Nitric oxide and the treatment of right heart failure with atrial fibrillation and rapid ventricular response.
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Administration, Inhalation↗
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Effects of alcohol on systemic and pulmonary hemodynamics in normal humans.
Even at low doses, alcohol has been reported to impair left ventricular pump function. To characterize further the effects of alcohol on the normal cardiovascular system, using the Swan-Ganz thermodilution catheter, we studied 6 healthy physicians, aged 27-36 years, while they were lightly intoxicated. Within a period of 30 min the subjects ingested 0.5 g/kg of ethanol diluted to 15% (w/v) in fruit juice. Hemodynamic measurements were obtained before the first ingestion and every half-hour thereafter for 2 hours. A peak blood ethanol concentration (mean +/- SE) of 13.3 +/- 1.6 mmol/l (0.61 mg/dl) was recorded at 60 min. Unexpectedly, pulmonary artery pressure rose during the early part of the increasing blood ethanol phase, probably due to pulmonary vascular constriction. At 30 min, the systolic pulmonary artery pressure had increased by 10% (p less than 0.05) and the diastolic pressure by 14% (p less than 0.001); both returned to baseline levels by the end of the experiment. Calculated pulmonary vascular resistance rose from a baseline value of 0.50 +/- 0.30 to 0.85 +/- 0.34 units (p less than 0.01) at 30 min. Left ventricular preload decreased significantly during the declining blood ethanol phase: mean pulmonary capillary wedge pressure decreased from 12 +/- 3 to 10 +/- 2 mmHg (p less than 0.01), and mean right atrial pressure decreased significantly. This study suggests that alcohol causes changes in cardiac function by altering its loading conditions. The combined diuretic and systemic venodilatory actions of alcohol provide the most probable explanation for the decrease in preload.
Adult↗
[The effect of heart rate on the time constant of isovolumic relaxation of the left ventricle].
A time constant (T) of the left ventricular isovolumic relaxation, which expresses the relaxation rate of the left ventricle, may be affected by change of the heart rate. There are few clinical reports concerning the relationship between T and heart rate. We studied the relationship between T and heart rate in 10 patients with normal coronary arteries and left ventricular function. Left ventricular pressure was measured using a catheter-tip manometer during right atrial pacing, which was performed at the rate of 10, 20, 40 beats/min in addition to the baseline rate, and finished at 140 or 150 beats/min. Two measurements were made for T.1) Tw from the slope of In (pressure) against time, and 2) Tb by exponential analysis which also estimated the asymptote. As the heart rate increased, both Tw and Tb gradually shortened (Tw: from 38.5 +/- 4.9 msec at the control heart rate to 28.9 +/- 5.6 msec at 140 or 150 beats/min; Tb: from 54.7 +/- 11.4 msec at the control heart rate to 34.9 +/- 5.7 msec at 140 or 150 beats/min). These findings suggest that left ventricular isovolumic relaxation is strongly affected by change of the heart rate in man.
Adult↗
Efficacy, safety, and tolerance of d-sotalol in patients with refractory supraventricular tachyarrhythmias.
