Marker Of Left Ventricular Systolic Function Research Articles

The Use of Global Longitudinal Strain to Detect Subclinical Reduction in Left Ventricular Pump Function.

Left ventricular (LV) ejection fraction (LVEF) is not a sensitive marker of LV systolic function in a subset of patients with preserved EF. The relation between LV pump function and global longitudinal strain (GLS) has not been elucidated well in patients with objectively preserved EF and no apparent heart failure (HF). We aimed to detect whether LV GLS can discover impaired LV pump function [presented as low stroke volume index (SVI) and low cardiac output (COP)] in patients with objectively preserved EF and no apparent clinical HF and its practice utility. In total, 100 participants with LVEF of ≥50% were studied for demographic and echocardiographic data, including LVEF, stroke volume, SVI, COP, LV longitudinal strain assessments, apical 4-, 3-, and 2-chamber views averaged for GLS, and were classified into 2 groups: group 1: normal GLS (more negative than -18%) and group 2: low GLS (less negative than -18%). Reduced LV GLS was associated with lower SVI (35.6 ± 13.6 vs. 43.8 ± 12.7 mL/m 2 ; P = 0.01), lesser COP (5.4 ± 1.9 vs. 6.5 ± 2.1 l/min; P = 0.02), GLS had strong positive correlations with SVI ( r = 0.75; P < 0.001), and COP ( r = 0.66; P < 0.001). LV GLS at a cutoff value less negative than -15% is a strong predictor of SVI ≤35 mL/m 2 (76% sensitivity and 79% specificity) and at a cutoff value less negative than -13.5% it is a strong predictor of COP ≤4 L/min (76% sensitivity and 73% specificity). LV GLS was the best independent predictor of low SVI (<35 mL/m 2 ) and low COP (<4 L/min). Impaired LV strain is associated with lower LV pump function, presented as lower COP and lower SVI in patients with preserved EF even in the absence of clinical HF. It is of great importance to incorporate GLS in the routine evaluation of LV function hand-by-hand with the noninvasive assessment of LV stroke volume and COP that can replace GLS on evaluation of LV pump function in old machines with no GLS modalities, for early pick-up of patients with impaired LV pump function before apparent HF.

Hypoglycaemia and rebound hyperglycaemia increase left ventricular systolic function in patients with type 1 diabetes.

To investigate echocardiographic changes during acute hypoglycaemia followed by recovery to hyperglycaemia or euglycaemia in patients with type 1 diabetes. In a randomized crossover study, 24 patients with type 1 diabetes took part in two experimental study days, consisting of a hyperinsulinaemic-euglycaemic phase (5.0-8.0 mmol/L) for 45 minutes followed by a hyperinsulinemic-hypoglycaemic phase (2.5 mmol/L) for 60 minutes, and a recovery phase in either hyperglycaemia (20 mmol/L) or euglycaemia (5.0-8.0 mmol/L) for 60 minutes. Cardiac function was evaluated with echocardiography during each phase. Acute hypoglycaemia increased all markers of left ventricular (LV) systolic function, including LV ejection fraction (LVEF), global longitudinal strain (GLS), GLS rate and peak systolic velocity of mitral annular longitudinal movement (s'; P < 0.001 for all). During the recovery phases, all markers of LV systolic function were increased during hyperglycaemia (P < 0.01 for all), and LVEF and GLS remained increased during euglycaemia (P=0.0116 and P=0.0092, respectively). The increment in LVEF during the recovery phase was greater during hyperglycaemia than euglycaemia (P=0.0046). Hypoglycaemia, recent hypoglycaemia, and overcorrection of hypoglycaemia to rebound hyperglycaemia increased LV systolic function in type 1 diabetes and may imply consideration of plasma glucose when evaluating LV function in patients with type 1 diabetes. An increase in LV systolic function may cause increased strain on the heart and partly explain the link between hypoglycaemia, high glycaemic variability and cardiovascular disease.

