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PubMed1992

Right atrial thrombus migration during echocardiography: a case for urgent intervention.

A 65-year-old woman presented with increasing shortness of breath, chest pain and ST-T wave abnormalities on the electrocardiogram suggestive of unstable angina. Cross-sectional echocardiography performed to assess wall-motion abnormality and left ventricular function revealed a pedunculated right atrial thrombus prolapsing into the right ventricle which suddenly dislodged and migrated into the pulmonary circulation during the examination. A diagnosis of recurrent pulmonary thromboembolism was made, necessitating urgent pulmonary angiography with infusion of streptokinase. The patient made an uneventful recovery.

Aged↗
PubMed1997

The effect of atrial fibrillation and the ventricular rate control on exercise capacity.

BACKGROUND: Atrial fibrillation (AF) is a common cardiac arrhythmia, affecting approximately 1.5 million patients in the United States. HYPOTHESIS: This study was designed to determine the effect of AF and the ventricular rate control during AF on cardiovascular performance as measured by exercise endurance on a standard Bruce protocol. METHODS: Sixty-three patients with AF who underwent exercise stress testing during both sinus rhythm and AF were analyzed. Heart rate, blood pressure, heart rate acceleration, exercise duration, and left ventricular (LV) systolic function were measured. RESULTS: Atrial fibrillation resulted in a small but statistically significant decrease in exercise endurance (426 +/- 180 vs. 402 +/- 168 s, p < 0.05). The drop in exercise tolerance was consistent regardless of the underlying heart condition or adequate ventricular rate control during AF. Heart rate in AF was consistently faster than in sinus rhythm, at rest, and at peak exercise (63 vs. 79 beats/min and 125 vs. 149 beats/min, respectively, p < 0.001). CONCLUSION: Our analyses indicated that (1) the loss of atrioventricular synchrony had minimal effect on cardiovascular performance in patients with preserved LV function, (2) the decrease in cardiovascular performance was related to loss of atrioventricular synchrony but not to underlying heart disease or ventricular rate control, and (3) compensation for the loss of the atrial contribution was provided by consistently faster heart rate during AF.

Atrial Fibrillation↗
PubMed1999

Impact of the maze procedure on the stroke rate in patients with atrial fibrillation.

OBJECTIVE: The incidence of stroke associated with atrial fibrillation, even in high-risk patients, can be reduced significantly by adequate anticoagulation. However, anticoagulation does not abolish the stroke rate, and unfortunately only 40% of patients with atrial fibrillation actually receive anticoagulant therapy, even in areas where adequate health care is available. METHODS: During the past 11.5 years, we have performed the maze procedure for the treatment of medically refractory atrial fibrillation in 306 patients, 58 of whom presented with a history of having had a stroke (n = 40) or transient ischemic attack (n = 18) before surgery. All patients with atrial fibrillation are at an increased risk for these complications, but they are especially prevalent in those patients with previous thromboembolic events and those with other recognized risk factors. RESULTS: Among the 306 patients who had surgery, there were only 2 perioperative strokes (0. 7%), and in the 265 patients followed for up to 11.5 years after the maze procedure, there has been only 1 late minor stroke that has now completely resolved. CONCLUSIONS: The ability of the maze procedure to decrease the risk of stroke associated with atrial fibrillation so dramatically is likely due to the restoring of sinus rhythm and atrial transport function in combination with surgical removal or obliteration of the left atrial appendage, where most thrombi associated with atrial fibrillation develop.

Atrial Appendage↗
PubMed2004

Elevation of the tumor marker CA125 in right heart failure.

Carbohydrate antigen 125, known as a marker for ovarian cancer, has been reported to be elevated in heart failure caused by left ventricular dysfunction. A case of elevated carbohydrate antigen 125 in isolated right heart failure due to atrial septal defect with preserved left ventricular function is reported.

Aged↗
PubMed1976

Abolition of ischemic response to atrial pacing following aortocoronary bypass surgery.