The efficacy, safety, and electrophysiologic effects of intravenous and oral d-sotalol, an investigational class III antiarrhythmic agent, are not yet well characterized. We evaluated the electrophysiologic, antiarrhythmic, and hemodynamic effects of d-sotalol infusion (1.5 to 2.75 mg/kg) and of chronic oral therapy (200 to 400 mg bid) in 10 patients with chronic, paroxysmal supraventricular tachyarrhythmias refractory to 5 +/- 2 standard agents. Four patients had paroxysmal supraventricular tachycardia (PSVT), four had paroxysmal atrial fibrillation, two had atrial flutter, and one had nonparoxysmal reciprocating junctional tachycardia (NPRJT). PSVT was inducible or spontaneously present in 4 of 4 before d-sotalol. After intravenous d-sotalol PSVT was noninducible in three patients and slowed by 40% in one. Atrial fibrillation was inducible or spontaneously present in 4 of 4 before therapy. After intravenous d-sotalol, one became noninducible, and three achieved rate-slowing (the mean falling from 69 to 61 bpm). In one patient, atrial flutter became noninducible; in another, d-sotalol slowed the rate of atrial flutter by 28%. D-sotalol restored sinus rhythm in the patient with NPRJT. Intravenous d-sotalol increased the sinus cycle length; the QTc, PR, and AH intervals; and the AV nodal functional refractory period, the AV nodal effective refractory period; and the right ventricular effective refractory period significantly. The atrial effective refractory period, sinoatrial conduction time, and corrected sinus recovery time tended to increase, but did not reach statistical significance. The QRS, PA, and HV intervals did not change. Mean BP fell 13.4 +/- 9.2% after intravenous d-sotalol, but no adverse symptoms developed.(ABSTRACT TRUNCATED AT 250 WORDS)
Administration, Oral↗
Myocardial beta-adrenoceptor changes in heart failure: concomitant reduction in beta 1- and beta 2-adrenoceptor function related to the degree of heart failure in patients with mitral valve disease.
In patients suffering from end-stage congestive cardiomyopathy, cardiac beta 1-adrenoceptor function is markedly reduced, whereas cardiac beta 2-adrenoceptor function is nearly normal. To determine whether beta 1-adrenoceptor function is impaired in heart failure selectively, beta 1- and beta 2-adrenoceptor density and functional responsiveness in the right and left atria and the left papillary muscles from patients with mitral valve disease (functional class III to IV) were studied. In all three tissues concomitantly beta 1- and beta 2-adrenoceptor density gradually declined when the degree of heart failure increased from functional class III to IV. This decrease in beta 1- and beta 2-adrenoceptor density was accompanied by similar decreases in the contractile response of isolated electrically driven right atrial and left ventricular papillary muscles to beta-adrenergic agonists. It is concluded that a decrease in cardiac beta-adrenoceptor function is a general phenomenon in heart failure, and its extent is related to the degree of heart failure. However, in contrast to congestive cardiomyopathy, in mitral valve disease the decrease in cardiac beta-adrenoceptor function is due to a concomitant decrease in beta 1- and beta 2-adrenoceptors.
Adrenergic beta-Agonists↗
Doppler echocardiography in suspected lone atrial fibrillation.
Echocardiography is frequently required in patients with atrial fibrillation (AF) to exclude underlying heart disease. In the present investigation the authors evaluated 56 patients with paroxysmal AF (PAF) (27 men, 29 women, mean age 54+/-11.3 years) in whom lone AF was suspected on clinical grounds. M-mode, B-mode, and Doppler examination were performed and measurements taken according to American Society of Echocardiography criteria. Left atrial diameter, left and right atrial volumes, left ventricular (LV) diameters, LV fractional shortening, and Doppler indexes of LV diastolic function were not different in patients with PAF in comparison with those of a control group of 56 age-matched subjects free from cardiovascular diseases. Echocardiographic examination results were entirely normal in 32/56 patients (57%) vs 39/56 of the control group (69%). Mitral valve prolapse was found in five patients (9%), but only one showed mild mitral regurgitation. Doppler examination disclosed a mild (+/++) mitral regurgitation in eight patients and a small aortic or pulmonary diastolic flow in four and two patients, respectively, in the absence of significant morphologic valvular abnormalities. In these patients the sizes of heart chambers were entirely normal. Aneurysm of the interatrial septum was found in one patient and an increased thickness of the epipericardial junction in another two patients. Finally two patients had a small increase of right atrial volume without demonstrable causes. The results suggest that lone AF can be correctly suspected on the basis of clinical findings (history, physical examination, and ECG) and that in these patients echocardiography rarely discloses organic heart disease.
Atrial Fibrillation↗
Cardiac function-related gene expression profiles in human atrial myocytes.