How to standardize measurement of global longitudinal strain.

Global longitudinal strain (GLS) is a robust and sensitive marker of left-ventricular systolic function, reflecting longitudinal shortening of the ventricle. A growing body of evidence indicates its superiority in identifying subclinical, early alterations in cardiac function compared to traditional markers, such as ejection fraction. Therefore, there is a growing demand to assess GLS in clinical settings, but limited availability on how to obtain GLS accurately and appropriately in the current literature. This review summarizes key aspects of GLS measurement, including image acquisition, post-processing, and training/experience needed to facilitate the clinical implication with standardization.

Coronary microvascular dysfunction in hypertrophic cardiomyopathy – impact from tissue characteristics to clinical manifestations

Abstract Background Coronary microvascular dysfunction (CMD) is an important pathophysiological feature in hypertrophic cardiomyopathy (HCM). Purpose This study investigated the role of CMD in tissue characteristics, left ventricular (LV) systolic performance and clinical manifestations in HCM. Methods This prospective study enrolled patients with HCM without obstructive epicardial coronary artery disease. Each patient underwent cardiovascular magnetic resonance (CMR) including parametric mapping, perfusion imaging during regadenoson-induced hyperemia, late gadolinium enhancement (LGE) and three-dimensional longitudinal, circumferential and radial strains analysis. Electrocardiogram and 24 hours Holter recording were performed to assess arrhythmias. Results 75P were enrolled, 47 (63%) males, mean age 54.6 (14.8) years; 51 patients (68%) had non obstructive HCM, mean maximum wall thickness (MWT) was 20.2 (4.6)mm, LV ejection fraction 71.6 (8.3)%, ischemic burden 22.5 (16.9)% of LV. Greater MWT was associated the severity of ischemia (β-estimate: 1.809, 95% CI: 1.073; 2.545; p&amp;lt;0.001). Ischemic burden was strongly associated with higher values of native T1 (β-estimate: 9.018, 95% CI: 4.721, 13.315; p&amp;lt;0.001). An association between ischemia and the extent of LGE was found (β-estimate: 2.02, 95% CI: 0.93, 3.10; p&amp;lt;0.001). Ischemia in ≥21% of LV was associated with LGE &amp;gt;15% (AUC 0.766, sensitivity 0.724, specificity 0.659). In multivariable analysis, in the overall population, MWT and LGE were independently associated with ischemia, however the evidence of association between ischemia and extent of LGE became weaker (β-estimate: 1.070, 95% CI: −0.106; 2.245; p=0.074). In subgroup analysis, the association between ischemia and LGE remained significant in individuals with MWT 15–20mm, non-obstructive HCM, female and age &amp;lt;40 years. The severity of ischemia was not associated with markers of LV systolic function, namely LVEF, longitudinal, radial and circumferential strain A strong evidence of association was found between ischemia and atrial fibrillation/flutter (AF/AFL) (OR: 1.481, 95% CI: 1.020,2.152; p=0.039), but no association was verified with non-sustained ventricular tachycardia. Conclusion In HCM, CMD is related to the severity of LV hypertrophy. Ischemia secondary to CMD promotes fibrosis and is associated with an increase in the odds of AF/ALF. Funding Acknowledgement Type of funding sources: None.

Визначення міокардіальної роботи – нова концепція неінвазивної оцінки систолічної функції лівого шлуночка

