Diastolic Heart Failure Karrowni, Wassef; Chatterjee, Kanu
Journal of intensive care medicine,
05/2014, Letnik:
29, Številka:
3
Journal Article
Recenzirano
Multiple recent epidemiologic studies have highlighted the importance of diastolic heart failure (DHF) as a public health problem. Approximately half of patients presenting with symptomatic heart ...failure (HF) have DHF and they suffer from morbidity and mortality comparable to those with systolic HF. Our understanding of the pathophysiology of DHF has evolved rapidly over the last decade, and the associated echo-Doppler findings that assist with its diagnosis are greatly refined. Recently, there has been increased recognition of the role of diastolic dysfunction and DHF in the care of critically ill patients, including those admitted to noncardiac units. The purpose of this review is to provide an up-to-date summary of the concepts of the pathophysiology of DHF. In addition, we provide an overview of the diagnostic approaches, prognostic identifiers, and associated comorbidities that make DHF more resistant to manage with a focus of the patients admitted to the intensive care unit. The current approach to managing patients with DHF is also reviewed.
The third heart sound (S(3)) is thought to be caused by the abrupt deceleration of left ventricular (LV) inflow during early diastole, increased LV filling pressures, and decreased LV compliance. We ...sought to determine whether the ratio of early mitral inflow velocity to diastolic velocity of the mitral annulus (E/E') could confirm the proposed mechanism of the S(3).
A total of 90 subjects underwent phonocardiography, echocardiography, tissue Doppler imaging, and left-sided heart catheterization.
Phonocardiography detected an S(3) in 21 patients (23%). Subjects with an S(3) had lower ejection fraction (P = .0006) and increased E deceleration rate (P < .0001), E/E' (P < .0001) and filling pressures (P < .0001). The phonocardiographic S(3) confidence score correlated with E/E' (r = 0.46; P < .0001) and E deceleration rate (r = 0.43, P = .0001). Of the echocardiographic variables, only E/E' was independently associated with the S(3) confidence score (P = .009), independently of invasively determined LV filling pressures (P = .001).
The most important determinants of the pathologic S(3) are an increased deceleration rate of early mitral inflow, elevated LV filling pressures, and abnormal compliance of the myocardium as measured by tissue Doppler imaging.
Background. Double-chambered right ventricle is a form of right ventricular outflow tract obstruction that develops over time, often in patients with an abnormally short distance between the ...moderator band and pulmonary valve. This lesion typically presents in childhood or adolescence and is often accompanied by a ventricular septal defect. Only a handful of previous cases have been described in which double-chambered right ventricle occurred in adulthood.
Methods. Since 1992, three patients more than 30 years old (38, 43, and 66 years of age) have presented at our institution with unusual symptoms or a previous incorrect diagnosis. We reviewed the clinical data in these patients.
Results. Presenting symptoms included syncope, angina, and severe dyspnea resembling pulmonary hypertension. In 1 patient, disease was categorized as New York Heart Association class IV, and in the other 2 as class III. Coexisting anomalies included a patent foramen ovale or secundum atrial septal defect in 2 patients, a small ventricular septal defect in 1 (with a probable history of ventricular septal defect in another), and mild aortic regurgitation in 1. All patients required urgent or emergent operations, with peak pressures in the proximal right ventricular chamber of 135 to 180 mm Hg and severely depressed left ventricular function in 1 patient. Resection of the anomalous right venticular muscle bundles was achieved through a right atrial approach in all patients. All patients were alive with improved functional status at follow-up, which was between 15 and 40 months.
Conclusions. Right ventricular outflow tract obstruction resulting from a double-chambered right ventricle is rare in adults, but when it does occur it can present with unusual symptoms. When evaluating the patient with signs or symptoms of primary right heart failure, cardiologists should make an effort to image the entire right heart complex. Subcostal echocardiography can facilitate adequate visualization of the right ventricle when it is difficult to distinguish the subpulmonary outflow tract from the parasternal and apical windows.
Hyponatremia in heart failure Chatterjee, Kanu
Journal of intensive care medicine,
2009 Nov-Dec, Letnik:
24, Številka:
6
Journal Article
Recenzirano
Hyponatremia is one of the newer and emerging risk factors for an adverse prognosis in chronic heart failure. Why decreased serum sodium is associated with worse prognosis remains unclear. It may ...reflect worsening heart failure and the deleterious effects of activation of neurohormones. The mechanism of hyponatremia in heart failure also remains unclear. A relatively greater degree of free-water retention compared to sodium retention is probably the major mechanism. The treatment of significant hyponatremia in heart failure is difficult. The conventional treatments such as fluid restriction, infusion of hypertonic saline, and aggressive diuretic therapies are not usually effective. Vasopressin receptor antagonists have been shown to enhance aquaresis and correct hyponatremia. However, long-term beneficial effects of such treatments in chronic heart failure have not been documented.
