Ventricular End-diastolic Area Research Articles

Pharmacokinetics and Pharmacodynamics of Nebulized and Intratracheal Milrinone in a Swine Model of Hypercapnia Pulmonary Hypertension

Milrinone pulmonary administration is used currently for the treatment of pulmonary hypertension. Several methods are available: simple jet nebulization, vibrating mesh nebulization, intratracheal instillation, and intratracheal atomization. The aim of this study was to explore the concentration-effect relationship of milrinone for each of these methods. Observational open-label pharmacokinetic/pharmacodynamics cohort study. Single-center, hospital animal laboratory. Twelve swine. After hypercapnia pulmonary hypertension, swine were administered equivalent inhaled milrinone doses of 15 or 50 µg/kg through simple jet nebulization, vibrating mesh nebulization, intratracheal instillation, and intratracheal atomization. Blood and urine samples were taken up to 360 minutes postadministration. The ratio of mean systemic arterial pressure to mean pulmonary arterial pressure was monitored continuously. Right heart echographies were taken before and after hypercapnia and after drug administration. Mean elimination half-lives were similar for the 4 administrations. Mean percent changes in the ratio were of 37 (60%), 18 (31%), 17 (36%), and 20 (20%), for simple jet nebulization, vibrating mesh nebulization, intratracheal instillation, and intratracheal atomization, respectively. Mean maximum plasma concentrations for intratracheal administrations were reached at 8 and 45 min for atomization and instillation, respectively. Significant increases in right atrial diameter and right ventricular end-diastolic area were witnessed during pulmonary hypertension as well as a return to baseline values after milrinone administration. The intratracheal methods, particularly intratracheal atomization, showed less hemodynamic effect than nebulizations and, in the case of intratracheal instillation, unpredictable drug exposure. Nebulization methods on the other hand, especially simple jet nebulization, suggest better efficacy and sensitivity but are less fit for emergency situations.

Assessment of Left Ventricular Dimensions by Transoesophageal Echocardiography in Patients During Coronary Artery Bypass Surgery.

Normative values of left ventricular (LV) end-diastolic area and diameter (EDA and EDD) for intraoperative transoesophageal echocardiography (TEE) have not been established. We aimed to define the ranges of LV EDA and EDD for intraoperative TEE examinations in patients undergoing coronary artery bypass graft (CABG) surgery. A MEDLINE search for studies reporting LV EDA and EDD in CABG patients was performed. Individual-level dataset from 333 anaesthetised and mechanically ventilated patients with preserved LV function (study population) were received from 8 studies. EDA and calculated EDD values in the study population were compared with summary mean EDD values obtained by transthoracic echocardiography (TTE) in 2 studies of 500 awake patients with coronary artery disease (CAD). Further, the influence of prespecified factors on EDD was evaluated through a multivariate regression model. LV EDA and EDD values measured by TEE in anaesthetised CABG patients were 16.7±4.7 cm2 and 4.6±0.6 cm, respectively. EDD values measured by TEE in anaesthetised patients were 10% to 13% less those measured by TTE in 2 studies of awake patients (p<0.001). Body surface area, age and fractional area change but not sex were factors that affected LV EDD. LV EDD values measured by intraoperative TEE in anaesthetised and mechanically ventilated CABG patients were 10% to 13% less than those measured by TTE in awake CAD patients. This finding indicates that independent normative values specific for intraoperative TEE should be established for guiding intraoperative clinical decisions.

Clinical risk score for the diagnosis of acute cor pulmonale in acute respiratory distress syndrome

