Simultaneous left and right atrial pressure curves during Valsalva's experiment.
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Atrial Pressure↗
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Simultaneous aortic, jugular bulb, and right atrial pressures during cardiopulmonary resuscitation in humans.
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Atrial Function↗
Coronary artery disease: evaluation by the multistage treadmill exercise test and right atrial pacing.
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Adult↗
Surgery of atrioventricular septal defects with left ventricular-right atrial shunt. Report of 23 cases.
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Abnormalities, Multiple↗
Influence of diabetes mellitus on changes in left ventricular performance and renal function produced by converting enzyme inhibition in patients with severe chronic heart failure.
Diabetes mellitus is frequently accompanied by specific abnormalities of the renin-angiotensin system, but it is not known whether these alterations modify the response to converting enzyme inhibition. To evaluate this possibility, 129 patients with severe chronic heart failure were treated with captopril or enalapril for one to three months, while doses of digoxin and diuretics were kept constant; 35 patients had diabetes mellitus. Prior to therapy, diabetic patients had lower plasma renin activity (3.4 +/- 0.5 versus 7.0 +/- 1.1 ng/ml/hour) than did nondiabetic control subjects (p less than 0.05); yet the initial hemodynamic response to captopril was similar in both groups. Plasma renin activity predicted the hypotensive response to the first dose of captopril in nondiabetic control subjects (r = 0.70, p less than 0.001) but not in diabetic patients (r = 0.29). During long-term treatment with captopril or enalapril, both diabetic and nondiabetic patients had similar increases in cardiac index and decreases in mean arterial pressure and systemic vascular resistance. Diabetic patients, however, showed larger reductions in left ventricular filling pressure (-13.8 versus -9.1 mm Hg, p less than 0.02) and mean right atrial pressure (-6.2 versus -3.9 mm Hg, p less than 0.05) than did nondiabetic subjects; this was accompanied by a notable decline in body weight in diabetic patients only. Renal function remained unaltered during converting enzyme inhibition in nondiabetic patients, but deteriorated significantly in diabetic patients, as reflected by a marked increase in serum creatinine concentration (1.7 +/- 0.1 to 2.1 +/- 0.1 mg/dl, p less than 0.001). In conclusion, despite lower pretreatment plasma renin activity, diabetic patients with severe chronic heart failure demonstrated improvement during long-term converting enzyme inhibition to a degree similar to (if not greater than) that seen in nondiabetic control subjects, but were more susceptible to the development of functional renal insufficiency than their nondiabetic counterparts. These differences are explicable by abnormalities of renin/aldosterone synthesis and angiotensin-mediated vasoregulation that are known to be present in the diabetic state.
Adult↗
Isolated ultrafiltration in moderate congestive heart failure.
OBJECTIVES: The aim of this study was to evaluate whether ultrafiltration is beneficial in patients with moderate congestive heart failure. BACKGROUND: Ultrafiltration is beneficial in patients with severe congestive heart failure. METHODS: We studied 36 patients in New York Heart Association functional classes II and III in stable clinical condition. Eighteen patients (group A) were randomly selected and underwent a single session of ultrafiltration (venovenous bypass, mean [+/- SEM] ultrafiltrate 1,880 +/- 174 ml, approximately 600 ml/h) and 18 (group B) served as control subjects. RESULTS: Two patients in group A and three in group B did not complete the 6-month follow-up study. In group A, soon after ultrafiltration there were significant reductions in right atrial pressure (from 8 +/- 1 to 3.4 +/- 0.7 mm Hg, pulmonary wedge pressure (from 18 +/- 2.5 to 10 +/- 1.9 mm Hg) and cardiac index (from 2.8 +/- 0.2 to 2.3 +/- 0.2 liters/min). During the follow-up period, lung function improved, extravascular lung water (X-ray score) decreased and peak oxygen consumption (ml/min per kg) increased significantly from 15.5 +/- 1 (day -1) to 17.6 +/- 0.9 (day 4), to 17.8 +/- 0.9 (day 30), to 18.9 +/- 1 (day 90) and to 19.1 +/- 1 (day 180). Oxygen consumption at anaerobic threshold (ml/min per kg) also increased significantly from 11.6 +/- 0.8 (day -1) to 13 +/- 0.7 (day 4), to 13.7 +/- 0.5 (day 30), to 15.5 +/- 0.8 (day 90) and to 15.2 +/- 0.8 (day 180). These changes were associated with increased ventilation, tidal volume and dead space/tidal volume ratio at peak exercise. The improvement in exercise performance was associated with a decrease in norepinephrine at rest, a downward shift of norepinephrine kinetics at submaximal exercise and an increase in norepinephrine during orthostatic tilt. None of these changes were recorded in group B. CONCLUSIONS: In patients with moderate congestive heart failure, ultrafiltration reduces the severity of the syndrome.
