Distensibility Measurements Research Articles

Abstract P097: Maternal Vascular Changes during Pregnancy may Persist Postpartum

Introduction: Higher parity (number of births) is associated with increased subclinical cardiovascular disease (CVD) in mid-life and older women, and with increased risk of CVD overall. In the only study of reproductive age women, common carotid artery intima-media thickness (CCA IMT) was greater after each birth. Prospective studies of arterial change throughout normal pregnancy are lacking; without them it is unclear whether unhealthy changes of the vasculature during pregnancy persist postpartum and raise women’s risk of CVD. The goal of this study was to prospectively assess normal vascular adaptation in healthy pregnant women. Hypotheses: During the course of healthy pregnancy: 1. CCA adventitial diameter (AD) will increase, then return to baseline postpartum, 2. CCA IMT will initially thin, then thicken as pregnancy progresses, then return to baseline postpartum, and 3. brachial artery distensibility will not change. Methods: We assessed 43 healthy women during each trimester of their first pregnancy and 6-8 weeks postpartum with B-mode ultrasound imaging of the CCA IMT and AD, independent predictors of CVD risk. Brachial artery distensibility, representing elasticity of the artery, was measured using the DynaPulse wave form analyzer. Linear mixed models were used to compare measures of CCA IMT, adventitial diameter, and brachial artery distensibility at each time point, after adjustment for age and pre-pregnancy BMI. Results: There were 37 women (age 28.2 ± 4.5 years, pre-pregnant BMI 24.4 ± 3.2 kg/m 2 ) with uncomplicated pregnancies. Six women with pregnancy complications were excluded from these analyses. After adjustment for age and pre-pregnancy BMI, mean (SE) CCA AD (mm) increased each trimester, from 6.38(0.08) in the 1 st trimester to 6.92(0.09) in the 3 rd trimester, and returned to baseline, 6.35 (0.07), postpartum. Pairwise comparisons were all statistically significant at p<.01. Mean (SE)CCA IMT (mm) was increased postpartum (0.567 (0.01)) compared to 1 st (0.539 (0.01)) and 2 nd trimester values (0.546 (0.01), p < .05 for each). Mean (SE) brachial artery distensibility (%/mmHg) decreased from 7.64 (0.28) 1st trimester to 6.84 (0.21) 3rd trimester (p < .01) and then remained unchanged at 6.82 (0.21) postpartum. Conclusions: As we hypothesized, in uncomplicated first pregnancies CCA AD increased throughout and returned to baseline postpartum. However, contrary to our hypotheses, CCA IMT increased postpartum, and the brachial artery stiffened during pregnancy and remained stiffer 6-8 weeks postpartum. In uncomplicated first pregnancies, some vascular changes resolved (CCA AD) and others persisted (CCA IMT and brachial artery stiffness). Whether this indicates that persistence of specific vascular effects of pregnancy may inform long term CVD risk remains to be explored.

Abstract MP83: Increases in Vigorous Physical Activity Improve Pulse Wave Velocity in Adolescents

Introduction: The beneficial effects of vigorous physical activity (VPA) on arterial stiffness have been established, but the effect of changes in VPA over time on these vascular measures is unclear. Hypothesis: Increases in VPA will be associated with improvement in measures of arterial stiffness. Methods: As part of a longitudinal study of the effects of obesity & diabetes on cardiovascular health, 317 subjects (mean age 17.2 years at baseline, 38% male, 63% non-Caucasian) were enrolled and followed up 5 years later. Anthropometrics, accelerometer-measured physical activity, blood pressure, central and peripheral measures of arterial stiffness (pulse wave velocity (PWV), brachial distensibility (BrachD), and augmentation index (AI)), and blood (lipids & metabolic tests) were collected. General linear modeling was performed to test for the independent relationship of change in VPA with change of arterial stiffness. Results: Overall, VPA increased slightly (0.2 minutes) from baseline to follow up. Increased VPA from baseline to follow up was significantly associated (P = 0.0364) with a decrease in PWV but was not associated with a change in BrachD nor AI. The effect of change in VPA on change in PWV was independent of change in glucose (P = 0.024), but not independent of changes in BMI, blood pressure, lipids, or CRP. Conclusions: Increase in vigorous physical activity during late adolescence is significantly associated with improved pulse wave velocity. This relationship may be mediated through improvements in other cardiovascular risk factors such as body mass index, blood pressure, and lipids.