To determine the effect of successful aortocoronary bypass surgery (ACBS) on left ventricular (LV) function, the ischemic response to right atrial pacing (RAP) was studied in 22 angina patients before and 3.8 +/- 1.1 months after surgery. All patients were free of angina after ACBS and had at least one patent graft. Before ACBS, RAP induced angina in 15 patients (Group 1) but not in 7 patients (Group 2). After ACBS, no patient had angina with RAP despite the increased maximum rate of pacing. Post-pacing LV end-diastolic pressure (LVEDP) after ACBS decreased in Group 1 from 25 +/- 6 to 15 +/- 6 mm Hg (P less than 0.01), but not in Group 2. Changes in ejection fraction, cardiac output, resting LVEDP, or LVEDP after LV angiography were not significant in either group and were therefore not useful in evaluating the result of ACBS. However the ischemic response to right atrial pacing was abolished by successful aortocoronary bypass surgery, suggesting improved myocardial perfusion during stress.

Angina Pectoris↗
PubMed1997

Atrial fibrillation is associated with a lower exercise capacity in male chronic heart failure patients.

OBJECTIVE: To study the influence of atrial fibrillation on peak oxygen uptake (peak VO2) in chronic heart failure. An unfavourable effect of atrial fibrillation has been shown in several patient populations, but the results have not been consistent in chronic heart failure. METHODS: Data were analysed from male heart transplant candidates who were able to perform graded bicycle ergometry until exhaustion with respiratory gas analysis and measurement of heart rate. Patients in atrial fibrillation (n = 18) were compared with patients in sinus rhythm (n = 93). RESULTS: Age, weight, height, and aetiology of chronic heart failure did not differ significantly between the two groups. Cardiac catheterisation at supine rest showed that heart rate was comparable, but that stroke volume and cardiac output were lower (p < 0.05) in atrial fibrillation. Systolic and diastolic left ventricular function, assessed by radionuclide angiography at rest, were not significantly different. Peak VO2 (mean (SD): 13.8 (3.6) v 17.1 (5.6) ml/kg/min; p < 0.01) and peak work load (78 (27) v 98 (36) W; p < 0.05) were lower in the patients with atrial fibrillation, though respiratory gas exchange ratio and Borg score were similar in the two groups. Patients with atrial fibrillation had a higher heart rate sitting at rest before exercise (93 (16) v 84 (16) beats/min) and at peak effort (156 (23) v 140 (25) beats/min) (p < 0.05). CONCLUSIONS: Atrial fibrillation is associated with a 20% lower peak VO2 in patients with chronic heart failure, suggesting that preserved atrial contraction or a regular rhythm, or both, are critical to maintain cardiac output and exercise performance.

Adult↗
PubMed1999

Extracorporeal right to left atrial bypass to treat right ventricular failure.

Graft right ventricular failure after heart transplantation, secondary to preoperative functional pulmonary hypertension, was successfully managed in a 49-year-old patient using an extracorporeal right to left atrial bypass. We comment on the case and discuss the type of mechanical assistance used.

Cardiomyopathy, Dilated↗
PubMed2000

Effect of rhythm regularization on left ventricular contractility in patients with atrial fibrillation.

In 10 patients with atrial fibrillation, echocardiographic measures of left ventricular function-interval relations were used to assess contractility and to test the hypothesis that rhythm regularization produces a higher contractile state than is seen when the rhythm is irregular. Regularization, following direct-current cardioversion, did not augment ventricular contractility above that seen during atrial fibrillation.

Analysis of Variance↗
PubMed1982

Echocardiographic observations of hemodynamic differences between mitral and aortic regurgitation. Quantitative interpretation of functional state by multivariate statistical analysis.

The hemodynamic differences between chronic mitral (MR: n = 30) and chronic aortic regurgitation (AR: n = 37) at various functional stages were investigated by echocardiography and compared with the findings in healthy subjects (n = 20). The ordinary statistical analysis revealed that in MR myocardial contractility and afterload to the left ventricle (LV) well preserved even at the stage of decompensation, while in AR the contractility deteriorated and the afterload was elevated even at the asymptomatic stage. By the multivariate statistical analysis, the functional differences and characteristics of the 2 diseases were clarified with 2 statistic factors derived from 6 hemodynamic parameters (LV end-diastole and end-systolic dimensions, mean velocity of circumferential fiber shortening, LV mid-systolic stress, LV mass, and left atrial dimension). In the differentiation between the 2 diseases by the multivariate analysis, left ventricular size tended to be smaller, contractility was preserved and loading of the left atrium was increased in MR more than in AR. Furthermore, a quantitative system which could explain the functional state by these echocardiographic parameters was derived from this multivariate analysis. The functional states was found to be strongly affected by LV end-systolic dimension and left atrial dimension. This quantitative method of determining the functional state, along with an accurate assessment of cardiac symptoms, provides a useful guideline for the clinical evaluation of the 2 diseases.