Aged↗
[Echocardiographic study of patients with alcoholic heart lesions].
The authors provide data obtained during echocardiographic examination of 16 patients with different patterns of alcoholic heart injury primarily at the early stages of alcoholism. The group of patients without heart rhythm abnormality showed a decrease in myocardial contractile function, moderate dilatation of the left ventricle and its hypertrophy. In patients with heart rhythm abnormalities, the progress of myocardial lesions, dilatation of the left ventricle, left atrium and right ventricle prevailed over hypertrophy of the left ventricle. Hypertrophy and dilatation of the left ventricle were most pronounced in patients with permanent atrial fibrillation. The disease was discovered to run its course in stages with gradual superimposition on left ventricle hypertrophy and dilatation followed by a decrease in myocardial contractile function.
Adult↗
[Electrophysiology of the atrioventricular node during atrial fibrillation. I. Ventricular rhythm].
Atrial fibrillation (AF) occurs in 0.9% of the population, in 6% of persons over 65 and in 10% of persons over 80. It is an important independent risk factor for thromboembolism, especially cerebral infarctions. The functions of the atrioventricular (AV) node are: (a) optimal adjustment of the time between the contractions of atria and ventricles; (b) protection of the ventricles against excessively high frequencies of atrial tachycardia; (c) a pacemaker function in case of atrial arrest. AF is an irregular, disorganized electrical activity of the atria. On the ECG, P waves are absent and the baseline shows wavelets constantly changing in shape, duration, amplitude and direction. Development and existence of AF are correlated with a sufficiently large number of myocardial cells and a sufficient degree of difference between the electrical properties of the myocardial cells. In the absence of an AV conduction block, the resulting ventricular rhythm is completely irregular. The constant irregularity of the ventricular rhythm is independent of ventricular frequency and independent of cardiac and other characteristics of the patient. Electrical stimulation of the right ventricle leads to complete AV block.
Adult↗
Restoration of atrial function after the maze procedure for patients with atrial fibrillation. Assessment by Doppler echocardiography.