Macrophage Inflammatory Markers Are Associated With Subclinical Carotid Artery Disease in Women With Human Immunodeficiency Virus or Hepatitis C Virus Infection

Infection with hepatitis C virus (HCV) or human immunodeficiency virus (HIV) may be associated with atherosclerosis and vascular disease. Macrophages are a major component of atherosclerotic plaque, and classically activated (M1) macrophages contribute to plaque instability. Our goal was to identify plasma biomarkers that reflect macrophage inflammation and are associated with subclinical atherosclerosis. We tested whether M1 macrophages produce galectin-3-binding protein in vitro. Then, we measured galectin-3-binding protein and the soluble macrophage biomarkers soluble cluster of differentiation (CD) 163 and soluble CD14 in 264 participants in the Women's Interagency HIV Study. Women were positive for HIV, HCV, both, or neither (66 in each group, matched for age, race/ethnicity, and smoking status). Carotid artery disease was assessed by ultrasound measurement of right distal common carotid artery intima-media thickness, distensibility, and presence of atherosclerotic lesions (intima-media thickness >1.5 mm). Plasma galectin-3-binding protein was higher in HCV+ than HCV- women (P<0.01) but did not differ by HIV status. The 3 inflammatory macrophage markers were significantly correlated with each other and negatively correlated with CD4+ counts in HIV-infected women. We defined a macrophage score as 1, 2, or 3 biomarkers elevated above the median. In models adjusted for traditional risk factors, higher macrophage scores were significantly associated with increased atherosclerotic lesions and lower carotid distensibility. Receiver-operator curve analysis of lesions revealed that the markers added predictive value beyond traditional risk factors and C-reactive protein. The macrophage inflammatory markers galectin-3-binding protein, soluble CD163, and soluble CD14 are significantly associated with carotid artery disease in the setting of HIV and HCV infection.

MR pulse wave velocity increases with age faster in the thoracic aorta than in the abdominal aorta

To assess the difference between thoracic and abdominal aortic pulse wave velocity (PWV) in apparently healthy subjects including young adults to elderly subjects. We performed PWV and distensibility measurements and analysis of thoracic and abdominal aortic segments in 96 apparently normal subjects aged 20-80 years with magnetic resonance (MR). Both unadjusted correlation and General Linear Model (GLM) analysis of log-transformed PWV (thoracic and abdominal aorta) and distensibility (four aortic cross-sections) were performed. Both thoracic and abdominal PWV values and distensibility values increased with age. In unadjusted analyses the correlation between the ln(thoracic PWV) and age (r = 0.71; P < 0.001) was stronger than between ln(abdominal PWV) and age (r = 0.50; P < 0.001). In GLM analysis, the only determinant of thoracic and abdominal PWV was age (F = 42.5 and F = 14.8, respectively; both P < 0.001). Similarly, correlation between ln(distensibility) and age was strong (r = -0.79, r = -0.67, r = -0.71, and r = -0.65 for ascending, descending, diaphragmatic, and low abdominal aorta, respectively; all P < 0.001). In GLM analysis, age was the major determinant for distensibility of the ascending aorta (F = 81.7; P < 0.001), descending aorta (F = 42.2; P < 0.001), diaphragmatic aorta (F = 39.2; P < 0.001), and low abdominal aorta (F = 32.8; P < 0.001). The thoracic aorta is less stiff than the abdominal aorta in young and middle-aged subjects, and stiffens more rapidly with age than the abdominal aorta, resulting in a stiffer thoracic than abdominal aorta at older age.

Arterial stiffness and hypertension in a large population of untreated individuals: the Rotterdam Study.