To obtain insights into the molecular pathogenesis of heart failure in humans, we have analyzed the expression profiles of>12,000 genes in a total of 17 human specimens of right atrial myocytes. From this large data set, we here tried to identify gene clusters, expression level of which is correlated precisely with clinical parameter values of cardiac function. We could reveal that cardiac myocytes with normal sinus rhythm were clearly differentiated, in the point of view of gene expression, from those with atrial fibrillation. Further, an expression profile-based prediction of arrhythmia by a newly developed "weighted-distance method" could efficiently diagnose our samples. We could even construct calculation formulae for the values of left ventricular ejection fraction based on the expression level of selected genes. To our best knowledge, this is the first report to indicate that pumping ability of heart can be predicted by any measures of atrium.
Adolescent↗
Targeted disruption of the gene for natriuretic peptide receptor-A worsens hypoxia-induced cardiac hypertrophy.
Targeted disruption of the gene for natriuretic peptide receptor-A (NPR-A) worsens pulmonary hypertension and right ventricular hypertrophy during hypoxia, but its effect on left ventricular mass and systemic pressures is not known. We examined the effect of 3 wk of hypobaric hypoxia (0.5 atm) on right and left ventricular pressure and mass in mice with 2 (wild type), 1, or 0 copies of Npr1, the gene that encodes for NPR-A in mice. Under normoxic conditions, right ventricular peak pressure (RVPP) was greater in 0 than in 2 copy mice, but there were no genotype-related differences in carotid artery PP (CAPP). The left ventricular free wall weight-to-body weight (LV/body wt) ratio was greater in 0 than in 2 copy mice and there was a trend toward a greater right ventricular weight-to-body weight (RV/body wt) ratio. Three weeks of hypoxia increased RVPP and RV/body wt in all genotypes. The increase in RVPP was similar in all genotypes (11-14 mmHg), but the hypoxia-induced increase in RV/body wt was more than twice as great in 0 copy mice than in 2 copy mice (1.11 +/- 0.06 to 2.65 +/- 0.46 vs. 0.96 +/- 0.04 to 1.4 +/- 0.09, P < 0.05). Chronic hypoxia had no effect on CAPP in any genotype and did not effect LV/body wt in 1 or 2 copy mice, but increased LV/body wt 41% in 0 copy mice. We conclude that absent expression of NPR-A worsens right ventricular hypertrophy and causes left ventricular hypertrophy during exposure to chronic hypoxia without increasing pulmonary or systemic arterial pressure responses.
Animals↗
Echocardiogram in atrial septal defect with small left-to-right shunt.
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Adolescent↗
["Slowing" right bundle-branch block in reciprocating tachycardia from a latent right lateral Kent bundle].
The authors report the case of a 56 year old man with paroxysmal reciprocating tachycardia. The participation of a right lateral Kent bundle, latent in sinus rhythm and with retrograde atrioventricular conduction during tachycardia was proved by : 1) the slowing of the tachycardia rhythm and lengthening of the ventriculo-atrial conduction time by 50 ms during right bundle branch block ; 2) atrial mapping during tachycardia showing right lateral atrial pre excitation ; 3) the spontaneous termination of some attacks after a blocked Hisian depolarisation. Analysis of the mechanisms of spontaneous termination of tachycardia showed a block in the accessory pathway in 80% of cases, leading to the successful use of Amiodarone. The particular electrophysiological mechanism of functional bundle branch block makes it the most reliable positive diagnostic criterion in reciprocating tachycardia. A review of previously reported series shows participation of right lateral and septal accessory pathways to be uncommon during reciprocating tachycardia. Functional bundle branch block does not necessarily lengthen the ventriculo-atrial interval with septal accessory pathways. Left lateral Kent bundles are much more common. These points are analysed together with the mechanism of functional bundle branch block in the discussion.
Bundle-Branch Block↗
Regional distribution of the molecular forms of acetylcholinesterase in adult rat heart.
