical studies, however, have compared this technique to that involving only posterior chordal preservation (MVR-PCP). This study was intended to cover this aspect. A total of 36 consecutive patients with chronic rheumatic mitral incompetence were operated upon by one surgeon and benefited from MVR-TCP (group I). During the same period and along similar selection criteria, 60 patients underwent MVR-PCP (group II) in our department. With the exception of a statistically significant higher preoperative left ventricular ejection fraction (LVEF) percentage and lower fractional shortening (LVFS) percentage in group II patients; both groups were comparable as regarding age, sex distribution New York Heart Association (NYHA) functional class (FC), preoperative left atrial diameter (LAD), left ventricular end-diastolic dimension (LVEDD), left ventricular end-systolic dimension (LVESD) as well as aortic crossclamp and cardiopulmonary bypass times. The means of the differences, between the pre- and postoperative values of NYHA FC and echocardiographic data were compared between both groups. As compared with group II, group I patients showed lower: hospital mortality rate (0 versus 8.3%; P > 0.05); need for positive inotropic support (11.1 versus 20.8%; P > 0.05) and total ICU stay (2.9 ± 0.17 versus 2.2 ± 0.13 days; P < 0.01). In addition, group I patients showed a better NYHA FC improvement (−2.08 ± 0.15 versus −1.93 ± 0.11; P > 0.05) as well as a statistically significant ( P < 0.00001) higher decrease in the LAD (−18.19 ± 0.97 versus −11.59 ± 0.58 mm), LVEDD (−14.44 ± 0.91 versus −6.17 ± 0.05 mm), LVESD (−6.17 ± 0.77 versus −3.23 ± 0.01 mm), LVFS percentage (−0.06 ± 0.01 versus −0.01 ± 0.001%) and a higher increase in the LVEF percentage (8.1 ± 0.9 versus 1.48 ± 0.02%). The smaller mean diameter of the implanted St Jude prosthesis, in group I patients (26.77 ± 0.22 versus 27.43 ± 0.21 mm; P = 0.046), was neither associated with the use of a smaller prosthesis than that predicted for the patient size nor a significantly higher mean transprosthetic pressure gradient. These data suggest that in rheumatic patients with chronic mitral incompetence, MVR-TCP is always feasible: it is associated with lower hospital mortality and morbidity rates and better preservation of the postoperative left ventricular systolic functions when compared with MVR-PCP.

Usefulness of Subnormal Midwall Fractional Shortening in Predicting Left Ventricular Exercise Dysfunction in Asymptomatic Patients With Systemic Hypertension

We have recently shown that a subgroup of asymptomatic hypertensive patients exhibit subnormal left ventricular (LV) midwall fiber shortening at rest and that this finding predicts morbidity and mortality independently of age, blood pressure (BP), or the presence of LV hypertrophy. However, it is unknown whether abnormal midwall fractional shortening predicts either subnormal LV functional reserve or extracardiac damage in asymptomatic hypertensive patients. Accordingly, we compared radionuclide cineangiographic LV ejection fraction at rest and maximum exercise as well as clinical findings between 89 patients with normal and 16 patients with subnormal midwall fractional shortening by echocardiogram. Patients with low midwall fractional shortening were similar in gender, age, and systolic BP to those with normal shortening but had higher mean diastolic BP and body mass indexes (both p <0.05). The 2 groups also had similar resting ejection fraction (56 ± 9% vs 55 ± 15%, with normal or subnormal shortening, respectively, p = NS). Patients with subnormal midwall fractional shortening had higher LV mass and tended to have higher urinary protein excretion and serum creatinine levels. Subnormal LV ejection fraction with exercise (<54%) was observed in 13 of 89 patients (15%) with normal midwall fractional shortening but in 7 of 16 patients (44%) with subnormal shortening (p <0.05). Multiple linear regression analysis revealed that midwall fractional shortening independently predicted exercise performance (p <0.001). Thus, subnormal midwall fractional shortening predicts depressed LV functional reserve in asymptomatic hypertensive patients and may contribute to identification of patients with extracardiac target-organ damage.Radionuclide cineangiographic left ventricular (LV) ejection fraction at rest and maximum exercise were compared between 89 patients with normal and 16 patients with subnormal midwall fractional shortening by echocardiogram. Patients with subnormal midwall fractional shortening had higher LV mass and were more likely to have subnormal (<54%) LV exercise ejection fraction (7 of 16 or 44% vs 13 of 89 or 15%, p <0.05); multiple linear regression analysis revealed that low midwall fractional shortening independently predicted subnormal exercise performance (p <0.001).