We studied whether arterial stiffness measured as aortic pulse wave velocity (aPWV) and carotid distensibility was associated with different subtypes of hypertension in a large population of untreated middle-aged and elderly men and women. The study was conducted within the framework of the population-based Rotterdam Study. We included 4088 individuals with information on aPWV, with 3554 individuals with carotid distensibility measurements without use of antihypertensive medication. Isolated systolic hypertension (ISH) was defined as SBP at least 140 mmHg and DBP less than 90 mmHg. Combined systolic and diastolic hypertension (Sys/Dia hypertension) was defined as SBP at least 140 mmHg and DBP at least 90 mmHg. Analysis of covariance was used to compare means of arterial stiffness for the different subtypes of hypertension. Multinomial logistic regression analysis was performed to investigate the association of arterial stiffness and the subtypes of hypertension in models adjusted for age, sex, mean arterial pressure, heart rate and cardiovascular risk factors. The mean age of the individuals was 68 years: 45.3% were men, 1597 individuals had ISH and 441 individuals had Sys/Dia hypertension. aPWV was higher (13.2 vs. 12.9 m/s; P = 0.008) in individuals with ISH compared to those with Sys/Dia hypertension. Multivariate odds ratios and corresponding 95% confidence interval of aPWV for ISH were 1.53 (1.38-1.71) and 1.28 (1.09-1.53) for Sys/Dia hypertension. Corresponding odds ratios associated with carotid distensibility were 0.84 (0.75-0.94) and 0.66 (0.54-0.81), respectively. Age significantly modified the association of aPWV with subtypes of hypertension (P < 0.001). In a large untreated population, we found significant associations of both aPWV and carotid distensibility with ISH and Sys/Dia hypertension. individuals with ISH had higher values of aortic stiffness when compared to individuals with Sys/Dia hypertension, a difference that was most pronounced at older age. The results suggest that aortic stiffness contributes to ISH in older individuals without treatment for hypertension.

Carotid hemodynamics during sympathetic nervous system stimulation via handgrip and cold pressure testing in young healthy subjects

Introduction. Assessing arterial properties and hemodynamics in response to a physiological perturbation might provide additional information on an individual’s “vascular health”. The aim of this study was to assess the feasibility of measuring changes in carotid stiffness and hemodynamics in response to sympathetic nervous system stressors (Hand Grip Test (HGT) or Cold Pressor Test (CPT)). Methods. A non-invasive protocol, consisting of two HGT (30% (HGT1) and 40% (HGT2) of maximal voluntary contraction) and CPT, was performed in 12 young healthy volunteers (6 males/6 females). Measurements included continuous finger blood pressure recordings (NexFin; non-dominant hand) and ultrasound measurement of common carotid diameter distension and flow velocity at discrete moments in time during the protocol (GE Vivid 7 system). Carotid distensibility (D/D), local wave speed using the waterhammer equation (PWVWH) and reflection magnitude (RM; ratio of backward to forward diameter wave) were derived from the data. Results. Consistent with the overall increase in blood pressure, carotid diameter increased while D/D decreased. PWVWH and RM showed an increase during both HGT and a decrease during CPT (see Figure). Conclusion. It is feasible to monitor the carotid hemodynamic response to a sympathetic nervous system stimulus. In this young, healthy population, the net result of the increased diameter and decreased distensibility on local PWVWH was similar for all tests (increase) and on the magnitude of reflections was different for HGT (increase) and CPT (decrease).

Response to Importance of Pressure Pulse Amplification in the Association of Resting Heart Rate and Arterial Stiffness

HomeHypertensionVol. 62, No. 6Response to Importance of Pressure Pulse Amplification in the Association of Resting Heart Rate and Arterial Stiffness Free AccessLetterPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessLetterPDF/EPUBResponse to Importance of Pressure Pulse Amplification in the Association of Resting Heart Rate and Arterial Stiffness Seamus P. Whelton and Michael J. Blaha Seamus P. WheltonSeamus P. Whelton Division of Cardiology, Johns Hopkins School of Medicine, Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, MD Search for more papers by this author and Michael J. BlahaMichael J. Blaha Division of Cardiology, Johns Hopkins School of Medicine, Johns Hopkins Ciccarone Center for the Prevention of Heart Disease, Baltimore, MD Search for more papers by this author Originally published21 Oct 2013https://doi.org/10.1161/HYPERTENSIONAHA.113.02263Hypertension. 2013;62:e47Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: January 1, 2013: Previous Version 1 In our analysis, demonstrating an independent and inverse association between resting heart rate and arterial distensibility in the Multi-Ethnic Study of Atherosclerosis (MESA) study, distensibility was measured using the noninvasive imaging modalities of carotid ultrasound and cardiac MRI.1 On the basis of these measurements, we calculated carotid and aortic distensibility using well-known equations that incorporate pulse pressure as measured from the routine resting brachial artery blood pressure. Avolio et al2 point out that this peripheral measurement of pulse pressure may be an overestimate of the central aortic pulse pressure, especially at higher heart rates. They propose the use of a model derived from pulse wave analysis work by Wilkinson et al3 to correct for differences in pulse pressure between the peripheral and the central arteries. Using this model, they think that the association between resting heart rate and distensibility would disappear for the carotid artery and would reverse for the aorta (higher heart rate would be associated with greater distensibility [less stiffness]).We agree that it would be ideal to measure the pulse pressure directly within the carotid and the aortic arteries. However, this would require invasive measurement techniques that are not feasible in a large population-based study and is a recognized limitation of these distensibility measurements. Pulse wave analysis is indeed an interesting novel methodology that uses peripheral wave forms and a generalized transfer function to estimate the central aortic pressures. However, it is important to note that in the study by Wilkinson et al,3 pulse wave analysis is conducted at different heart rates using a permanent pacemaker transiently to alter heart rate. A distinction should be drawn here between epidemiologically derived resting heart rate and near-term variability in heart rate. An individual who likely has a chronically elevated resting heart rate may over time develop structural changes to their vasculature that are not reflected in the measurements derived from short-term increases in heart rate.The pulse wave analysis derived estimates of central pulse pressure, and their effects on the association between resting heart rate and arterial distensibility proposed by Avolio et al2 are an interesting concept but not without their own limitations, including well-documented differences according to sex and an inverse relationship with height.4 We encourage further research investigating this association to determine whether these estimates of central amplification accurately predict directly measured values at differing physiological resting heart rates.Seamus P. WheltonMichael J. BlahaDivision of CardiologyJohns Hopkins School of MedicineJohns Hopkins Ciccarone Center for the Prevention of Heart DiseaseBaltimore, MDDisclosuresNone.