Context Acute cor pulmonale (ACP) is a common sequela in patients with acute respiratory distress syndrome (ARDS) and represents the most severe presentation of right ventricular dysfunction, secondary to pulmonary vascular dysfunction. Although most previous studies adopted transesophageal echocardiography in the diagnosis of ACP in patients with ARDS, transthoracic echocardiography (TTE) appears as a promising alternative, being noninvasive and more available with continuously improving expertise in its use by ICU physicians. Aims Our study aimed to test the accuracy of ACP risk score by TTE. Settings and design This is a prospective observational cross-sectional study that was carried out over 6 months in our department. Patients and methods Our study was carried out on 45 mechanically ventilated patients with ARDS, who had been subjected to lung-protective approach. TTE was performed within the first 72 h of ARDS diagnosis. ACP was diagnosed when the ratio of right ventricular/left ventricular end-diastolic area more than 0.6 on parasternal short-axis view or apical four chambers view associated with interventricular septum dyskinesia in a parasternal short-axis or long-axis view at end-systole. ACP risk score parameters were checked and scored; (one point for each parameter). It consisted of pneumonia, hypercapnia arterial carbon dioxide tension of at least 48 mmHg, driving pressure of at least 18 cmH2O, and arterial oxygen tension/fractional inspired oxygen less than 150 mmHg. Qualitative data were described using number and percentage. Quantitative data were described using mean and SD, median, minimum and maximum. Comparison between different groups’ variables had been tested using χ2-test. Receiver operating characteristic curve expressed a recommended cutoff. The area under the receiver operating characteristic curve denotes the diagnostic performance of the test. Area of significance of the obtained results was judged at the 5% level (P<0.05). Results ACP risk score showed high sensitivity (100%), average specificity (51.43%), and good overall accuracy (62.2%) when score of at least 2 was used as a cutoff value. Hypercapnia, pneumonia, hypoxia, high plateau pressure, and positive end-expiratory pressure were associated with increased ACP incidence in patients with ARDS. Conclusion ACP risk score is a highly sensitive score in predicting and diagnosing ACP in patients with ARDS.

Morphologic and Functional Changes in Right-Sided Cardiac Chambers in Patients With Chronic Liver Disease and Normal Pulmonary Artery Pressure.

To investigate the effects of chronic liver disease (CLD) on the structural and functional characteristics of right-sided heart chambers in patients with normal pulmonary artery pressure. Fifty-one patients with known CLD but without pulmonary hypertension or other cardiovascular conditions were consecutively enrolled, along with 25 age- and sex-matched participants. Patients with CLD were classified according to the Model of End-Stage Liver Disease score and Child-Pugh classification. Right ventricular (RV) and right atrial (RA) dimensions, indices of RV systolic/diastolic function, and myocardial strain were measured by standard echocardiographic methods. Patients in the study group had similar RV end-diastolic, end-systolic, and RA dimensions compared to controls. Similarly, neither the conventional indices of RV systolic/diastolic function nor the strain imaging findings were different between groups (P > .05). Only RV free wall thickness was significantly higher in the study group (mean ± SD, 4.15 ± 0.64 versus 3.75 ± 0.37 mm; P < .001). Right ventricular end-diastolic diameter (P = .018; r = 0.334) and RA area (P = .017; r = 0.335) had a significant correlation with RV free wall thickness in patients with CLD. Patients treated with beta blockers were found to have a significant reduction in mean RV free wall strain compared to patients who did not receive beta blocker treatment (-20.37 ± 6.6 versus -24.07 ± 6.52; P = .04). Patients with CLD had increased RV free wall thickness despite normal systolic pulmonary pressure, presumably secondary to cirrhotic cardiomyopathy. In the absence of pulmonary hypertension, however, cirrhotic cardiomyopathy did not cause impaired RV systolic or diastolic function.

Reproducibility of Left Ventricular Dimension Versus Area Versus Volume Measurements in Pediatric Patients With Dilated Cardiomyopathy.

Multiple echocardiographic methods are used to measure left ventricular size and function. Clinical management is based on individual evaluations and longitudinal trends. The Pediatric Heart Network VVV study (Ventricular Volume Variability) in pediatric patients with dilated cardiomyopathy has reported reproducibility of several of these measures, and how disease state and number of beats impact their reproducibility. In this study, we investigated the impact of observer and sonographer variation on reproducibility of dimension, area, and volume methods to determine the best method for both individual and sequential evaluations. In 8 centers, echocardiograms were obtained on 169 patients prospectively. During the same visit, 2 different sonographers acquired the same imaging protocol on each patient. Each acquisition was analyzed by 2 different observers; first observer analyzed the first acquisition twice. Intraobserver, interobserver, interacquisition, and interobserver-acquisition (different observers and different acquisition) reproducibility were assessed on measurements of left ventricular end-diastolic dimension, area, and volume. Left ventricular shortening fraction, ejection fraction, mass, and fractional area change were calculated. Percent difference was calculated as (interobservation difference/mean)×100. Interobserver reproducibility for both acquisitions was better for both volume and dimension measurements (P≤0.002) compared with area measurements, whereas intraobserver, interacquisition (for both observers), and interobserver-acquisition reproducibilities (for both observer-acquisition sets) were best for volume measurements (P≤0.01). Overall, interobserver-acquisition percent differences were significantly higher than interobserver and interacquisition percent differences (P<0.001). In pediatric patients with dilated cardiomyopathy, compared with dimension and area methods, left ventricular measurements by volume method have the best reproducibility in settings where assessment is not performed by the same personnel. URL: https://www.clinicaltrials.gov. Unique identifier: NCT00123071.

