Normal Left Ventricular Geometry Research Articles

CORRELATION OF STRUCTURAL AND FUNCTIONAL FEATURES OF LEFT VENTRICLE WITH AMBULATORY BLOOD PRESSURE MONITORING DATA IN PATIENTS WITH ESSENTIAL HYPERTENSION

Aim. To evaluate the relationship of 24-hour blood pressure (BP) monitoring data with myocardial mass and type of left ventricle hypertrophy (LVH) in non-treated patients with essential hypertension (HT). Patients and methods. We reviewed echocardiograms and BP monitoring data of 500 patients (250 females and 250 males; aged 53,1±12,2 y.o.). Results. Normal geometry of left ventricle (LV) was found in 143 patients (28,6%), concentric remodeling of LV – in 73 (14,6%), concentric LVH - in 138 (27,6%) and eccentric LVH – in 146 patients (29,2%). The least disturbances of 24-hour BP profile were observed in patients with normal LV geometry; 60,1% of patients had normal reduction of night BP. More than a third of patients had disturbances of circadian BP profile. Mostly severe disturbances of 24-hour BP profile were observed in patients with concentric and eccentric LVH. Circadian BP disturbances were revealed in two thirds of patients. Inadequate night BP reduction and inverted type of circadian BP profile predominated. Negative correlation between 24-hour systolic BP index and LV myocardial mass index was observed. Some LV structural disturbances as well as systolic dysfunction were revealed in patients with LV concentric remodeling. Besides HT of 3 grade and excessive night BP reduction were observed more often in these patients. Conclusion. The relationships between LV structural disturbances and 24-hour BP profile allow to reveal patients with unfavorable course of HT.

Heart Failure in Children

Why is heart failure in children important? If we just consider the number of individuals affected, adult heart failure is clearly a more compelling public health problem. However, the relatively small numbers belie the overall economic and social impact of pediatric heart failure. When a child is admitted to the hospital for heart failure, the costs are considerably higher for children than adults because of the frequent need for surgical or catheter-based intervention. The demands of medical care can fray the family structure and adversely affect parental economic productivity. When a child dies of heart failure, the economic impact is magnified enormously because of the number of potentially productive years lost per death. For these and other reasons, heart failure in children is a serious public health concern. In addition, growing numbers of children with heart failure are reaching adulthood because of the successful application of medical and surgical heart failure therapies and the improved outcomes of congenital heart surgery. A greater understanding of the pathophysiology of heart failure in childhood may help inform therapeutic strategies once these children become adults. Furthermore, given the recent explosion of research in the impact of cardiac development and cardiogenetics on pediatric cardiovascular disease, it is not outside the realm of possibility for a pediatric discovery to be made that will also benefit adults with heart failure. We may not yet be able to agree on a definition of heart failure, but the cardinal symptoms, dyspnea, anasarca (“dropsy”), and cachexia, were well recognized in antiquity.1 These symptoms were not specific for cardiac pathology, and it was not until the 17th century, when William Harvey definitively identified the heart as an organ that pumped blood rather than generating heat, that the heart could begin to be understood as a source of dyspnea, edema, and …

Independent Association of Coronary Flow Reserve with Left Ventricular Relaxation and Filling Pressure in Arterial Hypertension

It has been recognized that "cross-talk" occurs between coronary flow and left ventricular (LV) function. This study tested the hypothesis that impairment of coronary flow reserve (CFR) in arterial hypertension is associated with LV systolic and diastolic dysfunction, independent of abnormalities in LV geometry. We studied 59 newly diagnosed, never-treated hypertensive patients, using transthoracic Doppler echocardiography including pulsed Tissue Doppler of mitral annulus and CFR on left anterior descending artery (low-dose dipyridamole). The study population was divided into two groups on the basis of age-normalized relative wall thickness (RWTn): 36 patients with normal LV geometry (RWTn < or = 0.41) and 23 patients with LV concentric geometry (RWTn > 0.41). Patients with LV concentric geometry (RWTn > 0.41) had significantly lower values of midwall shortening (but not of endocardial shortening), longer isovolumic relaxation time (IVRT), lower Tissue Doppler-derived early diastolic velocity (Em), higher ratio of transmitral E velocity to Em, and lower CFR as compared to patients with normal LV geometry (RWTn < or = 0.41). In the whole population, a lower CFR was significantly associated with lower values of midwall shortening and Em, longer IVRT, and higher E/Em ratio. After controlling for heart rate, mean blood pressure, and RWTn, only the relation of CFR with IVRT, Em, and E/Em ratio remained significant. Reduced midwall mechanics is associated with lower CFR, a relationship that depends on LV concentric geometry. A reduced CFR is associated with both impaired relaxation and increased filling pressure, a relation that is independent of LV geometry and pressure load.