Carotid Artery Intima-Media Thickness and Distensibility in Children and Adolescents

Carotid intima-media thickness (cIMT) and carotid artery distensibility are reliable screening methods for vascular alterations and the assessment of cardiovascular risk in adult and pediatric cohorts. We sought to establish an international reference data set for the childhood and adolescence period and explore the impact of developmental changes in body dimensions and blood pressure (BP) on carotid wall thickness and elasticity. cIMT, the distensibility coefficient, the incremental modulus of elasticity, and the stiffness index β were assessed in 1155 children aged 6 to 18 years and sex-specific reference charts normalized to age or height were constructed from 1051 nonobese and nonhypertensive children. The role of body dimensions, BP, and family history, as well as the association between cIMT and distensibility, was investigated. cIMT increased and distensibility decreased with age, height, body mass index, and BP. A significant sex difference was apparent from the age of 15 years. Age- and height-normalized cIMT and distensibility values differed in children who are short or tall for their age. By stepwise multivariate analysis, standardized systolic BP and body mass index were independently positively associated with cIMT SD scores (SDS). Systolic BP SDS independently predicted all distensibility measures. Distensibility coefficient SDS was negatively and β SDS positively associated with cIMT SDS, whereas incremental modulus of elasticity was independent of cIMT. Morphological and functional aspects of the common carotid artery are particularly influenced by age, body dimensions, and BP. The reference charts established in this study allow to accurately compare vascular phenotypes of children with chronic conditions with those of healthy children.

Feasibility of esophagogastric junction distensibility measurement during Nissen fundoplication

Increased esophagogastric junction distensibility has been implicated in the development of gastroesophageal reflux disease (GERD). Previous authors have demonstrated a reduction in distensibility following anti-reflux surgery, but the changes during the operation are not clear. Our study aimed to ascertain the feasibility of measuring intraoperative distensibility changes and to assess if this would have potential to modify the operation. Seventeen patients with GERD were managed in a standardized manner consisting of preoperative assessment with symptom scoring, endoscopy, 24 hours pH studies, and manometry. Patients then underwent laparoscopic Nissen fundoplication with intraoperative distensibility measurement using an EndoFLIP EF-325 functional luminal imaging probe (Crospon Ltd, Galway, Ireland). This device utilizes impedance planimetry technology to measure cross-sectional area and distensibility within a balloon-tipped catheter. This is inflated at the esophagogastric junction to fixed distension volumes. Thirty-second median cross-sectional area and intraballoon pressure measurements were recorded at 30 and 40 mL balloon distensions. Measurement time points were initially after induction of anesthesia, after pneumoperitoneum, after hiatal mobilization, after hiatal repair, after fundoplication, and finally pre-extubation. Postoperatively, patients continued on protocol and were discharged after a two-night stay tolerating a sloppy diet. Patients with a hiatus hernia on high-resolution manometry had a significantly higher initial esophagogastric junction distensibility index (DI) than those without. Hiatus repair and fundoplication resulted in a significant overall reduction in the median DI from the initial to final recordings (30 mL balloon distension reduction of 3.26 mm(2) /mmHg (P = 0.0087), 40 mL balloon distension reduction of 2.39 mm(2) /mmHg [P = 0.0039]). There was also a significant reduction in the DI after pneumoperitoneum, hiatus repair, and fundoplication at 40 mL balloon distension. Two individual cases in the series highlight the utility of the system in potentially changing the operation. After fundoplication, patient 7 recorded a DI of 0.47 mm(2) /mmHg, the lowest in our series, and subsequently required reoperation because of significant symptoms of dysphagia. Patient 12 had a fundoplication that appeared visually too tight and was converted intraoperatively to a Lind 270° wrap resulting in a change in the DI from 0.65 to 0.89 mm(2) /mmHg. Laparoscopic Nissen fundoplication results in a significant reduction in the distensibility of the esophagogastric junction. The EndoFLIP system is able to demonstrate significant changes during the operation and may help guide intraoperative modification. Larger multicenter studies with long-term follow up would be beneficial to develop a target range of distensibility associated with good outcome.