The relationship between single and two-dimensional indices of left ventricular size using hemodynamic transesophageal echocardiography in trauma and burn patients

BackgroundConventional echocardiographic technique for assessment of volume status and cardiac contractility utilizes left ventricular end-diastolic area (LVEDA) and fractional area of change (FAC), respectively. Our goal was to find a technically reliable yet faster technique to evaluate volume status and contractility by measuring left ventricular end-diastolic diameter (LVEDD) and fractional shortening (FS) in a cohort of mechanically ventilated trauma and burn patients using hemodynamic transesophageal echocardiographic (hTEE) monitoring.MethodsRetrospective chart review performed at trauma/burn intensive care unit (TBICU). Data on 88 mechanically ventilated surgical intensive care patients cared for between July 2013 and July 2015 were reviewed. Initial measurements of LVEDA, left ventricular end-systolic area (LVESA) and FAC were collected. Post-processing left ventricular end-systolic (LVESD) and end-diastolic diameters (LVEDD) were measured and fractional shortening (FS) was calculated. Two orthogonal measurements of LV diameter were obtained in transverse (Tr) and posteroanterior (PA) orientation.ResultsThere was a significant correlation between transverse and posteroanterior left ventricular diameter measurements in both systole and diastole. In systole, r = 0.92, p < 0.01 for LVESD-Tr (mean 23.47 mm, SD ± 6.77) and LVESD-PA (mean 24.84 mm, SD = 8.23). In diastole, r = 0.80, p < 0.01 for LVEDD-Tr (mean 37.60 mm, SD ± 6.45), and LVEDD-PA diameters (mean 42.24 mm, SD ± 7.97). Left ventricular area (LVEDA) also significantly correlated with left ventricular diameter LVEDD-Tr (r = 0.84, p < 0.01) and LVEDD-PA (r = 0.90, p < 0.01). Both transverse and PA measurements of fractional shortening were significantly (p < 0.0001) and similarly correlated with systolic function as measured by FAC. Bland–Altman analyses also indicated that the assessment of fractional shortening using left ventricular posteroanterior diameter measurement shows agreement with FAC.ConclusionsLeft ventricular diameter measurements are a reliable and technically feasible alternative to left ventricular area measurements in the assessment of cardiac filling and systolic function.

Fluid loading and norepinephrine infusion mask the left ventricular preload decrease induced by pleural effusion

BackgroundPleural effusion (PLE) may lead to low blood pressure and reduced cardiac output. Low blood pressure and reduced cardiac output are often treated with fluid loading and vasopressors. This study aimed to determine the impact of fluid loading and norepinephrine infusion on physiologic determinants of cardiac function obtained by ultrasonography during PLE.MethodsIn this randomised, blinded, controlled laboratory study, 30 piglets (21.9 ± 1.3 kg) had bilateral PLE (75 mL/kg) induced. Subsequently, the piglets were randomised to intervention as follows: fluid loading (80 mL/kg/h for 1.5 h, n = 12), norepinephrine infusion (0.01, 0.03, 0.05, 0.1, 0.2 and 0.3 μg/kg/min (15 min each, n = 12)) or control (n = 6). Main outcome was left ventricular preload measured as left ventricular end-diastolic area. Secondary endpoints included contractility and afterload as well as global measures of circulation. All endpoints were assessed with echocardiography and invasive pressure-flow measurements.ResultsPLE decreased left ventricular end-diastolic area, mean arterial pressure and cardiac output (p values < 0.001), but fluid loading (20 mL/kg) and norepinephrine infusion (0.05 μg/kg/min) restored these values (p values > 0.05) to baseline. Left ventricular contractility increased with norepinephrine infusion (p = 0.002), but was not affected by fluid loading (p = 0.903). Afterload increased in both active groups (p values > 0.001). Overall, inferior vena cava distensibility remained unchanged during intervention (p values ≥ 0.085). Evacuation of PLE caused numerical increases in left ventricular end-diastolic area, but only significantly so in controls (p = 0.006).ConclusionsPLE significantly reduced left ventricular preload. Both fluid and norepinephrine treatment reverted this effect and normalised global haemodynamic parameters. Inferior vena cava distensibility remained unchanged.The haemodynamic significance of PLE may be underestimated during fluid or norepinephrine administration, potentially masking the presence of PLE.