Structure and torsion in the normal and situs inversus totalis cardiac left ventricle. II. Modeling cardiac adaptation to mechanical load

Mathematical models provide a suitable platform to test hypotheses on the relation between local mechanical stimuli and responses to cardiac structure and geometry. In the present model study, we tested hypothesized mechanical stimuli and responses in cardiac adaptation to mechanical load on their ability to estimate a realistic myocardial structure of the normal and situs inversus totalis (SIT) left ventricle (LV). In a cylindrical model of the LV, 1) mass was adapted in response to myofiber strain at the beginning of ejection and to global contractility (average systolic pressure), 2) cavity volume was adapted in response to fiber strain during ejection, and 3) myofiber orientations were adapted in response to myofiber strain during ejection and local misalignment between neighboring tissue parts. The model was able to generate a realistic normal LV geometry and structure. In addition, the model was also able to simulate the instigating situation in the rare SIT LV with opposite torsion and transmural courses in myofiber direction between the apex and base [Delhaas et al. (6)]. These results substantiate the importance of mechanical load in the formation and maintenance of cardiac structure and geometry. Furthermore, in the model, adapted myocardial architecture was found to be insensitive to fiber misalignment in the transmural direction, i.e., myofiber strain during ejection was sufficient to generate a realistic transmural variation in myofiber orientation. In addition, the model estimates that, despite differences in structure, global pump work and the mass of the normal and SIT LV are similar.

Reversibility of Cardiac Abnormalities in Morbidly Obese Adolescents

The purpose of this study was to evaluate changes in cardiac geometry, systolic and diastolic function before and after weight loss in morbidly obese adolescents. Cardiac abnormalities are present in morbidly obese adolescents; however, it is unclear if they are reversible with weight loss. Data from 38 adolescents (13 to 19 years; 29 females, 9 males, 33 Caucasians, 5 African Americans) were evaluated before and after bariatric surgery. Left ventricular mass (LVM), left ventricular (LV) geometry, systolic and diastolic function were assessed by echocardiography. Mean follow up was 10 +/- 3 months. Weight and body mass index decreased post-operatively (mean weight loss 59 +/- 15 kg, pre-operative body mass index 60 +/- 9 kg/m(2) vs. follow-up 40 +/- 8 kg/m(2), p < 0.0001). Change in LVM index (54 +/- 13 g/m(2.7) to 42 +/- 10 g/m(2.7), p < 0.0001) correlated with weight loss (r = 0.41, p = 0.01). Prevalence of concentric left ventricular hypertrophy (LVH) improved from 28% at pre-operative to only 3% at follow up (p = 0.007), and normal LV geometry improved from 36% to 79% at follow up (p = 0.009). Diastolic function also improved (mitral E/Ea lateral 7.7 +/- 2.3 at pre-operative vs. 6.3 +/- 1.6 at post-operative, p = 0.003). In addition, rate-pressure product improved suggesting decreased cardiac workload (p < 0.001). Elevated LVM index, concentric LVH, altered diastolic function, and cardiac workload significantly improve following surgically induced weight loss in morbidly obese adolescents. Large weight loss due to bariatric surgery improves predictors of future cardiovascular morbidity in these young people.