ELAT Study (Embolism in Left Atrial Thrombi): Baseline Clinical and Echocardiographic Data

By transesophageal echocardiography, the prevalence of left atrial/appendage thrombi and spontaneous echo contrast and the size of the left atrial appendage and their association with clinical and echocardiographic characteristics were evaluated in 409 nonrheumatic atrial fibrillation outpatients (62 +/- 12 years) without recent (< 1 year) embolism. Left atrial/appendage thrombi (2.5%) were associated with diabetes (p < 0.05), heart failure (p < 0.05) and low fractional shortening (p < 0.001); spontaneous echo contrast (12%) with advanced age (p < 0.01), constant atrial fibrillation (p < 0.01), hypertension (p < 0.01), heart failure (p < 0.05), valvular abnormalities (p < 0.01) and large left atrial diameter (p < 0.01), and large left atrial appendages with constant atrial fibrillation (p < 0.05), diabetes (p < 0.05) and valvular abnormalities (p < 0.05).

Fetal cardiac effects of oral ritodrine tocolysis.

The beta-sympathomimetic oral tocolytic ritodrine can cause maternal tachycardia and hypotension, and may cross the placenta. A new echocardiographic technique has been developed to explore fetal and placental ritodrine effects. Values in 76 healthy historic controls were compared to 18 studies in 16 patients performed while receiving stable oral ritodrine therapy, measured both at baseline and 30 minutes after a dose. Data collected included maternal pulse and blood pressure (BP), fetal cerebral and umbilical Doppler waveforms, and fetal heart rate. A new index of fetal myocardial contractility, combined ventricular shortening fraction, was derived from two-dimensionally directed M-mode. Maternal pulse and BP, fetal heart rate and heart size, and all Doppler indices were normal, without demonstrable dose-response effects. In the control subjects, combined ventricular shortening fraction fell with increasing gestational age (combined ventricular shortening fraction = -0.27 estimated gestational age + 49; r = 0.27; P < or = 0.02; standard error of the estimate, 11%). However, combined ventricular shortening fraction in ritodrine patients was abnormally decreased in 72% of cases. The mean index in normal subjects was 43 +/- 5%, but in ritodrine patients it was only 31%. We conclude that a history of premature labor or oral ritodrine, or both, is associated with reduced shortening fraction. Since there was no change in placental resistance, cerebral hypoxia, fetal heart rate, or heart size (preload), then low shortening fraction may be due to increased fetal systemic vascular resistance (BP) or decreased myocardial contractility.

Low mid-wall fractional shortening identifies a subgroup of hypertensive patients with increased left ventricular mass and ambulatory blood pressure

Low mid-wall fractional shortening identifies a subgroup of hypertensive patients with increased left ventricular mass and ambulatory blood pressure

Prognostic implications of subclinical left ventricular dilatation and systolic dysfunction in men free of overt cardiovascular disease (the framingham heart study)

To determine the prognostic significance of asymptomatic left ventricular (LV) dilatation and LV systolic dysfunction, 1,493 men who were free of symptomatic cardiovascular disease underwent M-mode echocardiography and were then followed for a mean of 4.15 years. At baseline examination, 170 men (11.4%) had an abnormally high end-diastolic LV internal dimension (≥56 mm) and 76 (5.1%) had an abnormally low fractional shortening (<30%). During the follow-up period, 68 men experienced 92 cardiovascular disease events. After adjusting for age and traditional cardiovascular disease risk factors in proportional-hazards analyses, fractional shortening was a significant independent predictor of cardiovascular risk (relative risk [RR] = 1.42, 95% confidence interval [CI] 1.12 to 1.81, for decrease of fractional shortening by 4%). Increased risk was also associated with combinations of low fractional shortening and high end-diastolic internal dimension (RR = 3.77, 95% CI 1.59 to 8.93) and with low percent fractional shortening with LV hypertrophy (RR = 5.93, 95% CI 1.97 to 17.85). In conclusion, subclinical LV dilatation and LV systolic dysfunction, although uncommon in men free of overt cardiovascular disease, are associated with increased risk for new cardiovascular disease events.

