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On this poster the authors discuss what is the best way to perform cardiac resynchronization implantation in regards to better response rate of left ventricle.

Na ovom posteru je prikazan rezultat implantacije CRT uređaja navođenjem implantacije elektrode za lijevi ventrikul pomoću transezofagijske ehokardiografije.

We sought to determine whether early postoperative conversion of AF to SR leads to restoration of atrial contractile function, as assessed by intraoperative velocity and deformation analysis. Restoration of atrial activation occurs in the early postoperative period, inducing atrial contraction. Nevertheless, this contraction occurs with low velocity and deformation both in patients with and without RFA, suggesting that, although atrial activation is restored, atrial mechanics do not recover in the early phase, potentially due to either atrial stunning or irreversible atrial structural remodeling.

U radu se prikazuju iskustva centra s primjenom postupaka terapijskog pothlađivanja bolesnika nakon izvanbolničkog aresta.

Na ovom posteru je prikazan slučaj pojave Takotsubo kardiomiopatije i subarahnoidalnog krvarenja.

Arteficial coaptation surface in mitral valve repair

Na ovom posteru je prikazan slučaj mladog bolesnika nakon transplantacije srca čiji se boravak komplicira razvojem influence A (H1N1) pneumonije i ARDS-a.

We sought to follow up and compare patients with CRT devices placed by the transvenous or mini-thoracotomy approach.In both study groups, a clinical response was noted in all patients while volume response was superior after CRT implantation via mini-thoracotomy. However, a more notable reduction of PAP was measured after transvenous device placement. Our results suggest that detailed preoperative assessment of CRT candidates should lead to a better response rate. With the shortcomings of a more invasive approach, mini thoracotomy with selective CRT LV lead placement provides better LV reverse remodelling compared to the standard venous approach.

On this poster the authors discuss early detection of atrial activity after radiogrequent ablation.

Beside multiple clinical benefits, cardiac resynchronization therapy (CRT) is linked to 30% of non-responders, due to the underlying disease not being influenced by the electrical therapy, or suboptimal therapy delivery. In case of inadequate coronary veins anatomy or failed coronary sinus lead placement, mini-thoracotomy is advocated as an alternative approach. It is known that CRT induces acute changes in haemodynamics and that lead placement can influence the amount of response. While TEE is regularly used during valve surgery, little attention is paid to using echo guided CRT implantation and monitoring acute response of differential LV lead positioning. 10 patents (3F/7M, 54±14 years) referred for surgical CRT implantation via a mini-thoracotomy were analyzed. Intraoperative TEE including Doppler myocardial imaging data were acquired pre- and post-CRT device activation. The right atrial and ventricular leads were placed transvenously, the LV screw-in lead was positioned epicardially on the lateral wall via an anterolateral mini-thoracotomy. Selective LV lead pacing was performed on 4 sites (basal and apical anterior/posterior wall), analysing acute changes in LV dimensions, mechanics and haemodynamics. Optimisation criteria included the septal flash reduction, the decrease in end-systolic volume (LVESV) and the increase in dP/dt and EF. The septal flash was defined as an early inward and outward ventricular septal motion within the isovolumic contraction period, imaged by gray-scale or Tissue Doppler colour (anatomical) M-mode. dP/dt was measured from the mitral regurgitation CW Doppler traces. Reverse remodelling was defined as a reduction of LVESV ≥10%. Assessing the acute response to CRT was feasible in all patients. The LV pacing site with optimal response was the basal anterior wall (50% of pts), followed by the basal posterior (30% of pts), apical anterior and apical posterior wall (10% of pts each). Such LV lead positioning lead to a significant LVESV reduction (172±91 ml vs.136±75 ml, p=0.0003) and EF increase (22±9% vs. 32±8%, p=0.0001) immediately following pacemaker activation, with reverse LV remodelling and septal flash resolution occurring in all patients. A significant increase of post-implantation dP/dt was also noted in all patients (333.5±64.4 mmHg/s vs. 633.6±196.9 mmHg/s, p=0.001). Conclusion: Intraoperative echocardiography is a feasible tool which can be used to assess acute response to CRT and to guide optimal LV lead placement based on septal flash reduction and increase in dP/dt, leading to immediate LV reverse remodelling.

