Left Heart Failure Symptoms Research Articles

Independent predictors of mortality in peripartum cardiomyopathy: Casablanca university hospital

Peripartum cardiomyopathy (PPCM) is a rare, unrecognized and a life-threatening pregnancy-associated disease. It is established as left ventricular dysfunction occurring in the last month of pregnancy or the first 5 months postpartum in the absence of known aetiology or preexisting heart disease. More than half of affected women recover systolic function, although a minority requires mechanical support or cardiac transplantation (or both). We have conducted a five-year retrospective study to determine independent predictors of mortality in meadows cardiomyopathy. We retrospectively reviewed all the patients admitted for suspected PPCM in obstetric gynecology, cardiology or intensive care department from January 2017 to December 2022. A total of 88 patients were included in this study, all the patients were followed for at least 12 months after diagnosis. The mean age of our patients was 29 ± 5 years. The diagnosis was established antepartum in 24%, postpartum in 48% and 26% at the start of labor. The mean age of pregnancy at diagnosis was 34 ± 6 weeks of amenorrhea. Mean parity was 2.2 ± 1.8 and mean gravidity was 2.4 ± 1.6. Dyspnea and left heart failure symptoms were the most frequent signs of PPCM observed in our patients with respectively 92% and 41% for each. Mortality rate was 11.5% in our population, and were associated significantly with the absence of pregnancy follow-up (P < 0.01), preeclampsia (P = 0.045), altered left ejection fraction LVEF < 30% (P = 0.029) and severe mitral regurgitation (P = 0.036). PPCM is a rare and potentially life-threatening heart disease with a significant maternal morbidity and mortality rate. Early diagnosis based on transthoracic echocardiography is essential and appropriate medical therapy should be started rapidly (Table 1).

931 EVALUATION OF IATROGENIC ATRIAL SEPTAL DEFECT CLOSURE AFTER TEER

Abstract Iatrogenic atrial septal defect (iASD) represents one of the main access-related cardiac complications after trancatheter edge to edge (TEER) mitral valve repair with Mitraclip system. Transesophageal echocardiography (TEE) guiding supports a controlled and safe transseptal puncture. The rate of persistent iASD is 57, 50, and 25% after 1, 6, and 12 months post procedure. An elevated left atrial pressure after clip positioning correlates with iASD persistence. Its clinical impact is controversially discussed: Post-TEER iASD has been associated with right heart volume overload, as well as increased rates of heart failure (HF) hospitalization and death in some studies. In contrast, other studies have shown an association between post-TEER iASD and improved hemodynamics. In theory, creation of an iASD can decompress an overloaded left atrium, mitigating heart failure. Some studies have demonstrated that iASD closure can reduce significantly both right and left heart failure symptoms. We did a retrospective study enrolling in the period 2012-2022 twenty-one patients with severe mitral regurgitation treated with TEER. Our aim was to evaluate the clinical outcomes (symptoms, signs of heart failure, NYHA functional class) and echocardiographic parameters (PAPs, TAPSE, Right Atrium Area) in two group of patients: Group A underwent iASD closure during the TEER and Group B after one month following the TEER. At 1-month follow-up all patients with repaired mitral regurgitation showed an improvement in the NYHA class (from IV-III to II-I) and no need for re-hospitalization with no significant differences between two groups. In the Group A there were two adverse events during the recovery (2 major bleeding); while there were no adverse events in patients undergoing iASD closure after wise. There was 1 death in the first month after the procedure in group A, while there wasn't any in group B. Statistical analysis showed no significant differences in terms of NYHA class improvement in the two groups (p=0.91). We observed a greater reduction in PAPs in patients going to encounter intraprocedural DIA closure which was found to be statistically significant (p=0.01). Regarding TAPSE, there was a difference in terms of improvement which was found to be greater in the group A. However, this finding was not found to be statistically significant. We also assessed the right atrium area: in group A, we registered a mean preprocedural value of 28 cmq and a postprocedural value of 34 cmq; in group B the values were 20 cmq and 24 cmq, respectively, with a nonstatistically significant difference in terms of atrial enlargement post device placement. In conclusion, we can assume that the improvements in symptomatology are not closely related to iASD closure. However, it must considered that patients in group A had more unfavorable echocardiographic values before the procedure than those in group B, and probably, if we had not closed the iASD immediately during the procedure, these patients would have had worse symptomatology. Therefore, targeted patient selection is essential.

Return to work in heart failure patients with suspected viral myocarditis.