Echocardiographic determinants of clinical outcome in subjects with coronary artery disease (the Framingham Heart Study)

Echocardiographic predictors of clinical outcome were examined in subjects from the Framingham Heart Study with overt coronary artery disease. The study population consisted of 185 men and 147 women with coronary artery disease who underwent M-mode echocardiography and were followed for a mean of 3.90 years. At baseline, 37 men (18.4%) and 16 women (10.9%) had reduced fractional shortening, 43 men (23.2%) and 28 women (19%) had left ventricular (LV) dilatation, and 76 men (41%) and 76 women (51.7%) had LV hypertrophy. During the follow-up period new cardiovascular disease events (coronary disease, stroke, transient ischemic attack, claudication, heart failure and deaths from cardiovascular disease) occurred in 60 men (32%) and 58 women (39%). With use of age-adjusted proportional hazards analyses, LV mass/height in men (relative risk [RR] = 1.25 50 g/m increment, 95% confidence interval [CI] 1.01 to 1.55) and LV end-diastolic diameter in women (RR = 1.36 5 mm increment, 95% CI 1.05 to 1.76) were predictors of new cardiovascular disease events. Cardiovascular risk was also associated with LV end-systolic diameter in both sexes (in men RR = 1.28 1 SD increment, 95% CI 1.02 to 1.63; in women RR = 1.40 1 standard deviation increment, 95% CI 1.09 to 1.82). Reduced fractional shortening alone (RR = 1.91, 95% CI 1.11 to 3.31) and in combination with LV dilatation (RR = 2.13, 95% CI 1.13 to 4.02) was associated with the incidence of new cardiovascular disease outcomes in men. In women, cardiovascular risk was increased with LV hypertrophy (RR = 2.30, 95% CI 1.29 to 4.12), high LV wall thickness (RR = 3.36, 95% CI = 1.18 to 9.55), high LV end-systolic diameter (RR = 2.59, 95% CI 1.45 to 4.62) and a combination of low fractional shortening and LV dilatation (RR = 3.25, 95% CI 1.28 to 8.25). Thus, M-mode echocardiography has prognostic value in identifying subjects with coronary artery disease who are at increased risk for new morbid or fatal events.

Cardiac performance in ECMO candidates: Echocardiographic predictors for ECMO

Twenty-one neonates with severe respiratory failure, who met criteria in this center for extracorporeal membrane oxygenation (ECMO), underwent echocardiographic examinations to assess the role of cardiac dysfunction in determining the need for ECMO. The echocardiographic indexes of function included peak aortic and pulmonary flow velocity, aortic and pulmonary acceleration, shortening fraction, velocity of circumferential fiber shortening, right ventricular output, and left ventricular output. Patients were offered a staged treatment protocol using high-frequency oscillatory ventilation (HFOV), followed by ECMO if failing HFOV rescue. Nine patients demonstrated progressive deterioration and required ECMO (group 1); 12 patients recovered without ECMO (group 2). There were no significant intergroup differences in AaDO 2, age, weight, gestational age, inotropic support, mean airway pressure, systemic blood pressure, or arterial blood gas parameters. Group 1 had significantly lower pulmonary and aortic peak flow velocities, lower pulmonary acceleration, lower shortening fraction, and lower velocity of circumferential fiber shortening ( P < .05). We found that values for peak pulmonary velocity < 0.70 m/s with pulmonary acceleration < 14 m/s 2 would predict the need for ECMO in 7 of 9 group 1 patients and recovery without ECMO in 11 of 12 group 2 patients ( P < .01, Fisher's Exact test). We conclude that on initial echocardiographic evaluation, cardiac performance was impaired in those patients who subsequently required ECMO compared with a group of patients with similar severity in gas exchange who recovered without ECMO. We speculate that echocardiographic assessment of cardiac performance in ECMO candidates may prove useful in prediction of the subsequent need for ECMO or expedient transfer to an ECMO center.