Acetylcholinesterase (AChE), the enzyme that degrades acetylcholine, exists as a multiple molecular forms that differ in their quaternary structure and mode of attachment to the cell surface. The distribution of the individual molecular forms of AChE in various cardiac regions with distinct anatomical characteristics was investigated. The results confirmed those of others by showing that the total pool of cardiac AChE had a nonuniform distribution in heart that paralleled the distribution of choline acetyltransferase. The rank order of this distribution was right atrial appendage greater than interatrial septum greater than left atrial appendage = right ventricle = interventricular septum greater than left ventricle. Velocity sedimentation in sucrose gradients of extracts from selected cardiac areas showed that four molecular forms were present in all areas but that the proportions of these forms differed as a function of area. The right and left ventricular walls, the apical portion of the interventricular septum, and the left atrial appendage contained G1 and G4 (globular) AChE in near-equal proportions, but in the basal portion of interventricular septum, the contribution of G4 AChE was greater than that of G1 AChE. The right atrial appendage and the interatrial septum had the largest amount of activity attributable to G4 AChE and the lowest amount attributable to G1 AChE. In all cardiac regions, A12 (asymmetric) AChE comprised 8-10% of the total AChE pool.(ABSTRACT TRUNCATED AT 250 WORDS)
Acetylcholinesterase↗
Percutaneous balloon catheter closure of a patent foramen ovale in a patient with pulmonary disease, profound hypoxemia, and normal right heart pressures.
Right-to-left intracardiac shunting across a patent foramen ovale (PFO) has been reported in patients with pulmonary embolism, right ventricular (RV) infarction, positive pressure ventilation with positive end-expiratory pressure, heart failure with left ventricular assist devices, cardiac tamponade, and unilateral diaphragmatic paralysis. The primary driving force for these shunts is a reduction in the compliance of the pulmonary bed or right ventricle; right atrial pressure is usually elevated and pulmonary hypertension is frequently present. Significant shunting and hypoxemia are unusual in the absence of these diseases. We encountered a patient with normal pulmonary pressures, severe hypoxemia, pulmonary disease, and intracardiac shunting across a PFO in whom it was difficult to determine how great a role intracardiac shunting was playing in his hypoxemia. To assess this, we performed percutaneous balloon catheter occlusion of the PFO, using transthoracic echocardiography with contrast to confirm closure of the PFO. Therapeutic balloon occlusion has been reported in severe hypoxemia due to shunting across a PFO in a patient with RV infarction. Our case is unique, however, in two respects. First, this patient had normal right-sided cardiac pressures and normal RV function and, thus, no obvious driving force for a significant right-to-left shunt. Second, transthoracic echocardiography with contrast was used before and after balloon inflation to confirm closure of the PFO. This technique helped to answer the important clinical question of whether surgical closure of the PFO in this patient with both lung disease and intracardiac shunting would significantly improve his oxygenation.
Adult↗
[Treatment of atrioventricular accessory pathways using catheter ablation: analysis of immediate and long-term results at the end of the learning curve period].
UNLABELLED: Immediate and long-term results of catheter ablation of atrioventricular accessory pathways (AP) are presented. METHOD: One hundred and seventy-one patients aged 41.8 +/- 14.4 years underwent catheter ablation of 179 AP. Right and left AP occurred simultaneously in 3 patients; thus 65 ablation procedures for 57 rights AP in 57 patients were compared with 125 ablation procedures for 122 left AP in 117 patients. RESULTS: Including repeated procedures ablation was successful in 116 (99%) patients with left AP and in 57 (100%) patients with right AP. First catheter ablation failed in 4 (7%) patients with right AP and in 4 (3.4%) patients with left AP (p = NS). Two of these patients with left AP and all 4 pts with right AP had successful reablation. AP conduction recurred after successful ablation in 7 (12.3%) patients with right AP and in u 5 (4.1%) patients with left AP (p = 0.1). Three patients with right AP did not undergo another ablation, other 9 patients with AP recurrence had successful reablation. Procedure time during left AP ablation was shorter (159.6 +/- 70.7 vs. 183.4 +/- 75.6 min.; p = 0.02) and number of RF current deliveries was lower during left AP ablation (9.3 +/- 8.5 vs. 13.3 +/- 11.8; p = 0.008) compared to right AP ablation. Fluoroscopy time during left AP ablation (22.4 +/- 19.1 min.) did not significantly differ from that during right AP ablation (20.9 +/- 17.1 min.). Concealed AP was present in 13 (22.8%) patients with right AP and in 59 (48.4%) patients with left AP (p = 0.002). Anatomico-functional variant of AP occurred in 5 (8.8%) patients with right AP and in 4 (3.3%) patients with left AP (p = NS). Atrial fibrillation complicated ablation procedure in 9 (15.8%) patients with right AP and in 7 (5.7%) patients with left AP (p = NS). During 30.3 +/- 17 (2-60) months follow-up period tachyarrhythmia associated with the presence of an AP occurred in 3 patients with right AP and in 1 patient with unsuccessful ablation of left AP. None of these patients underwent repeated ablation. CONCLUSION: Successful ablation of AP can be achieved successfully in 100%. Catheter ablation of right AP is generally more difficult and primary ablation failure and AP conduction recurrence is nonsignificantly more often. Irregularity of the tricuspid annulus, instability of the ablation catheter, presence of the conduction system, higher occurrence of anatomico-functional AP variants and sustained atrial fibrillation during the ablation procedure represent the main causes of this finding.