Analysis of Variance↗
PubMed1987

First-pass radionuclide ventriculography in conscious dogs.

Trained, chronically instrumented, conscious dogs were used to study the function of the left ventricle by first-pass radionuclide ventriculography (RNV). Six dogs were trained prior to a sterile left thoracotomy, where a left atrial catheter was implanted. After recovery of four days RNV was carried out by injecting a bolus of technetium-99m-DTPA via the catheter to the left atrium. The data was collected for 12 s to a computer by frame rate of 20 frames/s from left lateral view of the dog. The experiments were performed both in four-leg standing and in 60 degrees head-up tilted positions. The measurements were done with two injection volumes (0.25 and 1.0 ml/kg) to study the effect of volume on the results. The body position had effect on left ventricular end-diastolic and stroke volumes, whereas ejection fraction remained unchanged. In comparison of the two injection volumes a minor difference was found in left atrial emptying, while the differences in left ventricular function were non-significant. In spite of training and careful standardization of experimental procedures, relatively high individual variation between animals was found in most parameters studied. The first-pass RNV method proved to be promising for measuring the left ventricular function in conscious dogs. Although the left atrium has reflectory tachycardic potential to distension, the volumes used for RNV did not affect the results. The left ventricular adaptation to head-up tilting in conscious dogs seems to consist mainly of decrease in left ventricular volume without significant effect on ejection fraction.

Animals↗
PubMed2003

Doppler transmitral flow indexes and risk of atrial fibrillation (the Framingham Heart Study).

Atrial fibrillation (AF) is characterized by structural remodeling and atrial systolic failure. It is unclear if atrial filling abnormalities precede the onset of AF. We evaluated 942 Framingham Study subjects (587 women; mean age 75 years) who underwent Doppler echocardiographic evaluation at a routine examination and who did not have a history of AF. We used multivariable Cox regression models (stratified by gender and prevalent cardiovascular disease) to examine the relations of Doppler transmitral flow indexes (ratio of the velocity-time integrals of the early [E] and late [A] diastolic filling waves [VTI E/A], a correlate of atrial conduit function; E-wave deceleration time; the atrial filling fraction, an index of atrial systolic function; and peak A wave velocity) to the incidence of AF. At follow-up (mean 7 years), 85 subjects (41 women) developed AF. In models adjusting for established risk factors for AF (including left atrial size) at baseline, and for heart failure and myocardial infarction on follow-up, a 1 SD increment in VTI E/A was associated with a 28% increase in risk of AF (hazards ratio 1.28, 95% confidence interval 1.02 to 1.59). A 1 SD decrease in the atrial filling fraction was associated with a 28% higher risk of AF (hazards ratio 1.28, 95% confidence interval 0.98 to 1.67). There was a U-shaped relation between peak A-wave velocity and risk of AF. Thus, in our elderly community-based sample, increased VTI E/A and a low atrial filling fraction were markers of increased risk of AF, suggesting that altered atrial filling may antedate AF.

Aged↗
PubMed1983

Metastatic periosteal osteosarcoma causing cardiac and renal failure.

The case of a 25-year-old man who had periosteal osteogenic sarcoma with intravascular metastases in unusual locations is reported. The patient presented with acute renal failure, unilateral pulmonary edema, functional mitral stenosis, and low cardiac output. After successful surgical removal of a left atrial metastasis with subsequent improvement in cardiac output, renal function improved only transiently and urinary output varied markedly. At autopsy, metastatic osteogenic sarcoma was discovered within the lumen of the abdominal aorta obstructing both renal arteries. The case is the first report of a neoplasm metastatic to the aorta causing intermittent bilateral renal arterial obstruction; it illustrates the diagnostic difficulties presented by intravascular metastatic disease.