Efectos de la inducción inhalatoria con sevoflurano sobre la función ventricular izquierda

ObjectiveIn the present study, we studied the effect of inhalational induction with sevoflurane on left ventricular systolic and diastolic function. Patients and methodsA prospective study was carried out on 58 healthy patients, ASA I-II, aged 18- 60 years and scheduled for general surgery. After administration of 0.05mg kg–1 of intravenous midazolam, transthoracic echocardiography was performed, measuring: fractional shortening (FA), ejection fraction (EF), cardiac output (CO) and left ventricular end diastolic area index (LVEDAI). Subsequently, we used an apical four chambers view for measuring transmitral Doppler, calculating: wave E peak velocity (pE), wave A peak velocity (pA), E/A ratio (E/A) and deceleration time (DT). Immediately after an inhalational anesthesia was induced with sevoflurane 8% through a face mask maintaining spontaneous ventilation and when the end tidal of sevoflurane reached a value of 4% a new echocardiography was performed by the same observer measuring the same parameters. ResultsWe observed a decrease in mean arterial pressure of 8.33% (95% CI –11.77% - –4.90%), an increase in cardiac output 7.8% (CI95% 0.08%-15.52%) and an increase in E/A ratio 5.92% (95% CI 2.45%-9.38%), all with statistical significance. However, we found no statistically significant changes in heart rate, FA, FE, IC, PE, PA or DT. ConclusionsAccording to our study, induction with sevoflurane does not cause significant changes in systolic left ventricular function.

Dobutamine aggravates haemodynamic deterioration induced by pleural effusion: A randomised controlled porcine study.

Pleural effusion is a common finding in critically ill patients and may contribute to circulatory instability and the need for inotropic support. We hypothesised that dobutamine would affect the physiological determinants preload, afterload, contractility and changes of inferior vena cava characteristics during experimental pleural effusion. A randomised, controlled laboratory study. Animal laboratory, conducted from March 2013 to May 2013. Twenty-four Landrace and Yorkshire female piglets (21.3 ± 1.7 kg). Twenty piglets were included in the analyses. After inducing bilateral pleural effusion (30 ml kg), the piglets were block randomised to either incremental dobutamine infusion (n = 10) or control (n = 10). Ultrasonographic measures of left ventricular end-diastolic area, left ventricular afterload, left ventricular fractional area change and inferior vena cava diameter and distensibility were used to assess the basic physiological effect of incremental dobutamine administration during experimental pleural effusion. In the dobutamine group, preload, measured as left ventricular end-diastolic area, decreased from 11.3 ± 2.0 cm after creation of the pleural effusion to 8.1 ± 1.5 cm at a dobutamine infusion rate of 20 μg kg min (P < 0.001). In the same period, central venous pressure and the expiratory diameter of the inferior vena cava decreased from 9 ± 3 to 7 ± 4 mmHg (P < 0.001) and from 1.1 ± 0.2 to 0.9 ± 0.1 cm (P = 0.008), respectively. In a porcine model of pleural effusion, dobutamine affected basic haemodynamic determinants substantially by decreasing left ventricular preload. Changes in central venous pressure and inferior vena cava characteristics were minimal, discouraging their use as indices of preload. This study underlines the significance of evaluating basic haemodynamic determinants to avoid inappropriate, potentially harmful treatment.

Influence of the Valsalva maneuver on cardiac hemodynamics and right to left shunt in patients with patent foramen ovale

The purpose of this study was to investigate the influence of the Valsalva maneuver (VM) on cardiac hemodynamics in patients with patent foramen ovale (PFO). Sixty-five patients who were highly suspected to have PFO were included. The changes in E, A, E/A ratio of mitral valve blood flow, E, A, E/A ratio of tricuspid valve blood flow, left ventricular end-diastolic volume, area and right atrial area during the resting state and the strain phase of the Valsalva maneuver were observed by transthoracic echocardiography (TTE). Statistical analyses were performed using SPSS Version18.0. Compared to the resting state, mitral valve diastolic velocity E and A peaks at the strain phase of the Valsalva maneuver significantly decreased (P < 0.05), left ventricular end diastolic volume(LVEDV) and area(LVEDA) decreased significantly (P < 0.05), while E/A ratio of mitral valve, tricuspid valve systolic velocity E and A peaks and E/A ratio remained unchanged (P > 0.05). PFO hemodynamic changes mainly occurred in the left ventricle when the Valsalva maneuver was performed. The Valsalva maneuver increased pressure in the chest, then pulmonary venous return was impeded, which resulted in left ventricular limited filling, and E and A peaks decreased. The pressure of the left ventricle and atrium was lower than that of the right side, which resulted in right-to-left shunt (RLS) through PFO.