369: Prophylaxis vs. Pre-Emptive Strategies in Preventing Cytomegalovirus-Dependent Cardiac Allograft Vasculopathy

formed at 1 week, 1 and 5 years after HTx were analyzed in 104 heart recipients. The mean age of the cohort was 47 16 years and the period of follow up was 4.96 2.45 years. The total cohort was divided into three sub-groups based on determination of LV geometry at 1-week after transplantation: (1) NG normal left ventricle geometry (relative wall thickness (RWT) 0.42 and LVM 225 for males and 163 for females); (2) CR concentric remodeling (RWT 0.42, LVM 225 for males and 163 for females); and (3) CH concentric hypertrophy (RWT 0.42, LVM 225 for males and 163 for females). Results: Abnormal LV geometry was found as early as 1 week after HTx in 85% of patients (59% CR, 26% CH) with explosive mode of donor brain death being the most significant determinant for CH (OR 2.9, CI 0.4-3.18, p 0.01) by multivariable logistic regression. There was no significant difference in blood pressure control or cellular rejection score between the 3 groups. Patients with abnormal LV geometry at 1 week had significantly higher prevalence of graft vasculopathy by angiography at 5 years (0% in NG, 9% in CR and 30% in CH, p 0.0015). The prevalence of CH continued to increase to 30% at 1 year and 41% at 5 years after HTx primarily due to a progressive increase in RWT and LV mass in the NG group and increase in LV mass in the CR group. Patients with CH at 1 year had significantly higher mortality as compared to patients with normal LV geometry (RR-1.87, p 0.03). Conclusions: Cardiac allograft remodeling occurs early and frequently after HTX, with explosive mode of donor brain death a significant factor. Subsequently, the presence of CH is associated with increased graft arteriosclerosis and mortality.

Abstract 3154: Interacton of Left Ventricular Geometry and Cardiovascular Hemodynamics in 57,307 Patients wth Preserved Ejection Fraction

We and others have demonstrated the prognostic impact of LV geometry on subsequent survival in patients with preserved ejection. The purpose of this investigation was to describe parameters of cardiovascular hemodynamics and energetics associated with normal and abnormal LV geometry, including concentric remodeling (CR), eccentric hypertrophy (EH), and concentric hypertrophy (CH) fraction in patients who were referred for routine echocardiographic evaluation. Measures were obtained using standard non-invasive methods previously reported. Survival was obtained by the National Death Index after a mean follow-up of 2.8 years. Conclusion: Changes in LV geometry are associated with significant abnormalities in cardiac and vascular hemodynamics and energetics that in general progress from CR to frank hypertrophy. Intervention directed towards modifying these parameters are needed in order to evaluate the potential for improving clinical outcomes.

Brain natriuretic peptide and other cardiac markers predicting left ventricular remodeling and function two years after myocardial infarction

Left ventricular remodeling is a complex pathologic process of progressive left ventricular dilatation, leading to dysfunction and heart failure in patients after myocardial infarction. To evaluate biochemical markers, reflecting cardiac remodeling process after first myocardial infarction and compare those markers with clinical characteristics of left ventricular remodeling. Brain natriuretic peptide, troponin I, creatine kinase, creatine kinase MB mass, lactate dehydrogenase levels were measured in 30 patients with acute myocardial infarction on days 1, 2, 3-7 . Brain natriuretic peptide was measured at 3 months, 6 months, and 2 years after myocardial infarction. Echocardiographic parameters of left ventricular remodeling were determined in acute phase (day 1-3), at 3 months, 6 months, and 2 years after MI. In acute phase, brain natriuretic peptide level progressively increased according to worsening of left ventricular geometry: in normal left ventricle geometry group, brain natriuretic peptide level was 84.1 (58.7-121) pg/mL, in concentric remodeling group - 125 (69.2-165) pg/mL, in concentric hypertrophy group - 128 (74-368) pg/mL, and in eccentric hypertrophy group - 470 (459-494) pg/mL, P=0.02. Patients who had increased left ventricular end diastolic diameter index during 2-year period had higher brain natriuretic peptide level in the acute phase (584 (249-865) pg/mL vs. 120 (67-202) pg/mL, P=0.04) and also higher peak lactate dehydrogenase and troponin I levels. Brain natriuretic peptide level in acute phase of myocardial infarction is strongly associated with the markers of myocardial injury and related to left ventricular geometry changes and remodeling. Brain natriuretic peptide together with troponin I levels in acute phase of myocardial infarction might be useful in predicting subsequent cardiac function.