Adolescent↗
The erythrocyte sedimentation rate in congestive heart failure.
BACKGROUND AND METHODS: Physicians have long believed that the erythrocyte sedimentation rate is low in patients with congestive heart failure, but this concept is based on a misinterpretation of the results in a single report published in 1936. To reevaluate this concept in the modern era, we measured the sedimentation rate in 242 patients who were referred for treatment of chronic heart failure. RESULTS: The sedimentation rate was low (less than 5 mm per hour) in only 24 patients (10 percent) but was increased (above 25 mm per hour) in 50 percent. Patients with low or normal sedimentation rates (less than or equal to 25 mm per hour) had more severe hemodynamic abnormalities than patients with elevated rates: lower cardiac index (mean +/- SEM, 1.7 +/- 0.1 vs. 2.0 +/- 0.1 liters per minute per square meter of body-surface area) and higher mean right atrial pressure (mean +/- SEM, 12 +/- 1 vs. 9 +/- 1 mm Hg) (both P less than 0.0001). New York Heart Association functional class IV symptoms were present in 66 percent of the patients with a low or normal sedimentation rate, as compared with 42 percent of those with elevated rates (P less than 0.0001). After one to three months of therapy, patients whose sedimentation rates decreased showed little hemodynamic or clinical response to treatment, whereas both cardiac performance and functional status improved in patients whose rates increased (P less than 0.02 for the comparison between groups). The sedimentation rate was correlated with the plasma fibrinogen level (r = 0.64, P = 0.0025), and changes in the sedimentation rate during treatment were correlated inversely with changes in mean right atrial pressure (r = -0.57, P = 0.0002). During long-term follow-up, patients with low or normal sedimentation rates had a worse one-year survival than patients with elevated rates (41 vs. 66 percent, P = 0.01). CONCLUSIONS: These data indicate that the erythrocyte sedimentation rate is correlated with the severity of illness in patients with chronic heart failure. Because of its lack of discriminatory power, however, the test is of limited value in the clinical management of this disorder.
Blood Sedimentation↗
Role of atrial septostomy in the treatment of children with pulmonary arterial hypertension.
OBJECTIVES: To assess in retrospect the safety and effectiveness of atrial septostomy in children with severe pulmonary arterial hypertension without an intracardiac communication. METHODS: 20 patients were reviewed retrospectively, 19 with idiopathic pulmonary arterial hypertension. The mean age at septostomy was 8.4 years (range 3 months to 17 years). Graded balloon septostomy alone was carried out in eight patients, a blade septostomy was done in two, a blade septostomy plus graded balloon septostomy was done in three, and a fenestrated device was inserted in seven. RESULTS: There were no fatalities. Four children suffered complications during the procedure. None had further syncope and all improved symptomatically with a significant (p < 0.01) decrease in World Health Organization functional class (mean shift -0.6) and a significant improvement in the semiquantitative echocardiographic assessment of right ventricular function (p < 0.03). The mean oxygen saturation decreased by 7.8 percentage points. The atrial communication closed in two children, necessitating a repeat procedure. After a mean follow up of 2.1 years (range one month to 6.7 years), 18 of 20 children are still alive. CONCLUSION: Atrial septostomy improved symptoms and quality of life in a group of children deteriorating with severe pulmonary arterial hypertension. This procedure is to be recommended for severely symptomatic children, before they become critically ill. Fenestrated devices may help ensure indefinite patency of the atrial communication.