Frequency and Associated Clinical Features of Functional Tricuspid Regurgitation in Patients With Chronic Atrial Fibrillation

Significant functional tricuspid regurgitation (TR) can develop in some but not all patients with chronic atrial fibrillation (AF). This study sought to identify factors likely to be involved in determining the severity of TR in patients with chronic AF. In this retrospective cohort study of adult patients referred for transthoracic echocardiography for evaluation of AF between 2004 and 2015, we identified 170 patients with chronic AF in the absence of structural or known coronary heart disease. Patients were classified into nonsevere (89patients) versus severe TR (81 patients) groups based on a comprehensive assessment of color Doppler, spectral Doppler, and morphologic parameters of the tricuspid valve and right side of the heart. Patients with severe TR were significantly older (76 ± 10 vs 70 ± 11, p<0.001), with smaller body surface area (1.7 ± 0.3m2 vs 1.9 ± 0.23m2, p= 0.001) and with female predominance (percentage of men 30% vs 57%, p <0.001). Although comorbidities, use of cardiovascular medications, and left-sided cardiac parameters were statistically indistinguishable between these 2 groups, right-sided cardiac dimensions, tricuspid valve tethering height, and tricuspid valve tethering area were significantly larger in the severe TR group. A comprehensive multivariate logistic regression model (model 1) identified the age, gender, right ventricular systolic pressure, right atrial volume index, and right ventricular end-diastolic area as independent factors associated with TR severity. A simplified logistic regression model using only clinical factors (model 2) confirmed the age, gender, and right ventricular systolic pressure as clinically relevant factors in relation to TR.

Sonographic Evaluation of Internal Jugular Vein Diameter and Cross-sectional Area Measurements in Correlation with Left Ventricular End Diastolic Area as a Tool for Perioperative Assessment of Volume Status in Pediatric Patients Undergoing Cardiac Surgery.

Aim:The aim of this study is to compare the ultrasound estimation of the cross-sectional area (CSA) and diameter of internal jugular vein (IJV) with left ventricular end diastolic area (LVEDA) for the assessment of intravascular volume in pediatric patients during cardiac surgery.Patients and Methods:The CSA and diameter of the left IJV were defined, using ultrasound machine, and compared with LVEDA, estimated by transesophageal echo, in four times intervals (immediately after induction [T1], before the start of cardiopulmonary bypass [CPB] [T2], immediately after weaning of CPB [T3], and at the end of surgery before transfer to the Intensive Care Unit [T4]) as a tool for intravascular volume assessment in 16 pediatric patients undergoing cardiac surgery.Results:There was a poor correlation between IJV CSA and diameter with LVEDA. r values were 0.158, 0.265, 0.449, and 0.201 at the four time intervals (T1, T2, T3, and T4), respectively.Conclusion:Estimation of the CSA and diameter of the left IJV using ultrasound is not reliable and cannot be used alone to decide further management.

A Clinical and Echocardiographic Score to Identify Pulmonary Hypertension Due to HFpEF

BackgroundHeart failure with preserved ejection fraction (HFpEF) is a frequent cause of pulmonary hypertension (PH) that is not easy to differentiate from precapillary PH. We aimed to determine whether the characteristic features of the patients may help differentiate between HFpEF and precapillary PH. Methods and resultsClinical and echocardiographic parameters were analyzed in 156 patients referred to our PH referral center. Right heart catheterization identified 78 PH-HFpEF patients and 78 with precapillary PH. Compared with precapillary PH, PH-HFpEF patients were older, with a smaller proportion of women, a higher proportion of hypertension, diabetes mellitus, atrial fibrillation and sleep apnea syndrome, and a higher body mass index. On echocardiography, PH-HFpEF patients had higher left ventricular mass index, higher left atrial area, and smaller right ventricular end-diastolic area. Following multivariate analysis, a model predicting the probability of PH-HFpEF was built with history of diabetes mellitus, presence of atrial fibrillation, left atrial area, right ventricular end-diastolic area, and left ventricular mass index. The score was internally validated using bootstrap method (area under the curve 0.93 [95% confidence interval 0.918–0.938]). A score <5 ruled out PH-HFpEF. ConclusionA score including clinical and echocardiographic criteria may help physicians to identify PH-HFpEF from precapillary PH.