Left Ventricular Architecture and Survival in African-Americans Free of Coronary Heart Disease (from the Atherosclerosis Risk in Communities [ARIC] Study)

Published studies of the prognostic value of left ventricular (LV) hypertrophy and LV geometric pattern in African-Americans were based on referred or hospitalized patients with hypertension or coronary heart disease. All-cause mortality rates and survival associated with LV geometric pattern were determined using echocardiography in a population-based sample of middle-aged and elderly African-American men and women. During the third (1993 to 1995) visit of the ARIC Study, echocardiography was performed at the Jackson, Mississippi, field center on the cohort of 2,445 African-Americans aged 49 to 75 years. M-Mode LV echocardiographic measurements were available for 1,722 persons. Mortality data were available through December 31, 2003. During the follow-up period (median 8.8 years, maximum 10.4), 160 deaths were identified. In men, multivariable-adjusted hazard ratios for all-cause mortality (compared with men with normal LV geometry) were 1.75 (95% confidence interval [CI] 0.71 to 4.33) in those with concentric LV hypertrophy, 0.38 (95% CI 0.08 to 1.88) in those with eccentric LV hypertrophy, and 0.79 (95% CI 0.41 to 1.54) in those with concentric remodeling. In women, multivariable-adjusted hazard ratios for all-cause mortality (compared with women with normal LV geometry) were 1.17 (95% CI 0.48 to 2.84) in those with concentric LV hypertrophy, 1.23 (95% CI 0.46 to 3.28) in those with eccentric LV hypertrophy, and 1.17 (95% CI 0.60 to 2.28) in those with concentric remodeling. In conclusion, in this population-based cohort of middle-aged and elderly African-Americans free of coronary heart disease, adjustment for baseline differences in cardiovascular disease risk factors and LV mass greatly attenuated the strength of the association between LV pattern and all-cause mortality risk in women. In men, an association between concentric LV hypertrophy and mortality risk remained.

Use of the 12 Lead EKG in Distinguishing Concentric LV Remodeling from Normal LV Geometry

Introduction: The EKG is a simple inexpensive tool to screen for the presence of increased LV mass in patients with hypertension. Studies have shown that in addition to increased LV mass, patients with concentric remodeling (CR, as defined by increased relative wall thickness (RWT) and normal LV mass) also have an increase in adverse cardiovascular events. It remains unclear whether or not the 12 lead EKG criteria used for identifying increased LV mass can similarly differentiate these patients from those with normal LV geometry. Hypothesis: We hypothesized that the 12 lead EKG in CR has a significantly increased frequency of increased voltage, ST depressions, T wave inversions and left atrial enlargement in comparison to normal geometry. Methods: We reviewed data from 640 consecutive hypertensive patients with a normal LV ejection fraction, no ischemic heart disease, no prior infarction (as evidenced by a q wave on EKG), no atrial fibrillation and no valvular dysfunction. CR was based upon a RWT >/= 45% (RWT = (2 X posterior wall thickness)/(LV internal diameter during diastole)) and normal LV mass indexed for body surface area (males < 125 gm/m2; females < 110 gm/m2). Increased voltage was determined using the modified Cornell criteria. ST depression > 0.1 mV and T wave inversions of any degree were considered present if found in any lead except aVR, and V1 to V3. Left atrial enlargement was present if the p wave inversion in lead V1 > 1mm in length and >1mV in amplitude. Results: There were 217/640 patients (34%) with echocardiographic evidence of CR and 173/640 patients (28%) that were normal. For CR, 13% had increased voltage criteria, 10% had ST depressions, 28% had T wave inversions and 36% had left atrial enlargement. For normals, there were 0% that had increased voltage criteria, 0% with ST depression, 17% with T wave inversions and 23% with left atrial enlargement. (CR vs normal p < 0.01 for every criteria). Conclusion: Despite the previous association of increased LV mass with specific 12 lead EKG criteria, patients with CR are also identified by these EKG patterns. Additional studies are necessary, to distinguish further, appropriate criteria that can separate CR from both normal geometry and increased LV mass.