Background: A 30% rate of non-responders to cardiac resynchronization therapy (CRT) poses a challenge to better define the potential candidates before device implantation. A mechanism based approach to patient selection has been recently proposed, part of which suggests the septal flash as a sign of intraventricular dyssynchrony, predictive of CRT response. We hypothesize that immediate response to CRT implantation can be detected by resolution of the septal flash immediately following device activation, thus demonstrating that the presence of a septal flash prior to CRT pacing is a direct consequence of early septal activation in LBBB, correctable by CRT. Methods: Data from 12 consecutive patents (5F/7M, 55±14 years) referred for surgical CRT implantation via a mini-thoracotomy were analyzed. Intraoperative transoesophageal echocardiography as well as Doppler myocardial imaging data were acquired pre- and post-CRT device activation. The septal flash was defined as an early ventricular inward and outward septal motion within the isovolumic contraction period, imaged using gray-scale or Tissue Doppler color (anatomical) M-mode. Reverse remodeling was defined as a reduction of end-systolic volume (LVESV) ≥10%. The right atrial and ventricular leads were placed transvenously and the LV screw-in lead was positioned epicardially on the lateral wall. Additionally, selective LV lead pacing was performed on 4 sites (basal and apical anterolateral/posterolateral wall) in order to optimize the LV pacing lead position, guided by echocardiographic measurements of the greatest septal flash reduction and increase in dP/dt. Results: The septal flash was detected preoperatively in all patients and resolved immediately after onset of biventricular pacing. Immediately following pacemaker activation, a significant reduction of LVESV (177±90 ml vs.132±75 ml, p=0.0002) and increase in EF (23±9% vs. 33±8%, p=0.00003) were measured in all patients. Likewise, a significant increase of post-implantation dP/dt (measured from the mitral regurgitation trace) was noted in all patients (343.7±61.3 mmHg/s vs. 664.7±202.4 mmHg/s, p=0.001). The most frequently chosen LV pacing site was the basal posterolateral wall (50% of pts). Conclusion: Preoperative presence of the septal flash is a valid predictor of response to CRT. Immediately after CRT device activation, the septal flash disappears and LV reverse remodeling as well as an increase in contractility are observed. Additionally, intraoperative echocardiography is a feasible tool which can be used in the guidance of optimal LV lead placement.

Are overweigh patients prone to new onset postoperative atrial fibrillation after isolated coronary artery bypass grafting

U radu je prikazan zanimljiv slučaj bolesnika s akutnim aortnim sindromom kod kojega su komplementarne dijagnostičke metode bile oprečnih rezultata.