Measurement of esophago‐gastric junction cross‐sectional area and distensibility by an endolumenal functional lumen imaging probe for the diagnosis of gastro‐esophageal reflux disease

Measurement of esophago-gastric junction (EGJ) cross-sectional area (CSA) and distensibility by an Endolumenal Functional Lumen Imaging Probe (EndoFLIP®) may distinguish between gastro-esophageal reflux disease (GERD) patients and healthy volunteers (HV). We aimed to assess the agreement of EndoFLIP® measurements with clinical and physiologic diagnosis of GERD. Twenty-one HV and 18 patients with typical GERD symptoms were studied. After gastroscopy, EGJ CSA, and distensibility were measured by EndoFLIP®. Forty-eight hour esophageal pH monitoring was then performed by a wireless system. The ability of EndoFLIP® to discriminate GERD patient and HVs was assessed. Planned secondary analysis then assessed whether EGJ CSA and distensibility were increased in individuals with pathologic acid exposure. Healthy volunteers were younger and had lower body mass index (BMI; both p < 0.001). Pathologic acid exposure was present in 3/21 (14%) HVs and 9/18 (50%) patients (p = 0.126). At 30 mL EndoFLIP® bag volume, EGJ CSA was higher (p = 0.058) and EGJ distensibility was lower (p = 0.020) in HVs than patients. Secondary analysis showed that EGJ measurements were similar in participants with and without pathologic acid exposure (CSA 98 mm² vs 107 mm²; p = 0.789, distensibility; p = 0.704). An inverse association between BMI and CSA (R² = 0.2758, p = 0.001) and distensibility (R² = 0.2005, p = 0.005) was present. Endolumenal Functional Lumen Imaging Probe is not useful for GERD diagnosis because EGJ CSA and distensibility do not distinguish between HVs and GERD patients defined by clinical presentation or pH measurement. This unexpected result may be due to an important, confounding interaction of obesity.

Impairment in aortic elastic properties and mechanics of ascending aorta in patients with bicuspid aortic valve

Background: Bicuspid aortic valve (BAV), which is one of the most common congenital heart defects, is a genetic disorder of the aortic valve and ascending aorta. Aortic dilation is common in subjects with BAV. In the present study we aimed to investigate the elastic and mechanical properties of the aorta by using a novel strain method, velocity vector imaging (VVI), in patients with BAV. Methods: We studied 22 patients with BAV (age 43.31±4.5, 57% female) and 20 age and sex-matched healthy subjects with tricuspid aortic valve. All the patients and healthy controls were subjected to assessment of aortic strain, stiffness and distensibility measurements of M-mode images of the aorta. VVI measurements were obtained from off-line analysis of standard B-mode ultrasound images of the ascending aorta. Results: Aortic strain (5.2±1.5% to 13.91±4.77%, respectively, p=0.0001), and distensibility 0.19±0.06% to 1.6±0.77%, respectively, p=0.0001) were significantly impaired in patients with BAV, compared to the control group. Aortic stiffness was markedly increased in patients with BAV (4.45±1.73 to 2.6±1.3, respectively, p=0.001).Regarding VVI-based strain measurements, peak longitudinal strain (S), strain rate (SR) and total longitudinal displacement (TLD) values were significantly impaired in patients with BAV, compared to the controls. (S: 11.49±1.2% to 14.6±2.58%, p=0.03; SR: 0.57±0.03 1/s to 1.66±0.40 1/s, p=0.0001; TLD: 3.98±1.78 mm to 10.42±2.38 mm, p= 0.0001). Conclusions: BAV is associated with reduced elasticity of the aorta. Longitudinal wall motion of ascending aorta is also impaired in patients with BAV. VVI is a novel strain method which provides detailed data in assessing the longitudinal deformation of the ascending aorta, in patients with BAV.