Echocardiographic B-mode evaluation of the right heart in older people: The ActiFE Study

PurposeRight heart B-mode echocardiography reference values have been predominantly obtained in younger age cohorts (<65years). Aims of the study were to describe and evaluate the feasibility of right heart B-mode echocardiography in a large geriatric cohort and to analyze standard parameters in defined subgroups with or without any evidence for structural cardiac disease. MethodsActiFE-Ulm study is a population-based cohort study including a sample of people≥65years old living in the region of Ulm, Germany. Echocardiography including right heart parameters was performed within a cardiovascular follow-up of 688 subjects. Principal resultsNon-obtainability of right heart B-mode data was rather not a consequence of accompanying cardiac diseases or risk factors but of a more obese body composition. Mean values of right heart measurements of our subpopulation of subjects without evidence for structural cardiac disease were continuously higher than those of the guidelines (e.g. mean right ventricular end diastolic area 23.5±5.6cm2 (males), 20.3±5.0cm2 (females)). On an individual basis, guideline-suggested abnormality thresholds were also often exceeded, whereas this situation occurred more often in male than in female subjects. Major conclusionsMethodically, right heart B-mode echocardiography in older subjects is challenging. Our results suggest an ageing-associated right heart enlargement. Utilization of published right heart reference values in older adults seems to be problematic and in clinical practice, they always have to be interpreted within the clinical and functional context and in relation to other right heart echocardiographic parameters.

Association of Weight and Body Composition on Cardiac Structure and Function in the ARIC Study (Atherosclerosis Risk in Communities).

Obesity increases cardiovascular risk. However, the extent to which various measures of body composition are associated with abnormalities in cardiac structure and function, independent of comorbidities commonly affecting obese individuals, is not clear. This study sought to examine the relationship between body mass index, waist circumference, and percent body fat with conventional and advanced measures of cardiac structure and function. We studied 4343 participants of the ARIC study (Atherosclerosis Risk in Communities) who were aged 69 to 82 years, free of coronary heart disease and heart failure, and underwent comprehensive echocardiography. Increasing body mass index, waist circumference, and body fat were associated with greater left ventricular (LV) mass and left atrial volume indexed to height(2.7) in both men and women (P<0.001). In women, all 3 measures were associated with abnormal LV geometry, and increasing waist circumference and body fat were associated with worse global longitudinal strain, a measure of LV systolic function. In both sexes, increasing body mass index was associated with greater right ventricular end-diastolic area and worse right ventricular fractional area change (P≤0.001). We observed similar associations for both waist circumference and percent body fat. In a large, biracial cohort of older adults free of clinically overt coronary heart disease or heart failure, obesity was associated with subclinical abnormalities in cardiac structure in both men and women and with adverse LV remodeling and impaired LV systolic function in women. These data highlight the association of obesity and subclinical abnormalities of cardiac structure and function, particularly in women.

Comparison between Variable and Conventional Volume-Controlled Ventilation on Cardiorespiratory Parameters in Experimental Emphysema.