Оцінювання систолічної функції лівого шлуночка (ЛШ) – це обов’язковий компонент діагностики захворювань серцево-судинної системи. Для цього в клінічній практиці використовують фракцію викиду та глобальну поздовжню деформацію ЛШ. Обидва показники мають низку обмежень, зокрема залежність від постнавантаження. В огляді описано нову методику неінвазивної оцінки глобальної та сегментарної скоротливості міокарда на основі розрахунку міокардіальної роботи, що проводиться за аналізом кривих «тиск-деформація». Головною перевагою технології є можливість врахування умов постнавантаження на базі традиційного вимірювання артеріального тиску на плечовій артерії. Представлено характеристику ключових параметрів методики (індекс глобальної роботи, глобальна конструктивна робота, глобальна ефективна та неефективна робота) та їх нормативні значення. Окремо описані етапи проведення аналізу й обмеження методики. Висвітлені результати основних пілотних досліджень з вивчення показників міокардіальної роботи при різних серцево-судинних захворюваннях. Представлені можливості методики щодо характеристики сегментарної функції ЛШ при повній блокаді лівої ніжки пучка Гіса з метою відбору пацієнтів для кардіоресинхронізувальної терапії та подальшого оцінювання її ефективності. Проаналізовано діагностичне й прогностичне значення параметрів міокардіальної роботи при артеріальній гіпертензії, гострих і хронічних формах ішемічної хвороби серця, гіпертрофічній і дилатаційній кардіоміопатії, хронічній серцевій недостатності. Описані приклади застосування методики для оцінювання ефективності терапії в пацієнтів з недостатністю кровообігу. Визначені потенційні переваги параметрів міокардіальної роботи над іншими маркерами систолічної функції ЛШ, такими як фракція викиду та глобальна поздовжня деформація. Огляд проілюстровано клінічними прикладами використання методики при різних серцево-судинних захворюваннях із власної практики.

Myocardial work of the athlete's heart: the new champion of systolic function?

Abstract Background Regular, vigorous exercise induces morphological changes in the heart, including increased left ventricular (LV) volumes and mass. Although this represents a physiological adaptation to the increased cardiovascular demand, in a certain number of highly trained athletes, the LV remodelling is accompanied by decreased resting values of global longitudinal strain (GLS), exceeding even pathological limits. In this case, the differential diagnosis of overlapping pathological conditions represents a clinical challenge. Myocardial work (MW) evaluates myocardial deformation in the context of afterload; therefore, it may potentially overcome the limitations of GLS, and may better reflect the contractility of the athlete's heart. Purpose We sought to evaluate MW of elite athletes compared to sedentary volunteers. We also aimed to validate its robustness by investigating its relation to the invasively measured parameters of myocardial contractility in a rat model of the athlete's heart. Methods A total of 30 elite swimmers (19±4 years, 23±5 hours of training/week, 50% males) and 23 healthy sedentary controls (19±4 years, 40% males) were enrolled. Global MW index (GMWI) and constructive MW index (CMWI) were calculated using a vendor-specific module through the simultaneous evaluation of GLS by speckle-tracking echocardiography (STE) and the non-invasively approximated LV pressure curves (estimated from brachial cuff systolic pressure). In the rat model, LV hypertrophy was induced by swim training (n=18, 200 min/day for 12 weeks). An additional group of 17 untrained control rats were examined as well. STE was performed to assess GLS, which was followed by invasive pressure-volume (P-V) analysis to register LV pressure and to calculate cardiac contractility (slope of end-systolic P-V relationship [ESPVR]). GMWI and CMWI were assessed by evaluating the area of the LV pressure-strain loop. Results GLS was decreased in human athletes (athletes vs. controls: −18±2 vs. −19±1, p&amp;lt;0.05). However, athletes had higher values of CMWI (2097±293 vs. 1943±213 mmHg%, p&amp;lt;0.05), whereas GMWI was unchanged compared to controls (1850±299 vs. 1755±189 mmHg%, p=NS). The trained group of rats was characterized by unchanged GLS (−22±3 vs. −20±4, p=NS), however, ESPVR, GMWI, and CMWI were increased (3.64±0.70 vs. 2.55±0.38 mmHg/μL, p&amp;lt;0.001; 3002±488 vs. 2554±375 mmHg%, p&amp;lt;0.05; 3200±532 vs. 2780±591 mmHg%, p&amp;lt;0.05) compared to control rats. MW indices correlated with cardiac contractility measured by P-V analysis (ESPVR vs. GMWI r=0.38, p&amp;lt;0.05; vs. CMWI r=0.39, p&amp;lt;0.05). Conclusions Due to the adaptive LV remodelling, resting markers of LV systolic function may be decreased in elite athletes. Despite the reduced GLS, GMWI was preserved, and CMWI was supernormal in human athletes and the experimental model verified their correlation with contractility. Our findings indicate that MW indices in athletes may be better markers of systolic function compared to GLS. Funding Acknowledgement Type of funding source: Public grant(s) – National budget only. Main funding source(s): National Research, Development and Innovation Office of Hungary