Alterations in vascular function in primary aldosteronism: a cardiovascular magnetic resonance imaging study

Excess aldosterone is associated with increased cardiovascular risk. Aldosterone has a permissive effect on vascular fibrosis. Cardiovascular magnetic resonance imaging (CMR) allows study of vascular function by measuring aortic distensibility. We compared aortic distensibility in primary aldosteronism (PA), essential hypertension (EH) and normal controls and explored the relationship between aortic distensibility and pulse wave velocity (PWV). We studied PA (n=14) and EH (n=33) subjects and age-matched healthy controls (n=17) with CMR, including measurement of aortic distensibility, and measured PWV using applanation tonometry. At recruitment, PA and EH patients had similar blood pressure and left ventricular mass. Subjects with PA had significantly lower aortic distensibility and higher PWV compared with EH and healthy controls. These changes were independent of other factors associated with reduced aortic distensibility, including ageing. There was a significant relationship between increasing aortic stiffness and age in keeping with physical and vascular ageing. As expected, aortic distensibility and PWV were closely correlated. These results demonstrate that PA patients display increased arterial stiffness compared with EH, independent of vascular ageing. The implication is that aldosterone invokes functional impairment of arterial function. The long-term implications of arterial stiffening in aldosterone excess require further study.

Pelvic floor dysfunction—Does menopause duration matter?

ObjectiveTo explore the effect of menopause and hormone replacement therapy on pelvic organ prolapse and pelvic floor muscle function. MethodsThe records of patients who attended a tertiary urogynaecological center were reviewed retrospectively. A standardised interview included menopausal age, i.e. years since last period or onset of menopausal symptoms, current or previous hormone use. The clinical examination included prolapse assessment (POP-Q) and palpation of the levator ani muscle. 4D transperineal ultrasound, supine and after voiding, was performed in all patients. Volume data sets were analysed for pelvic organ descent and measures of contractility and distensibility of the pelvic floor at a later date, blinded to all clinical data. ResultsOf 311 women seen during the inclusion period, 65% were postmenopausal. Current systemic or local hormone use was reported by 7% and 6%, respectively. 163 women (52%) reported prolapse symptoms with a mean bother of 5.7/10. Significant pelvic organ prolapse was found on clinical examination (POP-Q stage≥2) in 77%, and diagnosed on ultrasound in 61%. On multivariate analysis, controlling for calendaric age, parity and levator avulsion, there was no evidence for menopausal age as an independent predictor of any symptom and sign of pelvic organ prolapse and pelvic floor muscle function. Local oestrogen use and past or present hormone replacement therapy had no detectable effect on any pelvic floor parameter. ConclusionsHormone deficiency following menopause is unlikely to play a major role in pelvic organ support and levator ani function. Hence, both do not appear to be substantially influenced by local or systemic hormone replacement therapy.

SAT0399 Impairment in aortic elastic properties and mechanics of carotid artery system in patients with takayasu’ s arteritis

BackgroundTakayasu’s arteritis (TA) is a chronic inflammatory vasculitis of the aorta and its major branches. Increased arterial stiffness is known to be a predictor of cardiovascular mortality. Impairment of the...

Tu1197 A Subgroup of Achalasia Patients With Manometrically Normal LES Relaxation Can Be Identified by Measurements of Esophagogastric Junction Distensibility