Emphysema is characterized by loss of lung tissue elasticity and destruction of structures supporting alveoli and capillaries. The impact of mechanical ventilation strategies on ventilator-induced lung injury (VILI) in emphysema is poorly defined. New ventilator strategies should be developed to minimize VILI in emphysema. The present study was divided into two protocols: (1) characterization of an elastase-induced emphysema model in rats and identification of the time point of greatest cardiorespiratory impairment, defined as a high specific lung elastance associated with large right ventricular end-diastolic area; and (2) comparison between variable (VV) and conventional volume-controlled ventilation (VCV) on lung mechanics and morphometry, biological markers, and cardiac function at that time point. In the first protocol, Wistar rats (n = 62) received saline (SAL) or porcine pancreatic elastase (ELA) intratracheally once weekly for 4 weeks, respectively. Evaluations were performed 1, 3, 5, or 8 weeks after the last intratracheal instillation of saline or elastase. After identifying the time point of greatest cardiorespiratory impairment, an additional 32 Wistar rats were randomized into the SAL and ELA groups and then ventilated with VV or VCV (n = 8/group) [tidal volume (VT) = 6 mL/kg, positive end-expiratory pressure (PEEP) = 3 cmH2O, fraction of inspired oxygen (FiO2) = 0.4] for 2 h. VV was applied on a breath-to-breath basis as a sequence of randomly generated VT values (mean VT = 6 mL/kg), with a 30% coefficient of variation. Non-ventilated (NV) SAL and ELA animals were used for molecular biology analysis. The time point of greatest cardiorespiratory impairment, was observed 5 weeks after the last elastase instillation. At this time point, interleukin (IL)-6, cytokine-induced neutrophil chemoattractant (CINC)-1, amphiregulin, angiopoietin (Ang)-2, and vascular endothelial growth factor (VEGF) mRNA levels were higher in ELA compared to SAL. In ELA animals, VV reduced respiratory system elastance, alveolar collapse, and hyperinflation compared to VCV, without significant differences in gas exchange, but increased right ventricular diastolic area. Interleukin-6 mRNA expression was higher in VCV and VV than NV, while surfactant protein-D was increased in VV compared to NV. In conclusion, VV improved lung function and morphology and reduced VILI, but impaired right cardiac function in this model of elastase induced-emphysema.

Early subclinical dysfunction of right cardiac system induced by anthracycline manifested as morphological changes

Objective Both right and left ventricular function should be taken into account in the assessment of anthracycline (ATC)-induced cardiotoxicity. The aim of this study was to assess the subclinical dysfunction of right cardiac system in patients with newly diagnosed lymphoma who received ATC treatment by echocardiography. Methods A total of 74 patients with lymphoma who received ATC treatment were enrolled. Each patient underwent transthoracic echocardiographic examination before chemotherapy as well as after two, four and six cycles of ATC remedy. Right atrial (RA) and right ventricular (RV) end-diastolic area (EDA) and end-systolic area (ESA) were calculated. RV end-diastolic volume (EDV) and end-systolic volume (ESV), as well as RV ejection fraction (EF) were measured simultaneously. Tissue Doppler imaging (TDI) measurements of systolic and early or late diastolic myocardial velocities of RV free wall at tricuspid annuals were also analyzed. Two-dimensional speckle tracking echocardiography (2DSTE) was conducted to evaluate RV free wall strain along with strain rate. Results None of the echocardiographic parameters showed significant alteration after two and four cycles of chemotherapy compared with those at baseline (P>0.05). At the end of the therapy (i.e. after six cycles of ATC treatment), there was still no statistical difference on TDI data as well as 2DSTE measurements (P>0.05). An unexpected finding was that the RAEDA((6.6±1.9) cm2 vs (7.7±2.4) cm2) and RAESA ((8.8±2.5) cm2 vs (10.8±2.8) cm2) revealed obvious dilatation after six cures of the regimen compared with those at baseline (P 0.05). Conclusions Echocardiography can be used easily and noninvasively to assess right cardiac system subclinical dysfunction. ATC-induced cardiotoxicity of right cardiac system is firstly manifested as morphological changes than the measurements with novel echocardiographic techniques. In addition, RVEF expresses as a valuable parameter for assessing subtle RV impaired performance in patients with lymphoma received ATC therapy. Key words: Anthracycline; Lymphoma; Right atrial function; Right ventricular function; Echocardiography

Importance of Relationship between Ductus and Isthmus in Fetal Diagnosis of Coarctation of Aorta.

The prenatal diagnosis of coarctation of aorta (CoA) can prove problematic, with relatively high false-positive and false-negative rates. This significantly impacts both prenatal counseling and postnatal management. We sought to evaluate a variety of prenatal echo indices to determine which would best predict neonatal CoA. Fetal echocardiograms of those with prenatal diagnosis of COA were analyzed for the following: diameter of cardiac valves, ascending aorta, distal transverse arch, aortic isthmus, and ductus; right (RV) and left ventricular (LV) length and end-diastolic area and isthmus-ductal angle (IDA). Ratios of RV: LV area, aortic: pulmonary valve diameter, mitral: tricuspid valve ratio (MV:TV ratio), and isthmus: ductal diameter (IDD) were calculated. These measures were compared between those with CoA after birth (CoA group) and those without (no CoA group). Of the 62 subjects, 27 were in CoA and 35 in no CoA group. CoA group had a significantly smaller mitral valve, MV:TV ratio, IDD, and IDA compared to no CoA group. The ROC curves for each of these significant measures showed that mitral valve, IDD, and IDA had an AUC of 0.72, 0.80, and 0.83, respectively. Multiple variable model using at least two of these measures had 85% sensitivity and 60% specificity. A smaller mitral valve, MV:TV ratio, IDD, and IDA are associated with development of neonatal coarctation. In cases with suspected prenatal diagnosis of CoA, careful evaluation of the relation between the isthmus and the ductus arteriosus using IDD and IDA may enhance the diagnostic accuracy of fetal echocardiograms.