BACKGROUND: The purpose of the present study was to evaluate the effects of the maze procedure on atrial function in patients operated on for atrial fibrillation. The maze procedure is a new surgical intervention that is designed to restore sinus rhythm and active mechanical atrial contraction as a definitive treatment for patients with atrial fibrillation. METHODS AND RESULTS: Doppler echocardiographic analysis of mitral and tricuspid inflow as well as pulmonary venous flow velocity was carried out in 46 patients 8 +/- 7 months after the maze procedure, and results were compared with those obtained from 27 age-matched control subjects. To evaluate atrial contraction, we determined the presence of atrial contribution to ventricular filling at the mitral and tricuspid valve levels and measured the percent atrial filling fractions of the left and right atria. To evaluate atrial compliance, we measured the systolic and the systolic-to-diastolic flow velocity ratios of the pulmonary venous inflow. Results were compared with similar measurements obtained from control subjects. Restoration of active atrial contraction was detected in 40 of the 46 patients (87%); right atrial contraction was noted in 38 patients (83%), and left atrial contraction was noted in 28 patients (61%). In patients with active atrial contraction, the percent atrial filling fraction of the right atrium was comparable to that of control subjects (32 +/- 7% versus 33 +/- 8%, P = NS), whereas that of the left atrium was smaller (20 +/- 5% versus 36 +/- 7%, P < .005). In addition, compared with control subjects, pulmonary venous flow in maze patients exhibited a reduced systolic component (17 +/- 4 versus 53 +/- 16 cm/s, P < .001) and decreased systolic-to-diastolic flow velocity ratio (0.3 +/- 0.01 versus 1.1 +/- 0.3, P < .001) and velocity integral ratio (0.3 +/- 0.01 versus 1.3 +/- 0.4, P < .001), all suggesting decreased left atrial filling. CONCLUSIONS: The maze procedure restores active right atrial contraction and improves left atrial contraction in most patients. Obtained measurements suggest decreased left atrial compliance and reduced left atrial contribution to ventricular filling compared with control subjects. Despite the reduced indexes, qualitative restoration of function in either atria should translate in improved atrioventricular synchrony and reduction in thromboembolic events in patients with chronic or paroxysmal atrial fibrillation.
Atrial Fibrillation↗
Reversibility of tachycardiomyopathy after successful radiofrequency catheter ablation: intermediate results.
Left ventricular function in patients with tachycardia induced cardiomypopathy can improve after cessation of the arrhythmia. We reported the intermediate results of 10 patients, 6 men and 4 women, with tachycardiomyopathy who successfully underwent radiofrequency catheter ablation (RFCA) for incessant tachycardia. Three had right atrial tachycardia, 5 ventricular tachycardia (2 and 3 from the right and left ventricles, respectively), 1 atrial flutter and 1 right accessory pathway. During the mean follow-up period of 19 months (range 11-38 months), one patient, right atrial tachycardia, had recurrence and reablation was successfully done without recurrence. Left ventricular ejection fraction, endsystolic and diastolic diameters from echocardiography gradually improved from 35 per cent, 51 and 61 mm to 58 per cent, 36 and 52 mm, respectively (p<0.001). The mean duration of reversibility was 7 months (range 1-15 months). There was no recurrence of tachycardiomyopathy after the return of left ventricular function. Conclusion, RFCA can terminate tachyarrhythmia and lead to significant improvement of left ventricular diameters and systolic function in patients with tachycardia induced cardiomyopathy.
Adolescent↗
Divided right atrium (prominence of the eustachian and thebesian valves).
Division of the morphologically left atrium (cor triatriatum) is a recognized clinical and surgical entity. Division of the right atrium (prominence of the eustachian and thebesian valves) is recognized pathologically, but is rare. It is unusual for this entity to be diagnosed during life. Stimulated by our experience with two patients seen at operation, one with an obstructive spinnaker-like formation and the other with a partitioned right atrium in the setting of pulmonary atresia, we reviewed the specimens in the heart museum of Children's Hospital of Pittsburgh that had prominence of the eustachian and thebesian valves. We identified 14 such hearts, which could be divided into two groups. In the first group, comprising six hearts, the valves were prominent in the form of Chiari networks and were of no functional significance. The valves were more extensive in the other eight hearts and partitioned the right atrium. In two of these, the valves themselves were the impediment to flow through the right side of the heart. In the other six, there was either atresia or severe stenosis along the right-sided pathways so that, after birth, the prominent valves retained their role during fetal life; namely, to deflect inferior caval venous return across the atrial septum to the left atrium. The partitions in these latter hearts would be of functional significance only if it were necessary to perform a Fontan procedure, when they might obstruct flow through an atriopulmonary (or atrioventricular) anastomosis.
Female↗
A study in ventricular-ventricular interaction. Single right ventricles compared with systemic right ventricles in a dual-chamber circulation.