Acute Kidney Injury↗
PubMed1975

Cardiac features of an unusual X-linked humeroperoneal neuromuscular disease.

To characterize an unusual, sex-linked recessive neuromuscular disease, we studied two families with 37 males who had involvement of distal leg and proximal arm muscle groups. Electromyography and muscle biopsy in five subjects showed features of both neuropathy and myopathy. Bradycardia and syncope in 15 involved subjects were associated with early death (before the age of 50 years). Electrocardiograms in 15 others showed a spectrum of atrial abnormalities that ranged from abnormal P waves to permanent atrial paralysis and from first-degree atrioventricular block to complete heart block. No patient exhibited clinical muscle disease without electrocardiographic atrial disease. Dilated, hypertrophied left ventricles with normal indexes of function were found in three cases with permanent atrial paralysis and chronic junctional bradycardia. Cardiomegaly and cardiac failure were not present in the other cases. We conclude that permanent ventricular pacing (instituted four patients) is indicated in many of these patients to prevent serious sequelae.

Adult↗
PubMed1989

Ca2+-dependent heterometric and homeometric autoregulation in hypertrophied rat heart.

There is evidence to suggest that the alterations in cardiac function that accompany several forms of myocardial hypertrophy are due in part to desensitization of the heart to the positive inotropic effect of extracellular Ca2+ (Cae2+). In this study the heterometric and homeometric functional responsiveness of normal (SH) and hypertrophied (HYP) isolated working rat hearts was examined as a function of extracellular Ca2+ concentration [( Ca2+]e). Surgically induced renovascular hypertension was used to produce a 39% increase in left ventricular (LV) weight in HYP hearts relative to LV weights of SH hearts. The Cae2+ dependence of heterometric autoregulation was examined in SH and HYP hearts. At high left atrial filling pressures, HYP hearts were functionally less sensitive to changes in [Ca2+]e than were SH hearts; this difference appeared to be due to a preload-dependent increase in the functional sensitivity of SH hearts but not HYP hearts to changes in [Ca2+]e. In both SH and HYP hearts, a step increase in afterload resulted in a beat-by-beat increase in peak aortic outflow systolic pressure (AoP) independent of changes in LV diastolic pressure. Under our experimental conditions, the magnitude of this homeometric AoP increase (the Anrep effect) was similar in both SH and HYP hearts. The AoP increase occurred at a monoexponential rate (kHA) and was much faster in SH than in HYP hearts. Furthermore, KHA varied directly as a function of [Ca2+]e only in the SH hearts.

Animals↗
PubMed1988

Sickle cell heart disease. Two-dimensional echo and Doppler ultrasonographic findings in the hearts of adult patients with sickle cell anemia.

Sickle cell anemia (SCA) is a commonly diagnosed condition in the black population in the United States. With better medical management, patients with SCA are living longer and what were previously uncommon sequelae are being recognized frequently, including those involving the cardiovascular system. Previous reports on the cardiovascular effects of SCA have focused predominantly on children, but the conclusions remain controversial. To study this question further, 40 adult patients with documented SCA were examined using two-dimensional and Doppler cardiac ultrasound. Valvular structures were normal despite an increased incidence of flow murmurs. Abnormalities were found more frequently in the left heart than the right, as manifested primarily by increased left ventricular mass, and left ventricular and left atrial dilatation with preservation of systolic function. Pulmonary hypertension, which was present in two thirds of the sample, was minimal to moderate as assessed by our Doppler technique. The effects of SCA on the heart seem to be minimal and similar to those of other anemias, predominantly confined to the left atrium and ventricle with passive elevation of pulmonary pressures. Clinical murmurs were most often physiologic; there was no association with myxomatous valvular degeneration or mitral valve prolapse.

Adult↗
PubMed1984

A randomized comparison of crystalloid and blood-containing cardioplegic solutions in 60 patients.