Influence of antihypertensive therapy and blood pressure control on left ventricular geometry and function in subjects with type II diabetes: The Augsburg Diabetes Family Study

Cross-sectional data often fail to show beneficial effects of antihypertensive therapy in patients with hypertension. We, therefore, examined the influence of hypertension control on left ventricular (LV) structure in diabetic persons separated into those having and not having any known cardiovascular disease (CVD) symptoms. The study population consisted of 394 subjects with type II diabetes. According to the presence of CVD, subjects were classified as symptomatic (N=181) or asymptomatic (N=213). In addition, three groups were differentiated: controlled hypertensives (CHs), that is, known hypertension with normal blood pressure (BP), uncontrolled hypertensives (UHs), that is, elevated BP regardless of antihypertensive medication, and normotensives (Ns). Symptomatic subjects showed a significantly higher prevalence of LV hypertrophy (LVH) (34.5 vs 23.4%, P<0.02). In contrast to symptomatic subjects where hypertension control status had no further significant impact on LV geometry, a considerable impact on preservation of normal LV geometry was observed in asymptomatic persons (LVH of 30, 15 and 18% in UH, CH and N, respectively, P<0.001). Control of hypertension in early diabetes seems especially to prevent the development of concentric hypertrophy (24 vs 11% in UH vs CH, P<0.04). In conclusion, in subjects with diabetes and CVD, the prevalence of LV structural abnormalities is very high. Although in this population-based study setting, in the latter group BP control does not seem to positively influence LV mass and function, hypertension control in still asymptomatic diabetic persons is beneficial and has a considerable impact on preservation of normal LV geometry.

Left Ventricular Geometry and Survival in Patients With Normal Left Ventricular Ejection Fraction

In hypertensive populations, left ventricular (LV) geometry, which is characterized by hypertrophy, predicts cardiovascular outcome. The left ventricle can also alter its shape by concentric remodeling (CR) in the absence of LV hypertrophy, a feature that is detected by echocardiography. This study assessed the prevalence and prognostic significance of various forms of LV geometry and changes in LV geometry over time in patients with normal LV systolic function. Retrospective analysis of a large clinical population (n = 35,602) that was referred for echocardiography was done, with all-cause mortality as the primary outcome. Abnormal LV geometry was identified in 46% of patients, with CR present in 35% (n = 12,362) and LV hypertrophy in 11% (n = 3,958). Patients with abnormal LV geometry were older and more obese compared with subjects with normal LV geometry. There was a strong relation between abnormal LV geometry and mortality, and patients with CR and LV hypertrophy exhibited considerably higher relative risk for all-cause mortality compared with subjects with normal LV geometry (relative risk [RR] 1.99, 95% confidence interval [CI] 1.88 to 2.18, p <0.0001; RR 2.13, 95% CI 1.89 to 2.40, p <0.0001, respectively). Subjects with CR who reverted to a normal geometric pattern had improved survival (RR 0.64, 95% CI 0.42 to 0.97, p = 0.03) compared with those who progressed to LV hypertrophy (RR 1.54, 95% CI 1.01 to 2.47, p = 0.05). In conclusion, CR, a form of cardiac adaptation, is frequently noted in patients with normal LV ejection fractions and confers a risk of death similar to that of LV hypertrophy. Normalization of CR is associated with better survival, whereas transition to LV hypertrophy increases mortality.

Differences of the Exercise Capacity According to Left Ventricular Geometrical Changes and Its Associated Factors in Hypertensive Patients with Isolated Diastolic Dysfunction

Background : Left ventricular(LV) adaptation to high blood pressure produces unique geometrical change, which is closely associated with the prognosis and quality of life in hypertensive patients irrespective of the presence of LV hypertrophy. Exercise capacity assessed by treadmill test(TMT) can provide prognostic information in these patients. We evaluated relationship between LV geometry and exercise capacity in hypertensive patients with isolated diastolic dysfunction. Methods : According to the echocardiographic results, 109 patients with essential hypertension, who performed TMT for estimating exercise capacity, were classified as having normal LV geometry (NG, n=40) or concentric LV geometry (CG, n=69). Patients with concentric LV geometry were categorized into moderate (n=55) or marked (n=14) CG on the basis of the criteria previously reported. Conventional echocardiographic and tissue Doppler imaging indices were obtained with standard techniques. Results : There were no differences in age, gender and resting heart rate between NG and CG. Maximal exercise time was longer in NG than in CG (617.3±131.5 vs. 566.0±155.0 seconds, p<0.05). Late diastolic mitral annular velocity (A’) exhibited a significant correlation with maximal exercise time in moderate and marked CG (r=0.30 and 0.56, both p<0.05), which remained significant after multivariate linear regression analysis with variables such as age, LV mass, early to late mitral inflow ratio, A’ velocity, LV ejection fraction and left atrial size, whereas such a correlation could not be found in NG. Conclusion : Since exercise performance decreases when there is LV concentric remodeling, LV geometry needs to be considered in the assessment of exercise capacity in patients with essential hypertension and isolated diastolic dysfunction. Atrial systolic function plays a crucial role in maintaining exercise capacity in these patients, especially in those with increased LV concentricity.