BACKGROUND: Ventricular-ventricular interaction is known to occur in normal human heart. To determine whether it plays a role in the function of single right ventricles, systemic right ventricles were compared with and without a left ventricle mechanically coupled to it. METHODS AND RESULTS: A noninvasive magnetic resonance tagging technique (spatial modulation of magnetization [SPAMM]) that lays intersecting stripes down on the myocardium was used to examine 18 patients with systemic right ventricles: 7 with a single right ventricle who have undergone the Fontan procedure (age, 38.8 +/- 8.9 months) and 11 with transposition of the great arteries who have undergone an atrial inversion operation (age, 16.3 +/- 3.9 years). The motion of the intersection points was tracked through systole to determine regional twist and radial shortening. Shortening rates also were evaluated. Finite strain analysis was applied to the grid lines using Delaunay triangulation, and the two-dimensional strain tensor and principal E1 strains were derived for the various anatomic regions. Basal and apical short-axis planes through the ventricular wall were categorized into four distinct regions spaced equally around the circumference of the slice. We observed the following results. (1) Strain was greatest and heterogeneity of strain was least in patients with transposition of the great arteries who were status post atrial inversion operation (six of eight regions). Marked differences were noted in the distribution of strain within a given region, from endocardium to epicardium, and from atrioventricular valve to apical plane between patient subtypes and those with a normal left ventricle. (2) Contrary to the normal subject studied by the use of the same method, for both patient subtypes, there was counterclockwise twist in one region, clockwise twist in the posterior or inferior wall, and a transition zone of no twist at which the two regions of twist met. Normal human adult left ventricles studied in short-axis twist uniformly counterclockwise as viewed from apex to base. (3) Radial inward motion was greatest in the superior wall of both types of systemic right ventricle. The inferior walls of Fontan patients and the posterior (ie, septal) walls of patients with transposition of the great arteries, status post atrial inversion, moved paradoxically in systole. The shortening rate at the atrioventricular valve of patients with transposition of the great arteries, status post atrial inversion, was significantly lower than at the apex or in Fontan patients. CONCLUSIONS: Marked differences in regional wall motion and strain were demonstrated in systemic right ventricles, depending on whether a left ventricle was present to augment its function. Ventricular-ventricular interaction appears to play an important role in affecting the biomechanics of systemic right ventricles. These observations were markedly different from those in the normal systemic left ventricle. These techniques demonstrate tools with which we can begin to evaluate surgical outcomes using regional myocardial mechanics and may provide a clue to single right ventricle failure.
Adolescent↗
Reduction of atrial fibrillation inducibility by radiofrequency ablation: an experimental study.
UNLABELLED: A study is made of the antifibrillatory effects of radiofrequency (RF)-induced atrial lesions using nine Langendorff-perfused rabbit hearts in which the atrial electrophysiological properties and atrial fibrillation (AF) inducibility were modified by atrial stretching. Using a multiple electrode consisting of 121 unipolar electrodes, determinations were made of the atrial refractory periods, conduction velocity, wavelength of the atrial activation process, and the inducibility of sustained AF episodes (duration over 30 s) by atrial burst pacing in four situations: (a) control; (b) following dilatation of the right atrium; (c) after adding an RF linear lesion at the cava-tricuspid annulus isthmus; and (d) after adding two RF linear lesions rounding the base of the right atrial appendage and extending from the inferior zone of the sulcus terminalis to the anterior wall of the appendage. Under control conditions, AF was not induced in any of the experiments. The wavelengths were 10.5 +/- 1.2 cm for basic cycles of 250 ms and 6.6 +/- 0.5 cm for cycles of 100 ms. Following dilatation, a significant decrease was recorded in the atrial refractory periods, conduction velocity, and wavelength, which reached values of 6.1 +/- 0.7 cm (250-ms cycle, P < 0.01), and 3.9 +/- 0.3 cm (100-ms cycle, P < 0.01); AF was induced in five cases (P < 0.05). After producing the lesion at the cava-tricuspid isthmus, the electrophysiological modifications induced by atrial dilatation persisted (wavelength = 6.2 +/- 0.6 cm (250-ms cycle) and 4.3 +/- 0.3 cm (100-ms cycle); P < 0.01 vs the control) and AF was triggered in eight cases (P < 0.0001). In turn, on adding the two lesions at the right atrial free wall and appendage, AF was induced only in one experiment (P = NS vs control), and the dilatation-induced decrease in refractoriness and wavelength was attenuated. Nevertheless, differences remained significant with respect to the controls, with the exception of the functional refractory periods determined at cycles of 100 ms. In this phase, the wavelength was 6.6 +/- 0.7 cm (250-ms cycle, P < 0.01 vs control) and 4.9 +/- 0.5 cm (100-ms cycle; P < 0.05). Atrial conduction between the zones separated by the lesions was blocked at any frequency, or selectively at rapid atrial activation frequencies. IN CONCLUSION: (a) the production of three linear lesions in the right atrium (cava-tricuspid isthmus, atrial appendage, and inferior free wall) reduces AF inducibility in the experimental model used; (b) conduction block (either absolute or frequency dependent) through the lesions, reduction in tissue mass caused by lesion creation, and possibly the attenuation of the shortening of atrial refractoriness and wavelength in the zones not separated by the lesions are implicated in the reduction of AF inducibility; and (c) the single lesion in the cava-tricuspid isthmus does not impede AF inducibility.
Animals↗
Effects of sublingually administered nifedipine on left ventricular isovolumic relaxation, diastolic filling, and distensibility in patients with chronic coronary artery disease.
The acute effects of nifedipine (20 mg) on left ventricular diastolic function were investigated in 16 patients with chronic coronary artery disease by measuring left ventricular pressure with a manometer-tipped catheter and by measuring volume with cineangiography. Heart rates were maintained by right atrial pacing. Left ventricular peak systolic pressure (-15%; p less than 0.01 vs control) decreased significantly. With afterload reduction, left ventricular ejection fraction (+11%; p less than 0.01) increased. There was no significant change in left ventricular end-diastolic pressure. The diastolic peak filling rate of left ventricular volume significantly increased (+36%; p less than 0.05), whereas the time from end-systole to the peak filling rate remained unchanged. Administration of nifedipine did not improve left ventricular relaxation as assessed by the isovolumic pressure decay. There was also no significant change in the left ventricular diastolic pressure-volume relationship. We conclude that nifedipine improves left ventricular systolic function with afterload reduction but has little or no effect on left ventricular diastolic properties in patients with chronic coronary artery disease.
Administration, Sublingual↗
Hemodynamic status in repaired tetralogy of Fallot assessed by Doppler echocardiography and cardiac catheterization. Comparisons with healthy subjects and elucidation of factors associated with cardiorespiratory function.
Thirty-four patients were studied after corrective surgery for tetralogy of Fallot (mean follow-up 10 years) and compared with healthy matched controls. All underwent Doppler echocardiography, spirometry and treadmill exercise test. Post-operative cardiac catheterization had been performed on 26 (76%) of the patients and showed poor hemodynamic results in four (15%). Significant correlations of pressure gradients obtained from catheterization and estimated by Doppler echocardiography were right ventricular to right atrial (r = 0.77), pulmonary outflow (r = 0.75), pure valvular pulmonary outflow (r = 0.94) and diastolic pulmonary pressure gradients (r = 0.53). Pulmonary outflow gradients and right ventricular to right atrial pressure gradients estimated from tricuspid regurgitation jets were significantly increased in the patients. Diastolic pulmonary artery pressure, vital capacity and ventilatory anaerobic threshold were independent factors of maximal oxygen consumption. It is suggested that Doppler-derived diastolic pulmonary artery pressure, lung function studies and exercise testing with assessment of the ventilatory anaerobic threshold should be included in follow-up after repair of Fallot's tetralogy.
Adolescent↗
Advanced quantitative echocardiography in arrhythmogenic right ventricular cardiomyopathy.