Background: Esophageal manometry is the gold standard for diagnosing achalasia. Typical findings are absent peristalsis and incomplete relaxation of the LES (integrated relaxation pressure (IRP) .15 mmHg). However, in a subgroup of patients with typical symptoms of achalasia, stasis on barium esophagogram and absent peristalsis onmanometry, LES relaxation is not impaired. The aim of our study was to further characterize these patients using distensibility measurements of the esophagogastric junction (EGJ) and to study the effect of treatment. Methods: Consecutive patients with typical symptoms of achalasia, no abnormalities on upper endoscopy, significant stasis on barium esophagogram, absent peristalsis but normal IRP were included. Distensibility of the EGJ was measured using impedance planimetry (EndoFLIP). Distensibility was defined as the minimal cross-sectional area (CSA) of the EGJ divided by balloon pressure at volumes of 20, 30, 40 and 50 ml (mm2/mmHg) and was compared to previously established data of 15 healthy controls. The cut-off for normality was determined at the lower 90th percentile of the EGJ distensibility at 50 ml in these controls. Symptom severity was assessed using the Eckardt score, a score ,4 was considered as treatment success. Measurements of EGJ distensibility and Eckardt score were repeated .3 months after treatment. Results: We included 9 patients (5 male; age 21-59 years) with typical symptoms of achalasia, Eckardt score 6 (5-7) (median (IQR)). On esophageal manometry failed contractions were observed in 5 patients, panesophageal pressurization in 3 patients and spastic contractions in 1 patient. The median IRP was 9.3 mmHg (3.712), baseline LES pressure was 8.6 mmHg (4.5-11.9). Distensibility of the EGJ was significantly reduced in patients compared to controls at all balloon volumes: 20 ml (1.97 ± 0.16 vs 2.46 ± 0.54 mm2/mmHg, P ,.05 (mean ± SEM)), 30 ml (1.81 ± 0.08 vs 2.67 ± 0.36 mm2/mmHg, P ,.0001), 40 ml (1.08 ± 0.12 vs 5.02 ± 0.58 mm2/mmHg, P ,.0001) and 50 ml (1.08 ± 0.11 vs 6.28 ± 0.65 mm2/mmHg, P ,.0001). All patients exhibited EGJ distensibility below the cut-off value set for normality (2.9 mm2/mmHg). Treatment was performed in 6 patients (4 pneumodilation, 2 Heller myotomy). Post-treatment, in all of these patients symptomatic improvement was seen (Eckardt 2 (1-2)) and a substantial increase in EGJ distensibility, to a value within the normal range (5.32 ± 0.9 mm2/mmHg) was observed. Conclusions: A subgroup of patients with typical symptoms of achalasia, significant esophageal stasis, absent peristalsis but no impaired LES relaxation on esophageal manometry can have impaired EGJ distensibility at impedance planimetry. These patients can be regarded as having achalasia and respond favorably to achalasia treatment.

Esophageal Distensibility as a Measure of Disease Severity in Patients With Eosinophilic Esophagitis

The aim of this study was to assess whether measurements of esophageal distensibility, made by high-resolution impedance planimetry, correlated with important clinical outcomes in patients with eosinophilic esophagitis. Seventy patients with eosinophilic esophagitis (50 men; age, 18-68 y) underwent endoscopy with esophageal biopsy collection and high-resolution impedance planimetry using the functional lumen-imaging probe. The patients were followed up prospectively for an average of 9.2 months (range, 3-14 mo), and the risk of food impaction, requirement for dilation, and symptom severity during the follow-up period was determined from medical records. Esophageal distensibility metrics and the severity of mucosal eosinophilia at baseline were compared between patients presenting with and without food impaction and those requiring or not requiring esophageal dilation. Logistic regression and stratification assessments were used to assess the predictive value of esophageal distensibility metrics in assessing risk of food impaction, the need for dilation, and continued symptoms. Patients with prior food impactions had significantly lower distensibility plateau (DP) values than those with solid food dysphagia alone. In addition, patients sustaining food impaction and requiring esophageal dilation during the follow-up period had significantly lower DP values than those who did not. The severity of mucosal eosinophilia did not correlate with risk for food impaction, the requirement for dilation during follow-up evaluation, or DP values. Reduced esophageal distensibility predicts risk for food impaction and the requirement for esophageal dilation in patients with eosinophilic esophagitis. The severity of mucosal eosinophilia was not predictive of these outcomes and had a poor correlation with esophageal distensibility.