Background:Endomyocardial biopsy is considered as the gold standard in patients with suspected myocarditis. We aimed to evaluate the impact of bioptic findings on prediction of successful return to work.Methods:In 1153 patients (48.9 ± 12.4 years, 66.2% male), who were hospitalized due to symptoms of left heart failure between 2005 and 2012, an endomyocardial biopsy was performed. Routine clinical and laboratory data, sociodemographic parameters, and noninvasive and invasive cardiac variables including endomyocardial biopsy were registered. Data were linked with return to work data from the German statutory pension insurance program and analyzed by Cox regression.Results:A total of 220 patients had a complete data set of hospital and insurance information. Three quarters of patients were virus-positive (54.2% parvovirus B19, other or mixed infection 16.7%). Mean invasive left ventricular ejection fraction was 47.1% ± 18.6% (left ventricular ejection fraction <45% in 46.3%). Return to work was achieved after a mean interval of 168.8 ± 347.7 days in 220 patients (after 6, 12, and 24 months in 61.3%, 72.2%, and 76.4%). In multivariate regression analysis, only age (per 10 years, hazard ratio, 1.27; 95% confidence interval, 1.10–1.46; p = 0.001) and left ventricular ejection fraction (per 5% increase, hazard ratio, 1.07; 95% confidence interval, 1.03–1.12; p = 0.002) were associated with increased, elevated work intensity (heavy vs light, congestive heart failure, 0.58; 95% confidence interval, 0.34–0.99; p < 0.049) with decreased probability of return to work. None of the endomyocardial biopsy–derived parameters was significantly associated with return to work in the total group as well as in the subgroup of patients with biopsy-proven myocarditis.Conclusion:Added to established predictors, bioptic data demonstrated no additional impact for return to work probability. Thus, socio-medical evaluation of patients with suspected myocarditis furthermore remains an individually oriented process based primarily on clinical and functional parameters.

A Case of Accelerated Hypertension Complicated by Acute Coronary Syndrome and Bezold Jarisch Reflex

A 73-year-old woman presented with acute coronary syndrome on a background of worsening symptoms of left heart failure and accelerated hypertension. Patient was severely hypertensive with clinical findings suggestive of acute pulmonary congestion on presentation. Whilst being stabilised with medical therapy, patient developed multiple episodes of prolonged asystole (Fig. 1) with ongoing severe uncontrolled hypertension requiring haemodynamic support with temporary wire. Improved hypertension control over the next 24 hours stabilised the patient without recurrence of bradyarrhythmia. Secondary causes of severe hypertension were excluded and culprit ramus artery was stented. Bezold Jarisch reflex is a triad of bradycardia, asystole and hypotension which has been implicated in various cardiac conditions [[1]Mark A.L. The Bezold Jarisch reflex revisited: clinical implications of inhibitory reflexes originating in the heart.J Am Coll Cardiol. 1983; 1: 90-102Crossref PubMed Scopus (568) Google Scholar]. This case demonstrates accelerated hypertension complicated by acute coronary syndrome and acute pulmonary odema with multiple episodes of Bezold Jarisch Reflex mediated bradycardia and asystole. Asystolic episodes resulted from increased vagal stimulation due to stretching of mechanoreceptors in ventricular myocytes during accelerated hypertensive episode [[2]Julius S. Esler M. Increased central blood volume: a possible pathophysiological factor in mild low-renin esse ntial hypertension.Clin Sci Mol Med Suppl. 1976; 3: 207s-210sPubMed Google Scholar]. Decongestive therapy and optimisation of hypertension control resulted in complete resolution of bradyarrhythmia. Recognition of association of BJR with accelerated hypertension is important because treatment of hypertension restores the baroreceptor function without requiring permanent pacing.

Treatment of a GIST patient with modified dose of sunitinib by measurement of plasma drug concentrations

In this study we report the pharmacokinetics and severe adverse effects of sunitinib in a woman with a gastrointestinal stromal tumor (GIST). A 60-year-old woman with small intestinal GIST developed severe thrombocytopenia (1.7×10(4)/μl) following 1 week of treatment with sunitinib at 50 mg/day. Although the dose of sunitinib was reduced to 25 mg/day, platelet levels remained low. On day 7, the trough concentration of sunitinib plus SU12662 was 46.1 ng/ml and the area under the curve (AUC) was 1,393.0 ng·h/l. The dose was again reduced to 12.5 mg/day. However, the day after resumption of treatment, the patient developed symptoms of left heart failure due to myocardosis caused by sunitinib. Sunitinib has been reported to inhibit platelet-derived growth factor receptor (PDGFR) phosphorylation at concentrations over the range of 50-100 ng/ml (sunitinib plus SU12662) in vivo. In this case, the plasma concentration was sufficient to inhibit PDGFR at 25 or 50 mg/day. However, thrombocytopenia appeared at both dosages. Although the results in this case did not suggest a correlation between thrombocytopenia and plasma concentration, the degree of thrombocytopenia was decreased by reduction of the dose. In conclusion, the findings reported here indicate that the plasma concentration of sunitinib plus SU12662 is an important indicator to reduce adverse effects.