Effects of angiotensin II receptor blockade‐based therapy with losartan on left ventricular hypertrophy and geometry in previously treated hypertensive patients

Background. The 2003 European Society of Hypertension/European Society of Cardiology (ESH/ESC) guidelines recommend angiotensin II receptor antagonists (AIIRAs) as a first‐line therapy in hypertensives with left ventricular hypertrophy (LVH). Aim. We investigated the long‐term effects of an AIIRA‐based therapy on left ventricular (LV) structure and geometry in previously, unsatisfactorily treated essential hypertensive patients. Methods. Sixty‐eight consecutive patients referred to our hypertension hospital outpatient clinic with: (i) LVH (LV mass index, LVMI ⩾51 g/m2.7 in men and ⩾47 g/m2.7 in women), (ii) uncontrolled clinic blood pressure (BP⩾140 and/or 90 mmHg) and (iii) antihypertensive therapy not including angiotensin‐converting enzyme (ACE) inhibitors or AIIRAs were selected for this study. Two‐dimensionally guided M‐mode echocardiograms were carried out at baseline and after 6, 12, 18 and 24 months of follow‐up. In all patients, losartan (50–100 mg/day, mean dose 82 mg/day) was added as first step to the previous therapy. Additional drugs, tailored to the single patient, were added, if necessary, to achieve target BP values (<140/90 mmHg). Results. Overall, 59 patients completed the study with the primary efficacy measurements (LVMI) at all appropriate times. A significant reduction in both clinic systolic BP and diastolic BP was found across the entire period of study respect to baseline (−17/10, −22/12, −24/13 and −26/14 mmHg at 6, 12, 18 and 24 months, p<0.001 respectively), leading to target clinic BP in 75.6% of cases. LVMI was significantly lower after 1 year of treatment (−11±12%, p<0.05) with a further significant reduction at the end of treatment (−22±18%, p<0.01). The proportion of patients achieving normalization of LVMI was 47.4% and more importantly, the prevalence of concentric LVH fell from 38.9% to 6.7% (p<0.01). Conclusions. Our findings indicate that long‐term intensive treatment based on the AIIRA losartan induced a normalization of LVH in about 50% of patients and more importantly caused an almost complete regression of concentric LVH, the most dangerous adaptive pattern. The transition from concentric to normal or eccentric LV geometry may have in these high‐risk patients a favourable prognostic implication in addition to the recognized positive effect of reducing LVMI.

Left Ventricular Geometric Patterns After 1 Year of Antihypertensive Treatment

Left ventricular hypertrophy increases the risk for cardiovascular target organ damage, myocardial infarction, and stroke. The authors assessed the patterns of ventricular adaptation in 107 essential hypertensives whose treatment had been withdrawn and its modification after 1 year of hypertension treatment. Blood pressure decreased from 158+/-17/96+/-12 mm Hg to 137+/-15/83+/-10 mm Hg (mean +/- SD; p<0.001); 45% of the patients (49 of 107) had their blood pressure controlled below 140 mm Hg and 90 mm Hg. Although a significant decrease of left ventricular mass index was found in the study, the percentage of patients with normal left ventricular geometry at the completion of the study increased by only 9% (27% to 36%, p>0.05). Left ventricular mass geometry improved in 31% of the patients, remained unaffected in 51%, and worsened in 18%. The data suggest that even while suboptimal antihypertensive treatment reduces left ventricular mass index, either left ventricular hypertrophy or concentric remodeling remains present in a significant number of patients at the end of a 1-year treatment period. The authors conclude that these patients should be considered as a subgroup at high risk and should be treated more aggressively.