Association Between Sleep Disordered Breathing and Left Ventricular Function: A Cross-Sectional Analysis of the ECHO-SOL Ancillary Study.

Prior studies have found that sleep-disordered breathing (SDB) is common among those with left ventricular (LV) dysfunction and heart failure. Few epidemiological studies have examined this association, especially in US Hispanic/Latinos, who may be at elevated risk of SDB and heart failure. We examined associations between SDB and LV diastolic and systolic function using data from 1506 adults aged 18 to 64 years in the Hispanic Community Health Study/Study of Latinos ECHO-SOL Ancillary Study (2011-2014). Home sleep testing was used to measure the apnea-hypopnea index, a measure of SDB severity. Echocardiography was performed a median of 2.1 years later to quantify LV diastolic function, systolic function, and structure. Multivariable linear regression was used to model the association between apnea-hypopnea index and echocardiographic measures while accounting for the complex survey design, demographics, body mass, and time between sleep and echocardiographic measurements. Each 10-unit increase in apnea-hypopnea index was associated with 0.2 (95% CI, 0.1-0.3) lower E', 0.3 (0.1-0.5) greater E/E' ratio, and 1.07-fold (1.03-1.11) higher prevalence of diastolic dysfunction as well as 1.3 (0.3-2.4) g/m2 greater LV mass index. These associations persisted after adjustment for hypertension and diabetes mellitus. In contrast, no association was identified between SDB severity and subclinical markers of LV systolic function. Greater SDB severity was associated with LV hypertrophy and subclinical markers of LV diastolic dysfunction. These findings suggest SDB in Hispanic/Latino men and women may contribute to the burden of heart failure in this population.

4300Strain parameters at rest and after exercise in symptomatically stable patients with improved heart failure - STRESS-HF

Abstract Background Optimal medical therapy (OMT) results in improvement in left ventricular (LV) ejection fraction (EF) and reduction in LV size in approximately 40% of patients of heart failure with reduced ejection fraction (HFrEF). Recent studies have proposed to continue treatment in all patients of this subgroup as improvement in LVEF does not indicate actual myocardial recovery. Global Longitudinal strain (GLS) is more sensitive marker of LV systolic function and better predictor of mortality than LVEF. GLS may identify probable patients in whom the therapy can be minimized or stopped. Aim To determine global longitudinal strain at rest and after exercise in patients with idiopathic dilated cardiomyopathy (DCM) who have improved LVEF ≥50% on guideline directed medical therapy (GDMT) and compare with resting &amp; exercising LVEF on 3-dimesional (3D). Material and methods This Observational study was conducted in a tertiary care referral hospital, from February 2018 to October 2018. All patients with idiopathic DCM who had a documented LVEF of ≤40% in the past and improved LVEF (LVEF ≥50%) on GDMT were included in the study. Patients with secondary causes of HFrEF, poor echocardiographic window and inability to exercise were excluded from the study. Strain parameters were calculated at rest and after atleast 5 METS of exercise. GLS value of ≥ minus 12.6% was considered as mildly reduced strain, ≤ minus 8% as severely reduced strain and the values in between as moderately reduced strain. Post exercise, drop of &gt;5% in absolute LVEF value or decrease in GLS &gt;15% from baseline was considered as poor myocardial recovery. Results A total of 44 patients [mean age of 46.8±13.1 years and 24 males (54.5%)] constituted the study group. At the time of diagnosis, 31 (70.5%) patients were in NYHA class II and the remaining were in class III. Duration of GDMT ranged from 4 to 38 (median 12) months. Following improvement on GDMT, 25 (56.8%) were in class I and rest were in class II. Mean LVEF at diagnosis and after recovery was 33.6±4.9% and 55.1±4.5%, respectively with a mean absolute change in LVEF of 21.3±6.1%. At rest, mean 3D LVEF was 53±3.5% and GLS was −12.3±3.1. Mild, moderate and severely reduced strain was seen in 24 (54.5%), 13 (29.6%) and 7 (15.9%), respectively. After exercise, mean 3D LVEF was 51.5.±4.5% (mean decrease 1.5±2.1%) and mean GLS was −7±4.2% (mean decrease −5.3±4.6%). After exercise, none had a fall of LVEF &gt;5% however 32 (72.7%) had a decrease of &gt;15% in GLS. Seven (15.9%) patients had improvement in GLS, 4 (9.1%) had &lt;15% decrease and 1 (2.3%) showed no change in GLS on exercise. The change in GLS on exercise was significant (p=0.001), but change in 3D LVEF was not significant (p=0.956). Conclusion Global longitudinal strain is a better marker for assessing myocardial recovery than LVEF in patients of heart failure with improved ejection fraction. Acknowledgement/Funding None