Mediastinal Testicular Tumor Compressing the Left Atrium in a Young Male Presenting Initially with Symptoms of Left Heart Failure

Extrinsic left atrial compression is an uncommon source of hemodynamic compromise that can be caused by many mediastinal structures including bronchogenic cysts, carcinoma, lymphoma, thymoma, aortic aneurysm and diaphragmatic hernia. We describe an unusual case of a 26-year-old man presenting with symptoms of left heart failure. Transthoracic echocardiography demonstrated extrinsic left atrial compression caused by a metastatic testis non-seminomatous germ cell tumor. Compression of the left atrium caused impaired left atrial filling, leading to pulmonary venous hypertension and pulmonary edema. To our knowledge, the present case is the first reported case of mediastinal metastatic testis non-seminomatous germ cell tumor causing symptoms of left heart failure by externally compressing the left atrium.

Multiple cardiac lipomas and pericardial lipomatosis: Multidedector-row computer tomography findings

Being rare tumors of the heart, cardiac lipomas are usually discovered incidentally during non-cardiac-related examinations of the chest. Although they are reported to be typically solitary, multiplicity has been described in tuberosclerosis patients. Here we reported the multidedector-row computer tomography (MDCT) findings of a nontuberosclerosis case with multiple cardiac lipomas along with pericardial lipomatosis, who presented with symptoms of left heart failure after a hysterectomy surgery but otherwise healthy before that operation.

Left Ventricular Diastolic Function

Two-dimensional echocafdiography has gained widespread acceptance I as the procedure of choice to evaluate left ventricular function. In the last decade, the importance of diastolic function in the overall performance of the left ventricle has received much attention. Recent evidence suggests that diastolic dysfunction may contribute to symptoms of left heart failure in many patients, including those with normal sys tolic function. Alterations in transmitral Dop pler flow velocity patterns have been used to assess changes in left ventricular diastolic func tion. This article reviews the concept and clin ical signincance of diastolic function and the assessment of diastolic function by Doppler echocardiography.

Clinical Diagnosis of Congestive Heart Failure in Patients with Acute Dyspnea

The validity and utility of physical examination maneuvers were determined in diagnosing congestive heart failure (CHF) in patients with acute dyspnea. Fifty one patients presented to the emergency room with the chief complaint of shortness of breath. History and physical examination were obtained independently, and the physical examination included hepatojugular reflux and the Valsalva maneuver. The diagnosis of CHF was made by predetermined criteria, and was compared with the diagnosis of the emergency room (ER) physician and with the response to bedside maneuvers. The hepatojugular reflux and Valsalva maneuvers were valid in the diagnosis of congestive heart failure in acutely dyspneic patients. Although these maneuvers rarely added to the routine assessment of patients in this study, they may provide a useful, noninvasive adjunct to clinical diagnosis in problematic cases.

Studies on Starling's Law of the Heart

The hemodynamic functions of the left atrium were studied in 26 patients with disturbances of left ventricular function and in 16 subjects without any abnormalities of the cardiovascular system. Attention was directed to the effect of atrial systole on the relationship between mean left atrial pressure (MLAP) and left ventricular end-diastolic pressure (LVEDP). This relationship was considered to be a meaningful one in view of the importance of the LVEDP in determining the characteristics of ventricular contraction, and of the MLAP in determining the symptoms of left heart failure. In the subjects with normal cardiovascular systems, LVEDP-MLAP averaged 0.2 mm. Hg, but this value averaged 9.0 mm. Hg in patients with left ventricular disease, in whom left atrial contraction elevated LVEDP while permitting MLAP to remain at a significantly lower level. The magnitude of the pressure difference between LVEDP and MLAP was found to be dependent on the characteristics of atrial contraction; the height of the "a" wave appeared to be related to the atrial pressure prior to the onset of atrial contraction. The elevation of atrial pressure produced by atrial systole was found to vary directly with the time interval between the onset and the peak of the "a" wave and to vary inversely with the time interval between the peak of the "a" wave and the onset of ventricular contraction. Evidence was presented that in intact human subjects the characteristics of left atrial and left ventricular contraction are functions of the pressures in these chambers prior to the onset of their contraction, thus lending further support to the concept that Starling's law is operative in the human heart.