Left ventricular geometric patterns and cardiac function in patients with chronic renal failure undergoing hemodialysis

The aim of this study was to estimate the impact and prevalence of left ventricular geometric alterations and systolic and diastolic dysfunction in hemodialysis patients, as well as the relationship with cardiac troponin as a marker of myocardial damage. 31 patients (pts), 19 males and 12 females, age 58.1+/-16.4 (26 on hemodialysis, 5 on peritoneal dialysis) and 31 healthy normal controls were enrolled. Echocardiography measurements were carried out according to the American Society of Echocardiography recommendations. Left ventricular mass was calculated, according to the Devereux formula and indexed to height and weight 2.7. Doppler echocardiography was performed to study diastolic function by measurements of isovolumetric relaxation period (IVRT), E wave deceleretion time (DTE) and E/A ratio. Cardiac troponin was measured by a third generation electro-chemiluminescence immunoassay. Statistical analysis was performed using the t-test for between-group comparisons and the Pearson and Spearman's tests to investigate correlations; p values of <0.05 were considered statistically significant. Eccentric hypertrophy was the most frequent pattern (n=17; 55%), followed by normal cardiac geometry (n=7; 23%), and concentric hypertrophy (n=5; 16%). Only 6% of pts (n=2) showed concentric remodelling. Systolic dysfunction was present in terms of endocardial parameters in 3 pts (9%) (fractional shortening <25%, EF<50%), but in terms of midwall myocardial shortening in 51% (n=16). Diastolic dysfunction was present in 87% (n=27) with a pattern of impaired relaxation (in 5 without left ventricular hypertrophy). E/A was negatively correlated with age (r=-0.41, p=0.02); DTE was positively correlated with posterior wall thickness (r=0.36, p=0.05) and interventricular septum thickness (r=0.45, p=0.01); cardiac troponin was positively correlated with age (r=0.50, p=0.00), left ventricular mass (r=0.41, p=0.02), posterior wall thickness (r=0.41; p=0.02) and interventricular septum thickness (r=0.39, p=0.03) but not with diastolic dysfunction parameters. No significant difference was found in terms of duration of dialysis between patients with normal left ventricular geometry and those with left ventricular hypertrophy, but a significant difference in age was found (p=0.03). Pts with diastolic dysfunction had more frequent hypotensive episodes during dialysis (p<0.01). Impaired geometry and cardiac function is frequently observed in pts undergoing hemodialysis. Diastolic dysfunction is associated to a geometric pattern of left ventricular hypertrophy, although it can be an isolated initial manifestation of myocardial damage. Depressed midwall myocardial shortening can discriminate left ventricular dysfunction better than traditional endocardial systolic indexes.

Left ventricular concentric geometry is associated with impaired relaxation in hypertension: the HyperGEN study

We tested the hypothesis that abnormal left ventricular (LV) relaxation is associated with concentric LV geometry. Doppler LV filling properties were studied in 1384 hypertensive participants without cardiovascular disease, from the HyperGEN population (731 women, 784 obese, 236 diabetic) and compared in four LV geometry groups; normal, concentric remodelling (3.5%), eccentric (23%), and concentric LV hypertrophy (4%), based on echocardiographic LV mass index (in g/m(2.7)). Abnormal LV relaxation was identified by European Society of Cardiology criteria in 275 subjects (20%). After accounting for significant confounders, E/A ratio and isovolumic relaxation time were not related to the presence of LV hypertrophy, but indicated abnormal relaxation when LV geometry was concentric (both P<0.0001). Deceleration time of E velocity was prolonged with LV hypertrophy (P<0.03), but the behaviour in relation to concentric LV geometry differed in the presence (prolonged) or absence (reduced) of LV hypertrophy (P=0.05), a difference independently related to the magnitude of both transmitral gradients and stroke volume (all P<0.05). Logistic regression showed that, compared with normal LV geometry, the odds of abnormal LV relaxation was 2.3-fold greater when LV geometry was concentric and that LV hypertrophy conferred a borderline higher risk than normal LV mass. In hypertensive individuals without prevalent cardiovascular disease from a multi-ethnic population-based sample, delayed LV relaxation is independently associated with concentric LV geometry.