Abstract 13135: Association of Three-Dimensional Tricuspid Valve Deformation With Functional Tricuspid Regurgitation

Introduction: Background: Functional tricuspid regurgitation (FTR) is widely recognized as being associated with poor outcomes in patients with various cardiac diseases, and the tricuspid valve (TV) deformation is an important mechanism of FTR. However, the precise assessment of TV deformation by means of two-dimensional echocardiography is limited. Purpose: The purpose of this study was thus to investigate the association of TV deformation with FTR by using three-dimensional transthoracic echocardiography (3D-TTE). Methods: We studied 65 patients with FTR. Their mean age was 60±16 years and 36 patients (55%) were female. FTR was quantified by the ratio of the jet area and corresponding RA area, and more than moderate FTR was defined as significant. 3D-TTE was performed to analyze the tricuspid deformation. Tricuspid tenting height and area were analyzed at the time of maximal systolic closure. TV area index, anterior-posterior (A-P) and septal-lateral (S-L) TV annular diameters were analyzed at end-diastole. Right ventricular longitudinal length, end-diastolic and end-systolic area index (EDAI, ESAI) and right atrial area index (RAA) were also obtained from 3D data set. Results: Twenty-one patients were classified as having significant FTR. Tenting height (6.5±3.1 vs. 4.0±1.8 mm, p&lt;0.001), tenting area (1.3±0.8 vs. 0.7±0.4 cm2, p=0.003), TV area (6.9±1.7 vs. 5.0±1.4 cm2/m2, p&lt;0.001) and S-L (35±4 vs. 28±6 mm, p&lt;0.001) in patients with FTR were significantly larger than those in patients with non-significant FTR, but A-L was not (38±6 vs. 36±7mm). After adjusting for age, ESAI, RAA and tenting height, a multivariate logistic regression analysis showed that TV area (odds ratio 3.1, p=0.04) was independently associated with significant FTR. Conclusions: TV-related parameters were associated with FTR, and TV area was the most important factor for FTR. Our findings by means of 3D-TTE may well have clinical implications for better management of patients with FTR.

What every ICU clinician needs to know about the cardiovascular effects caused by abdominal hypertension.

The effects of increased intra-abdominal pressure (IAP) on cardiovascular function are well recognized and include a combined negative effect on preload, afterload and contractility. The aim of this review is to summarize the current knowledge on this topic. The presence of intra-abdominal hypertension (IAH) erroneously increases barometric filling pressures like central venous (CVP) and pulmonary artery occlusion pressure (PAOP) (since these are zeroed against atmospheric pressure). Transmural filling pressures (calculated by subtracting the pleural pressure from the end-expiratory CVP value) may better reflect the true preload status but are difficult to obtain at the bedside. Alternatively, since pleural pressures are seldom measured, transmural CVP can also be estimated by subtracting half of the IAP from the end-expiratory CVP value, since abdominothoracic transmission is on average 50%. Volumetric preload indicators, such as global and right ventricular end-diastolic volumes or the left ventricular end-diastolic area, also correlate better with true preload. When using functional hemodynamic monitoring parameters like stroke volume variation (SVV) or pulse pressure variation (PPV) one must bear in mind that increased IAP will increase these values (via a concomitant increase in intrathoracic pressure). The passive leg raising test may be a false negative in IAH. Calculation of the abdominal perfusion pressure (as mean arterial pressure minus IAP) has been shown to be a better resuscitation endpoint than IAP alone. Finally, it is re-assuring that transpulmonary thermodilution techniques have been validated in the setting of IAH and abdominal compartment syndrome. In conclusion, the clinician must be aware of the different effects of IAH on cardiovascular function in order to assess the volume status accurately and to optimize hemodynamic performance.