To determine whether adding blood to a cardioplegic solution affects myocardial preservation, a randomized prospective study was carried out in 60 patients undergoing coronary revascularization to compare the effects of crystalloid potassium cardioplegics (group C) and potassium cardioplegic solutions to which blood has been added (group B) on markers of myocardial metabolism (lactate, inorganic phosphate, base deficit release, glucose and lactate uptake, oxygen extraction), myocardial damage (creatine kinase [CK]-MB levels), and cardiac performance (cardiac index and left atrial pressure). The solution with added blood had a significantly (p less than .05) greater oxygen content, a lower pH, and higher concentrations of potassium, calcium, sodium, and glucose. In group B patients there was a suggestion (p less than .06) of greater uptake of oxygen during the beginning of the initial cardioplegic infusion. During reperfusion there was no evidence of differential release of the metabolites of anaerobiosis and myocardial oxygen extraction and glucose and lactate uptake were similarly depressed in both groups. Likewise, CK-MB release after bypass was the same in both groups. Prompt, adequate functional recovery of cardiac index and left atrial pressure was observed in both groups. It was concluded that although there may be more oxygen available from the blood-containing solution during early infusion, there is no evidence that under the conditions of this investigation adding blood to cardioplegic solution improves myocardial preservation.

Blood↗
PubMed1998

Atrioventricular nodal ablation and implantation of mode switching dual chamber pacemakers: effective treatment for drug refractory paroxysmal atrial fibrillation.

OBJECTIVE: To assess the effect of atrioventricular node ablation and implantation of a dual chamber, mode switching pacemaker on quality of life, exercise capacity, and left ventricular systolic function in patients with drug refractory paroxysmal atrial fibrillation. PATIENTS: 18 consecutive patients with drug refractory paroxysmal atrial fibrillation. METHODS: Quality of life was assessed before and after the procedure using the psychological general wellbeing index (PGWB), the McMaster health index (MHI), and a visual analogue scale for cardiac symptoms. Nine of the patients also underwent symptom limited exercise tests and echocardiography to assess left ventricular systolic function. RESULTS: The procedure allowed a reduction in antiarrhythmic drug treatment (p < 0.01). PGWB and symptom scores improved (p < 0.01) but the MHI score did not change. Left ventricular systolic function and exercise capacity were unchanged. CONCLUSIONS: Atrioventricular node ablation and implantation of a DDDR/MS pacemaker is effective treatment for refractory paroxysmal atrial fibrillation, producing improved quality of life while allowing a reduction in drug burden. The popularity of the treatment is justified, but further studies are needed to determine optimum timing of intervention.

Adult↗
PubMed1998

Associations between human aldosterone synthase (CYP11B2) gene polymorphisms and left ventricular size, mass, and function.

BACKGROUND: Aldosterone has direct and indirect effects on the heart, and genetic variations in aldosterone synthesis could therefore influence cardiac structure and function. Such variations might be associated with polymorphisms in the gene encoding aldosterone synthase (CYP11B2), the enzyme catalyzing the last steps of aldosterone biosynthesis. METHODS AND RESULTS: A Finnish population sample of 84 persons (44 women) aged 36 to 37 years was studied by M-mode and Doppler echocardiography to assess left ventricular size, mass, and function. Subjects were genotyped through the use of the polymerase chain reaction for two diallelic polymorphisms in CYP11B2: one in the transcriptional regulatory region (promoter) and the other in the second intron. In multiple regression analyses, the CYP11B2 promoter genotype predicted statistically significant variations in left ventricular end-diastolic diameter (beta=.40, P<.0001), end-systolic diameter (beta=.33, P=.0009), and mass (beta=.17, P=.023). These effects were independent of potentially confounding factors, including sex, body size, blood pressure, physical activity, smoking, and ethanol consumption. Genotype groups also differed in a measure of left ventricular diastolic function, the heart rate-adjusted atrial filling fraction (P=.018). Increased dietary salt, which is known to predict increased left ventricular mass, had this effect only in association with certain CYP11B2 genotypes (P<.001). CONCLUSIONS: Genetic variations in or near the aldosterone synthase (CYP11B2) gene strongly affect left ventricular size and mass in young adults free of clinical heart disease. These polymorphisms may also influence the response of the left ventricle to increases in dietary salt.

Adult↗