Performance comparison of ventricular and arterial dP/dtmax for assessing left ventricular systolic function during different experimental loading and contractile conditions

BackgroundMaximal left ventricular (LV) pressure rise (LV dP/dtmax), a classical marker of LV systolic function, requires LV catheterization, thus surrogate arterial pressure waveform measures have been proposed. We compared LV and arterial (femoral and radial) dP/dtmax to the slope of the LV end-systolic pressure-volume relationship (Ees), a load-independent measure of LV contractility, to determine the interactions between dP/dtmax and Ees as loading and LV contractility varied.MethodsWe measured LV pressure-volume data using a conductance catheter and femoral and radial arterial pressures using a fluid-filled catheter in 10 anesthetized pigs. Ees was calculated as the slope of the end-systolic pressure-volume relationship during a transient inferior vena cava occlusion. Afterload was assessed by the effective arterial elastance. The experimental protocol consisted of sequentially changing afterload (phenylephrine/nitroprusside), preload (bleeding/fluid bolus), and contractility (esmolol/dobutamine). A linear-mixed analysis was used to assess the contribution of cardiac (Ees, end-diastolic volume, effective arterial elastance, heart rate, preload-dependency) and arterial factors (total vascular resistance and arterial compliance) to LV and arterial dP/dtmax.ResultsBoth LV and arterial dP/dtmax allowed the tracking of Ees changes, especially during afterload and contractility changes, although arterial dP/dtmax was lower compared to LV dP/dtmax (bias 732 ± 539 mmHg⋅s− 1 for femoral dP/dtmax, and 625 ± 501 mmHg⋅s− 1 for radial dP/dtmax). Changes in cardiac contractility (Ees) were the main determinant of LV and arterial dP/dtmax changes.ConclusionAlthough arterial dP/dtmax is a complex function of central and peripheral arterial factors, radial and particularly femoral dP/dtmax allowed reasonably good tracking of LV contractility changes as loading and inotropic conditions varied.

Cardiac autonomic and left ventricular mechanics following high intensity interval training: a randomized crossover controlled study.