Echocardiography of dilated cardiomyopathy in children.

Echocardiography is useful and reliable in the diagnosis and management of children with dilated cardiomyopathy. M-mode echocardiography provides quantitative information of left ventricular and left atrial dimensions and left ventricular wall thickness. Left ventricular function including shortening fraction, mean velocity of circumferential fiber shortening (V cf), systolic time intervals, left ventricular wall thickening and thinning rate, isovolumic contraction time, and wall stress can be derived from M-mode study. Left ventricular and left atrial dimensions are usually 1.5 times normal. Left ventricular systolic function is markedly reduced. Shortening fraction can be easily obtained and is the most informative index for assessing the severity of illness. Very low shortening fraction at presentation and follow-up (12-15%) is a poor prognostic sign. Two-dimensional echocardiography is valuable for excluding valvular lesion or coronary artery anomaly and detection of intracardiac thrombus. The left ventricular free wall is usually more severely affected than the ventricular septum as seen by two-dimensional echocardiography.

Clinical profile of conjestive cardiomyopathy in children

The clinical profile of 23 children with congestive cardiomyopathy was reviewed to detect any factors that might be predictive for their survival. Factors examined include age at onset (<2 versus >2 years), geader, severity of the clinical picture including data from the chest radiograph electrocardiogram (ECG), echocardiogram, hemedynamic study and endomyocardial biopsy. Follow-up study ranged from 1 month to 14 years (mean 43 months).There were 12 survivors and 11 nonsurvivors; the 1 year mortality rate was 30% (7 of 23), and the 5 year mortality rate was 44% (10 of 23). Age at onset, gender, cardiothoracic ratio on chest radiograph, pattern of infarction, ST-T changes or arrhythmia on ECG and left ventricular enddiastolic pressure were nonpredictive of outcome. However, low shortening fraction (mean 11.5% in nonsurvivors versus 20.9% in survivors, p < 0.01), familial cardiomyopathy and endocardial fibroelastosis Indicated a very poor prognosis.

Dyspnea of Cardiac Origin in 67-Year-Old Men: Relation to Clinical and Noninvasive Measures of Cardiac Function

The relation of presumed cardiac dyspnea to regional (presence of akinesia), systolic (fractional shortening), and diastolic (left atrial dimension, atrial emptying index, and heart rate adjusted A2 to O-point interval) cardiac dysfunction, as well as to nonspecific heart function indices (mitral valve E-point to septal separation and exercise test) and clinical information, was investigated in a sample from the general population. We selected, from a screened cohort of 644 67-year-old men, 42 subjects with presumed cardiac dyspnea and chose at random 45 nondyspneic controls. In univariate analysis the degree of dyspnea was most closely related to the E-point to septal separation (r = 0.58, p < 0.0001) and to presence of akinetic segments (r = 0.53, p < 0.0001). Clinical and noninvasive findings were compared in multivariate stepwise regression analysis, and, in order of significance, the E-point to septal separation, presence of akinetic segments, exercise capacity, history of angina pectoris and left atrial dimension contributed independently to the explanation of the dyspnea grade variance. Together they explained 74%. Of the 37 men with mild to moderate dyspnea, 27% had systolic dysfunction as evidenced by a low fractional shortening. Diastolic abnormalities and/or akinetic segments with normal fractional shortening were found in 44%. Increased E-point to septal separation was the only abnormality in 11 %, while 18 % had no detectable abnormality. The 5 men with severe dyspnea had several abnormalities, low fractional shortening being present in 4 men. Thus, severe dyspnea was associated with combinations of abnormalities, while, in men with mild to moderate dyspnea, diastolic dysfunction and/or akinetic segments were more prevalent than low fractional shortening, a finding with potential therapeutic implications. The mitral E-point to septal separation was found to be the measure most likely of those studied to reveal cardiac dysfunction as causing dyspnea.