Abstract Background Erythropoietin (EPO) has generated interest as a novel therapy after myocardial infarction (MI), but the safety and efficacy of prolonged therapy have not been studied in a large ...animal model of reperfused MI. Methods and Results MI was induced in pigs by a 90-minute balloon occlusion of the left anterior descending coronary artery. Sixteen animals were randomized to either EPO or saline (control group). Inflammatory markers, bone marrow cell mobilization, and left ventricular function (by both echocardiography and pressure-volume measurements) were assessed at baseline, 1 and 6 weeks post-MI. EPO therapy was associated with a significant increase in hemoglobin and mononuclear counts. D-dimer and C-reactive protein levels did not differ between groups. At week 6, EPO therapy prevented further deterioration of left ventricular ejection fraction (39 ± 2% vs. 33 ± 1%, P < .01) and improved wall motion score index ( P < .02). Histopathology revealed increased areas of viable myocardium, vascular density, and capillary-to-myocyte ratio in the EPO therapy compared with the control (all P < .05). Conclusion Prolonged EPO therapy after MI in a large animal model is safe and leads to an increase in viable myocardium, increased vascular density, and prevents further deterioration of left ventricular function. These results support future clinical studies in post-MI patients.
Abstract Background The third heart sound (S3) and systolic time intervals (STIs) are validated clinical indicators of left ventricular (LV) dysfunction. We investigated the test characteristics of a ...combined score summarizing S3 and STI results for predicting LV dysfunction. Methods and Results A total of 81 adults underwent computerized phonelectrocardiography for S3 and STI (Audicor, Inovise Medical Inc), cardiac catheterization for LV end-diastolic pressure (LVEDP), echocardiography for LV ejection fraction (LVEF), and B-type natriuretic peptide (BNP) testing. LV dysfunction was defined as both an LVEDP >15 mm Hg and LVEF <50%. The STI measured was the electromechanical activation time (EMAT) divided by LV systolic time (LVST). Z-scores for the S3 confidence score and EMAT/LVST were summed to generate the LV dysfunction index. The LV dysfunction index had a correlation coefficient of 0.38 for LVEDP ( P = .0003), −0.53 for LVEF ( P < .0001), and 0.35 for BNP ( P = .0008). This index had a receiver operative curve c-statistic of 0.89 for diagnosis of LV dysfunction; a cutoff >1.87 yielded 72% sensitivity, 92% specificity, 9.0 positive likelihood ratio, and 88% accuracy. Conclusions In this preliminary study, the LV dysfunction index combined S3 and STI data from noninvasive electrophonocardiography, and yielded superior test characteristics compared to the individual tests for the diagnosis of LV dysfunction.
We sought to examine the immediate vasodilator effect of intracoronary estrogen on epicardial and resistance coronary arteries in 19 dogs.
Although estrogen reportedly dilates coronary arteries in ...vitro, the site and mechanisms of its action have not been fully defined in vivo.
Epicardial coronary artery dimensions and coronary flow velocity were assessed using simultaneous intracoronary two-dimensional and Doppler ultrasound.
Estrogen (0.1 and 1 μmol/liter) induced a significant increase in coronary cross-sectional area, flow velocity and volumetric blood flow. Estrogen-induced vasodilation was not influenced either by pretreatment with Nω-nitro-l-arginine methyl ester (l-NAME) (100 μmol/liter intracoronary), indomethacin (5 mg/kg body weight intravenously), propranolol (0.75 mg/kg intravenously) or the classic estrogen receptor antagonist ICI 182,780 (10 μmol/liter). Balloon denudation of the endothelium did not attenuate estrogen-induced epicardial vasodilation. Pretreatment with glibenclamide (10 μmol/liter) attenuated estrogeninduced vasodilation only in epicardial arteries, as did verapamil (0.1 μmol/liter). Estrogen had no effect on a phenylephrine dose-response curve in either epicardial coronary arteries or the microcirculation.
Acute estrogen-induced dilation in canine coronary arteries is endothelium independent and is not mediated by the classic intracellular estrogen receptor but through nongenomic mechanisms, presumably at the membrane level, which in epicardial arteries may include effects on adenosine triphosphate-sensitive potassium or calcium channels, or both.
Balloon floatation pulmonary artery catheters (PACs) have been used for hemodynamic monitoring in cardiac, medical, and surgical intensive care units since the 1970s. With the availability of newer ...noninvasive diagnostic modalities, particularly echocardiography, the frequency of diagnostic pulmonary artery catheterization has declined. In this review, the evolution of PACs, the results of nonrandomized and randomized studies in various clinical conditions, the uses and abuses of bedside hemodynamic monitoring, and current indications for pulmonary artery catheterization are discussed.
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