Physical inactivity and sedentary behavior is associated with increased cardiovascular disease risk. Short duration high-intensity interval training (HIIT) has been shown to improve important health parameters. The aim of the present study was to assess the combined adaptations of the cardiac autonomic nervous system and myocardial functional and mechanical parameters to HIIT. Forty physically inactive and highly sedentary men completed two weeks of HIIT and control period. The HIIT protocol consisted of 3 × 30-s maximal cycle ergometer sprints against a resistance of 7.5% body weight, interspersed with 2 min of active recovery. Total power spectral density (PSD) and associated low-frequency (LF) and high-frequency (HF) power spectral components of heart rate variability were recorded. Conventional and speckle tracking echocardiography recorded left ventricular (LV) structural, functional, and mechanical parameters. HIIT produced a significant increase in total log-transformed (ln) PSD and ln HF and a significant decrease in LF/HF ratio (all P < 0.05) compared with the control period. HIIT produced significant improvements in LV diastolic function, including lateral E', estimated filling pressure (E/E' ratio), E deceleration time, and isovolumetric relaxation time ( P < 0.05 for all). Fractional shortening was the only conventional marker of LV systolic function to significantly improve ( P < 0.05). In this setting, there were significant improvements in global peak systolic strain rate, early and late diastolic strain rate, and early to late diastolic strain rate ratio, as well as apical rotation, apical systolic and diastolic rotation velocity, apical radial and circumferential strain and strain rate, LV torsion, and LV systolic and diastolic torsion velocity (all P < 0.05). A short-term program of HIIT was associated with a significant increase in cardiac autonomic modulation, demonstrated by a residual increase in cardiac vagal activity as well as significantly improved cardiac function and mechanics. This study demonstrates that HIIT may be an important stimulus to reduce the health implications associated with physical inactivity and sedentary behavior. NEW & NOTEWORTHY This is the first study to measure the combined adaptations of the cardiac autonomic nervous system and myocardial function and mechanics following high-intensity interval training (HIIT). This study demonstrates that a 2-wk HIIT intervention provides significant improvements in cardiac autonomic modulation and myocardial function and mechanics in a large cohort of young physically inactive and highly sedentary individuals. HIIT may be a powerful stimulus to reduce the health implications associated with physical inactivity and sedentary behavior.

Strain Echocardiography in Acute Cardiovascular Diseases.

Echocardiography has become a critical tool in the evaluation of patients presenting to the emergency department (ED) with acute cardiovascular diseases and undifferentiated cardiopulmonary symptoms. New technological advances allow clinicians to accurately measure left ventricular (LV) strain, a superior marker of LV systolic function compared to traditional measures such as ejection fraction, but most emergency physicians (EPs) are unfamiliar with this method of echocardiographic assessment.This article discusses the application of LV longitudinal strain in the ED and reviews how it has been used in various disease states including acute heart failure, acute coronary syndromes (ACS) and pulmonary embolism.It is important for EPs to understand the utility of technological and software advances in ultrasound and how new methods can build on traditional two-dimensional and Doppler techniques of standard echocardiography. The next step in competency development for EP-performed focused echocardiography is to adopt novel approaches such as strain using speckle-tracking software in the management of patients with acute cardiovascular disease. With the advent of speckle tracking, strain image acquisition and interpretation has become semi-automated making it something that could be routinely added to the sonographic evaluation of patients presenting to the ED with cardiovascular disease. Once strain imaging is adopted by skilled EPs, focused echocardiography can be expanded and more direct, phenotype-driven care may be achievable for ED patients with a variety of conditions including heart failure, ACS and shock.

Noninvasively determined radial dP/dt is a predictor of mortality in patients with heart failure

The left ventricular (LV) developed pressure is a marker of contractility, associated with a poor prognosis during systolic heart failure. The maximal first derivative or slope of the radial pulse wave (Rad dP/dt) has been proposed as a marker of LV systolic function. This study sought to assess the prognostic value of the baseline dP/dt of the radial pulse in patients with heart failure. The Rad dP/dt was noninvasively measured by applanation tonometry, and its effect on mortality was analyzed by using multivariate Cox regression models. We studied 310 consecutive patients. Mean follow-up was 327 +/- 187 days, and 64 patients died or were transplanted during this period. Death or transplantation was associated with New York Heart Association class III or IV, low systolic or mean blood pressure, low LV ejection fraction, and low Rad dP/dt (634.6 +/- 373.3 vs 730.2 +/- 367.4 mm Hg/s for patients who survived without transplantation, P < .02). A Rad dP/dt <440 mm Hg/s was associated with death or transplantation before and after adjustment for confounding variables (OR [95% CI] 2.19 [1.33-3.58] and 2.88 [1.29-6.38], respectively, P < .01 for both). This relationship was independent of pulse pressure and no significant interaction was found between the Rad dP/dt and the pulse pressure. This study demonstrates, for the first time, that the Rad dP/dt, proposed as a noninvasive peripheral marker of LV systolic function, is an independent predictor of death or transplantation in patients with HF regardless of LV ejection fraction.