BACKGROUND: Arrhythmogenic right ventricular (RV) cardiomyopathy (ARVC) is a regional disease of the RV myocardium with variable degrees of left ventricular involvement. Three-dimensional echocardiography and Doppler tissue imaging (DTI) are new echocardiographic modalities for the evaluation of global and regional function, but the diagnostic potential remains to be assessed. METHODS: Twenty patients with previously established ARVC were evaluated by 3-dimensional echocardiography and DTI, and compared with 32 age- and sex-matched control subjects. RESULTS: Using 3-dimensional echocardiography, patients with ARVC had a decreased RV ejection fraction (0.47 +/- 0.08 vs 0.53 +/- 0.05, P < .01), and a decreased peak lateral systolic annular velocity by pulsed wave imaging of both the RV (11.9 +/- 2.6 vs 15.1 +/- 3.7 cm/s, P < .01) and the left ventricle (7.0 +/- 2.6 vs 9.5 +/- 1.9 cm/s, P < .01). DTI showed decreased regional systolic strain, but with wide variation in the measurements. CONCLUSION: Three-dimensional echocardiography identifies decreased RV ejection fraction in ARVC. Assessment of regional contractility by DTI is limited by wide variation. Echocardiographic evaluation of the longitudinal motility appears to be a sensitive marker of preclinical left ventricular involvement.
Adult↗
Left ventricular function and autonomic nervous system balance during two different stages of the menstrual cycle.
We studied the left ventricular function and cardiac autonomic nervous system balance variations during two different stages of the menstrual cycle. These two variables, as well as plasmatic estradiol and progesterone concentrations, were measured in a drug-free state in 20 women (29+/-6 year-old) with regular menstrual periods. A clinical evaluation, an echo-Doppler and a Valsalva manoeuvre were performed in all the patients on the third day of their menstrual cycle (follicular phase) and three days prior to their next menstrual cycle (luteinizing phase). When comparing the results obtained in these two phases, a statistically significant increase was put forward in plasmatic estradiol (50.6+/-24 vs. 127.3+/-52.8 pg/ml) and progesterone (0.37+/-0.42 vs. 11.92+/-10.8 ng/ml) concentrations, Valsalva index (1.55+/-0.22 vs. 1.67+/-0.33; P=0.044) and E/A mitral wave ratio (1.63+/-0.36 vs. 1.75+/-0.35, P=0.02). The right and left atrial volumes, left ventricular volumes and ejection fraction were similar in the two menstrual phases studied. We conclude that the autonomic nervous system balance and the left ventricular diastolic function suffer significant changes during the luteinizing phase of the menstrual cycle in normal women.
Adult↗
Pulmonary arterial impedance analysis by the use of the oscillated assist flow.
Pulmonary arterial impedance is an important and interesting characteristic that can be used to evaluate the physiological properties of the pulmonary vessel. However, power spectrum analysis of the pulmonary artery pressure and flow pattern have suggested that peak power in the relatively high frequency range (> 10 Hz) is significantly low; thus, we cannot analyze the vessel properties in the high frequency range. In this study, we used the newly developed vibrating flow pump (VFP), which can generate oscillated blood flow with a relatively high frequency (10-50 Hz) for right heart bypass, to evaluate the pulmonary arterial impedance pattern in the high frequency range. Acute animal experiments of the right heart bypass from the right atrium to the pulmonary artery using 6 healthy adult goats were performed. The flow pattern and pressure of the pulmonary artery, electrocardiograms (ECGs), and arterial and right atrial pressures were continuously monitored during the experiments. Spectral analysis of the hemodynamic parameters using the fast Fourier transform (FFT) method was performed to evaluate the spectral properties. The coherence function, transfer function, and phase patterns were calculated to analyze the impedance pattern in the relatively high frequency area. Previously, various investigators had tried to analyze the impedance patterns of the pulmonary artery; however, they could not analyze the impedance patterns over 10 Hz because the spectral patterns of the pulmonary flow do not have high power at high frequencies. These physiological analyses may be useful in designing the optimal pulmonary circulation.
Animals↗