Echocardiographic Left Ventricular End-Diastolic Pressure Volume Loop Estimate Predicts Survival in Congestive Heart Failure

BackgroundThe left ventricular end-diastolic pressure-volume relationship (LV-EDPVR) is a measure of LV distensibility, conveying the size the LV will assume at a given LV end-diastolic pressure (LV-EDP). Measurement of LV-EDPVR requires invasive testing with specialized equipment. Echocardiography can be used to measure LV end-diastolic volume (EDV) and to grossly estimate LV-EDP noninvasively. We therefore hypothesized that categorization of patients based on these parameters to create an estimate of the end-diastolic pressure-volume loop position (EDPVE) could predict congestive heart failure (CHF) prognosis. Methods and ResultsEchocardiograms from 968 CHF clinic patients were reviewed. LV-EDP was considered to be elevated if mitral filling pattern was pseudo-normal or restrictive. EDPVE was categorized into 3 groups. EDPVE was considered to have evidence of rightward shift if the LV was severely dilated (>97 mL/m2). EDPVE was considered to have evidence of leftward shift if the LV was normal size (<76 mL/m2) and there was Doppler evidence of increased LV-EDP. Patients who did not meet criteria for leftward or rightward shift were classified as “intermediate.” Using the intermediate group for comparison, those with evidence of leftward shift in EDPVE had increased mortality (hazard ratio [HR] 1.77; 95% confidence interval [CI]: 1.23-2.54). Rightward shift only correlated with increased mortality in those older than age 70 years. Leftward shift remained an independent predictor of mortality even after adjusting for LV ejection fraction, atrial fibrillation, mitral regurgitation, and Doppler indices of diastolic dysfunction. ConclusionEDPVE is a strong predictor of CHF survival which is independent of LV ejection fraction and traditional Doppler indices of LV diastolic function.

Automatic carotid artery distensibility measurements from CTA using nonrigid registration

The distensibility of a blood vessel is a marker of atherosclerotic disease. In this paper we investigate the feasibility of measuring carotid artery distensibility on 4D CTA, both manually and using a new automatic method. On 4D CTA datasets manual (n=38) and automatic (n=76) measurements of the carotid distensibility were performed. A subset (n=10) of the manual annotations were repeated by a second observer. The interobserver variability was assessed using a Bland-Altman analysis and appeared to be too large to reliably measure the distensibility using manual annotation. We compared two versions of the automatic method: one using 3D registration and one using a 4D registration method. The latter resulted in a more smooth deformation over time. The automatic method was evaluated using a synthetic deformation and by investigating whether known relations with cardiovascular risk factors could be reproduced. The relation between distensibility and cardiovascular risk factors was tested with a Mann-Whitney U test. Automatic measurements revealed an association with hypertension whereas the manual measurements did not. This relation has been found by other studies too. We conclude that carotid artery distensibility measurements should be performed automatically and that the method described in this paper is suitable for that. All CTA datasets and related clinical data used in this study can be downloaded from our website (http://ctadist.bigr.nl).

Distensibility of the esophagogastric junction assessed with the functional lumen imaging probe (FLIP™) in achalasia patients

The functional lumen imaging probe (FLIP), measures esophagogastric junction (EGJ) distensibility (cross-sectional area/luminal pressure) during volume-controlled distension. The aim of this study is to apply this tool to the assessment of the EGJ in untreated and treated achalasia patients and to compare EGJ distensibility with other diagnostic tools utilized in managing achalasia. Findings from FLIP, high-resolution manometry (HRM), timed barium esophagram, and symptom assessment by Eckardt Score (ES) were compared in 54 achalasia patients (23 untreated, 31 treated). Twenty healthy volunteers underwent FLIP as a comparator group. The EGJ distensibility index (EGJ-DI) was defined at the 'waist' of the FLIP bag during volumetric distension, expressed in mm(2) mmHg(-1) . The ES was used to gauge treatment outcome: good response<3 or poor response≥3. Of the 31 treated patients, 17 had good and 14 poor treatment response. The EGJ-DI was significantly different among groups, greatest in the control subjects and least in the untreated patients; patients with good treatment response had significantly greater EGJ-DI than untreated or patients with poor response. The correlations between EGJ-DI and ES and integrated relaxation pressure on HRM were significant. The FLIP provided a useful measure of EGJ distensibility in achalasia patients that correlated with symptom severity. The measurement of EGJ distensibility was complementary to existing tests suggesting a potentially important role in the clinical management of achalasia.

Correlation of simultaneous measurements of coronary, carotid and aortic distensibility and vessel wall ratio as evaluated by cardiovascular magnetic resonance in patients with type 2 diabetes mellitus

Background Arterial distensibility can be measured non-invasively by cardiovascular magnetic resonance (CMR) in various arterial territories. However, no information is available comparing distensibility in different anatomical territories in individual patients. Therefore, we sought to compare CMR measurements of the distensibility of the coronary and carotid artery, and ascending aorta (AA) in patients with type 2 diabetes mellitus (DM). Methods