Radial pressure waveform dP/dt max is a poor indicator of left ventricular systolic function

The first derivative of left ventricular (LV) pressure over time (dP/dt max) is a marker of LV systolic function that can be assessed during cardiac catheterization and echocardiography. Radial artery dP/dt max has been proposed as a possible marker of LV systolic function and we sought to test this hypothesis. We compared simultaneously recorded radial dP/dt max (by high-fidelity tonometry) with LV dP/dt max (by high-fidelity catheter and echocardiography parameters analogous to LV dP/dt max). In study 1, beat-to-beat radial dP/dt max and LV dP/dt max were recorded at rest and during supine exercise in 12 males (aged 61 +/- 12 years) undergoing cardiac catheterization. In study 2, 2D-echocardiography and radial dP/dt max were recorded in 54 patients (separate to study 1; 39 men; aged 64 +/- 10 years) at baseline and peak dobutamine-induced stress. Three basal septum measures were taken as being analogous to LV dP/dt max: 1. Peak systolic strain rate; 2. Strain rate (SR-dP/dt max) during isovolumic contraction (IVCT) and; 3. Tissue velocity during IVCT. In study 1 there was a significant difference between resting LV dP/dt max (1461 +/- 383 mmHg s(-1)) and radial dP/dt max (1182 +/- 319 mmHg s(-1); P < 0.001), and a poor, but statistically significant, correlation between the variables (R(2) = 0.006; P < 0.05). Similar results were observed during exercise. In study 2 there were weak (R(2) = -0.12; P = 0.01) to non-significant associations between radial dP/dt max and all echocardiographic measures analogous to LV dP/dt max at rest or peak stress. Radial pressure waveform dP/dt max is not a reliable marker of LV systolic function.

Anaesthesia and anti-cancer chemotherapeutic drugs

This is a review of anti-cancer chemotherapeutic drugs, describing their actions, interactions, and toxicity with a particular focus on the relevance for the anaesthetist. Anti-cancer chemotherapeutics have a vast array of adverse effects, some of which, i.e. cardiac and pulmonary toxicity, are of particular anaesthesiological relevance. Recently it has been shown that following chemotherapy with anthracyclines subtle abnormalities in cardiac function may exist even in those patients with a normal resting cardiac function, which become apparent only during anaesthesia or exercise. Children and adolescents with previous anthracycline treatment and normal cardiac function at rest had a significantly greater decrease in fractional shortening, a marker of left-ventricular systolic function, and stroke-volume index during a balanced anaesthesia with isoflurane [1 minimum alveolar concentration (MAC)] in N2O/O2. Notably, delayed cardiotoxicity (years after completed chemotherapy) has been seen only after anthracycline therapy. With respect to regional anaesthetics, one should be aware that in a considerable percentage of patients a sub-clinical, unrecognized neuropathy may be present in patients with previous chemotherapy, particularly after cisplatin treatment. Recently, a diffuse brachial plexopathy after interscalene blockade has been reported in a patient receiving cisplatin chemotherapy. Thus, if regional anaesthesia is contemplated, a detailed pre-operative neurological examination and careful assessment of the risks and benefits is warranted. Anti-cancer chemotherapeutic drugs may cause generalized and specific organ toxicities and may also give rise to various unpredictable or life-threatening peri-operative complications, rendering a detailed pre-operative assessment of patients with previous chemotherapy mandatory.