Adolescent↗
Risk stratification for recurrent tachyarrhythmias in patients with paroxysmal atrial fibrillation and flutter: role of signal averaged electrocardiogram and echocardiography.
The value of signal-averaged P-wave electrocardiogram and echocardiography for predicting recurrent atrial tachyarrhythmias was prospectively investigated in 60 patients presenting with paroxysmal atrial fibrillation or flutter. All patients were followed up for 1 year after restoration of sinus rhythm. A stepwise discriminant function analysis was used to identify variables predicting recurrent atrial tachyarrhythmias. Analyzed variables included signal-averaged P-wave duration in 3 bipolar orthogonal leads (X,Y,Z) and their vector magnitude, as well as left and right atrial dimensions and volumes. During follow-up, 25 patients had recurrent atrial tachyarrhythmias, while 35 did not. Using discriminant function analysis, the left atrial antero-superior dimension was found to be the only variable predicting the recurrence of atrial tachyarrhythmias (p < 0.0038) and was able to correctly classify 65% of the study patients. It was concluded that, in patients with paroxysmal atrial fibrillation or flutter, the traditionally used determination of left atrial dimension was the variable most closely associated with a high risk for recurrent tachyarrhythmias. The signal-averaged P-wave duration did not improve tachyarrhythmia prediction.
Aged↗
[A study on the radionuclide method for assessment of right ventricular function in COPD with cor pulmonale].
Right ventricular ejection fraction (RVEF), right ventricular peak filling rate (RVPFR) and right atrial early diastolic emptying rate (RAER) were measured with radionuclide gated blood pool scintigraphy in 19 healthy subjects and 15 cases of COPD with cor pulmonale and right heart catheterization was performed in the latter group. It was shown that RVEF in the group of cor pulmonale patients with pulmonary arterial hypertension (PAH) was significantly lower than that of the group of healthy subjects and cor pulmonale patients without PAH (P < 0.001, P < 0.001), no difference in RVEF was found between cor pulmonale patients without PAH and healthy subjects. As pulmonary arterial pressure increased, RAER and RVPFR decreased gradually, and the reduction of RAER and RVPFR occurred earlier than that of RVEF. It is suggested that right ventricular diastolic function may be impaired before right ventricular systolic function.
Adult↗
[Percutaneous mitral commissurotomy and Lutembacher syndrome].
INTRODUCTION: Lutembacher syndrome refers to the rare combination of congenital atrial septal defect and acquired mitral stenosis. This condition is usually treated surgically by mitral valve operation with concomitant closure of the atrial septal defect. MATERIALS AND METHODS: Between 1993 and 2003, 4 patients with congenital Lutembacher syndrome had percutaneous mitral commissurotomy without closure of the atrial septal defect at our institution. The 4 patients were very symptomatic with right-sided heart failure signs and NYHA functional class III-IV. RESULTS: The procedure was carried out successfully for the four patients. Mitral valve area increased from 0.87 to 1.97 cm2 at mean; left atrial pressure decreased from 28.2 to 12.7 mmHg and the mean valve mitral gradient was reduced from 15.5 to 3.9 mmHg. Functional and clinical improvement was observed in all the cases. During a mean follow up of 55 +/- 29 months, our 4 patients remain pauci symptomatic under medical treatment. CONCLUSION: The percutaneous treatment of the Lutembacher syndrome is currently a possible alternative to the surgery among patients having an anatomy favourable to the procedure.
Adult↗