Prognostic value of left ventricular concentric remodeling in uncomplicated mild hypertension

The prognostic value of left ventricular (LV) concentric remodeling in essential hypertension, and particularly in uncomplicated mild hypertension, is not yet completely clear. We investigated cardiovascular outcome in uncomplicated mild hypertensive patients with normal LV geometry and LV concentric remodeling. The occurrence of fatal and nonfatal cardiovascular events was evaluated in 1088 uncomplicated mild hypertensive patients, 751 with normal LV geometry (LV mass index <125 g/m(2) in men and <110 g/m(2) in women and relative wall thickness <0.45) and 337 with LV concentric remodeling (LV mass index <125 g/m(2) in men and <110 g/m(2) in women and relative wall thickness >/=0.45). During follow-up (4.74 +/- 2.4 years, range 0.5 to 9.7 years) the event rates per 100 patient-years in subjects with normal LV geometry and LV concentric remodeling were 0.69 and 1.87, respectively. After adjustment for other covariates, Cox regression analysis showed that LV concentric remodeling (LV concentric remodeling versus normal LV geometry, RR 1.78, 95% CI 1.02 to 3.1, P < .05) was an independent predictor of cardiovascular events. In a population with uncomplicated mild hypertension, patients with LV concentric remodeling have a worse prognosis than those with normal LV geometry.

Update on mitral repair in dilated cardiomyopathy.

Heart failure is one of the leading causes of hospitalization worldwide. Mitral regurgitation (MR) is a known complication of end-stage cardiomyopathy and is associated with a poor prognosis due to progressive mitral annular dilation. A vicious cycle of continuing volume overload, ventricular dilation, progression of annular dilation, increased LV wall tension, and worsening of MR and CHF occur. Commonly, these patients were managed medically with diuretics and afterload reduction, and frequently with mitral valve replacement, both of which have poor long term survival in patients with CHF and MR. Over a 10-year period we prospectively studied over 200 patients with cardiomyopathy and severe MR who underwent mitral valve repair utilizing an undersizing overcorrecting annuloplasty ring. The mortality was low with one intraoperative death and eight 30-day mortalities. There were 26 late deaths; 2 of these patients had progression of heart failure and underwent transplantation. The 1-, 2-, and 5-year actuarial survivals have been 82%, 71%, and 52%, respectively. The NYHA class has improved for all patients from a preoperative mean of 3.2 +/- 0.2 to 1.8 +/- 0.4 postoperatively. All patients demonstrated improvement in ejection fraction, cardiac output, and end diastolic volumes with a reduction in sphericity index and regurgitant volume at 2 years post operation. All of the observed changes contribute to reverse remodeling and restoration of the normal left ventricular geometry. Mitral valve repair is a safe and effective operative intervention that corrects MR and offers a new strategy for patients with MR and end-stage cardiomyopathy.

The Influence of Aldosterone on the Development of Left Ventricular Geometry and Hypertrophy in Patients With Essential Hypertension

The identification of risk factors for the initiation of left ventricle hypertrophy (LVH), which is an independent risk factor for cardiovascular mortality and morbidity in hypertensive patients, is very important. The objective of the present study was to identify the relationship of aldosterone with LVH and different geometrical patterns of left ventricle that develop in patients with essential hypertension. A total of 83 patients with essential hypertension (44 females, mean age, 51 +/- 8 years, 39 males, mean age, 57 +/- 10 years) were included in this study. Thirty-two had LVH. When evaluated according to the geometrical patterns of LVH, 18 patients had concentric LVH, 14 had eccentric LVH, and 17 had concentric remodeling. Thirty-four patients had normal left ventricle geometry. Two weeks after the cessation of antihypertensive medications, sodium, potassium, and proteinuria in 24-hour urine samples and plasma aldosterone levels and plasma renin activity were measured. Plasma aldosterone levels of the patients with LVH were found to be significantly higher (9.92 +/- 6.34 ng/dL versus 5.83 +/- 3.5 ng/dL, P < 0.01). The difference between plasma renin activities was not statistically significant. Linear regression analysis revealed that plasma aldosterone level and age were independent parameters increasing left ventricle mass index. The plasma aldosterone levels of patients with concentric hypertrophy of the left ventricle were significantly higher than those of patients with normal geometry and concentric remodeling. There was no significant difference between plasma renin activities. Twenty-four hour urine protein concentrations of the patients with LVH were found to be significantly higher and sodium to be significantly lower. Plasma aldosterone levels seem to be correlated with LVH especially with concentric hypertrophy of the left ventricle in patients with essential hypertension.