U suvremenoj kardiologiji ehokardiografija ima vodeću ulogu u dijagnostici i odabiru postupaka u raznim oblicima remodeliranja miokarda. Nadalje, to je najčešće primjenjivana metoda u rasvjetljavanju temeljnih supstrata i patofizioloških mehanizama zatajenja srca kao posljedice remodeliranja klijetki. Zahvaljujući širokoj dostupnosti, neinvazivnosti, lakoći primjene i relativno malenoj cijeni, ehokardiografija je i dalje nezamjenjiva u odnosu na druge metode oslikavanja u kardiologiji, koje bi valjalo prihvatiti kao komplementarne dijagnostičke metode. Cilj je ove disertacije istražiti nekoliko oblika remodeliranja klijetki i njihovih posljedica na regionalnu i globalnu funkciju miokarda, primjenom različitih ehokardiografskih metoda i specifičnih algoritama analize signala i slike u otkrivanju disfunkcije srca. Novije ehokardiografske tehnike temeljene na oslikavanju miokardnih brzina gibanja (Myocardial Velocity Imaging) omogućuju podrobniji i integrirani pogled u (dis)funkciju srca. Na temelju novijih spoznaja, na početku disertacije prikazan je originalni, integrirani pregled „srčane funkcije“, razlikujući intrinzičnu funkciju miocita (obično nazivanu kontraktilitetom) i crpnu funkciju klijetki, kao i glavne sastojnice srčane funkcije, to jest razvoj sile i deformaciju., Uvjeti u kojima srce radi, koji određuju odnos između navedenih sastavnica, definirani su kao: a) svojstva stijenke poput građe/elastičnosti tkiva, strukture vlakna i globalne geometrije, te b) interakcija srca i periferne cirkulacije koja se većinom opisuje kao stanje punjenja (tlačno i volumno opterećenje). U ispitivanju remodeliranja protoka kao posljedici staničnog remodeliranja i remodeliranja sile u ishemijski remodeliranom srcu, obrađivali smo podatke Dopplerske ehokardiografije. Posebna automatska kvantifikacija Dopplerskih zapisa istiska lijeve klijetke primijenjena je u definiranju specifičnih svojstava krivulje, koja ukazuju na disfunkciju miokarda. Dokazali smo da smanjenje ukupne kontraktilnosti uzrokuje simetričniji oblik krivulje istiska lijeve klijetke, što sugerira remodeliranje globalne kontraktilne sile, kako bi se prilagodila smanjenju istiska zbog smanjene kontraktilnosti. Slična automatska kvantifikacija trenutnih vršnih brzina protoka kroz aortni zalistak primijenjena je i u bolesnika s hipertrofijskim remodeliranjem klijetki u aortnoj stenozi. Ovo istraživanje pokazalo je da predoperativne vrijednosti asimetrije Dopplerskog zapisa predskazuju poslijeoperacijsku promjenu ejekcijske frakcije: u svih bolesnika sa značajno simetričnim predoperativnim vršnim brzinama kroz aortni zalistak dokazali smo pogoršanje ili 114 istovjetnu ejekcijsku frakciju nakon operacije. Nadalje, ovo je istraživanje dokazalo da je simetričnost vršnih brzina pouzdaniji predskazatelj funkcijskog oporavka nakon zamjene aortnog zalistka, u usporedbi sa srednjim transaortnim gradijentom i površinom aortnog ušća koji se često koriste u predoperativnoj evaluaciji bolesnika s aortnom stenozom. U analizi električnog remodeliranja u bolesnika s blokom lijeve grane, provedeno je, uz standardnu ehokardiografiju, intraoperacijsko ispitivanje miokardnog Dopplera tijekom postupka ugradnje resinkronizacijskog elektrostimulatora. Uz potvrdu flash - septuma kao mehaničke posljedice temeljnog električnog problema te valjanog pokazatelja intraventrikulske disinkronije, u ovoj skupini bolesnika dokazano je i akutno poboljšanje kontraktilnosti, nestanak flash - septuma kao i povratno remodeliranje lijeve klijetke neposredno nakon uključivanja resinkronizacijskog elektrostimulatora. Za razliku od remodeliranja uzrokovanog promjenom uvjeta punjenja, u skupini bolesnika s akromegalijom dokazali smo hipertrofiju i hiperkontraktilnost lijeve klijetke uz posljedično povećanje minutnog volumena srca te razvoj znakova vaskularnog remodeliranja, bez dodatnih promjena u tlačnom opterećenju srca. Disertacija završava širim prikazom izmijenjene uloge ehokardiografije u dijagnozi hipertrofijskih bolesti miokarda. Prethodna saznanja kao i podatci o regionalnoj deformaciji (uključujući analizu uzoraka deformacije) povezani su u svrhu prepoznavanja bolesti koja je u podlozi hipertrofijskom remodeliranju klijetki: u hipertenzivnoj bolesti srca hipertrofija je većinom lokalizirana u bazalnom interventrikulskom septumu uz smanjenje vrijednosti sistoličkog strain-a te nastanak post-sistoličkog izduljenja. Sistemske bolesti poput Fabryjeve bolesti često zahvaćaju određenu regiju srca – bazalni (infero)lateralni segment u kojem je često prisutno post-sistoličko zadebljanje. Hipertrofijska kardiomiopatija je povezana s ograničenim područjima poremećene arhitekture srčanih vlakana, u kojima je deformacija u potpunosti odsutna, dok je u okolnim segmentima (često slične debljine stijenke) deformacija smanjena, no gotovo normalna. Odsutnost deformacije obično je povezana s najzadebljanijim segmentima. Čini se da amiloidoza predstavlja iznimku u kojoj smanjenje sistoličke funkcije globalno zahvaća miokard - nalazi se globalna hipertrofija lijeve klijetke te difuzno, teško oštećenje logitudinalnog straina dok je radijalni strain još očuvan, ali malenih vrijednosti.

Invited lecture at the Euroecho teaching course.

Background: Due to chronic GH and IGF-I excess, a specific cardiomyopathy associated with ventricular hypertrophy and diastolic dysfunction develops in patients with acromegaly. The first stage of acromegalic cardiomyopathy is characterized by a visually hyperkinetic left ventricle (LV) but normal ejection fraction (EF) and may be difficult to discern from LV remodelling taking place in arterial hypertension. We sought to analyze the potential difference in LV contractility among these two patient groups with a similar grade of hypertrophic remodelling. Methods: 37 patients with acromegaly (50.1 ± 10.5 years, 20 female/17 male) and normal EF were compared to 15 patients with arterial hypertension (52.7±16.6 years, 7 female/8 male, normal EF). 32 healthy sex- and age matched volunteers served as a control group. Patients in all three groups underwent a complete echocardiographic exam. LV mass was calculated and indexed by body surface area to obtain the LV mass index (LVMI). The outflow velocity time integral (VTI) and ejection time (ET) were measured from PW Doppler traces of left ventricular outflow. ET was indexed by heart cycle duration (R-R) to obtain the relative ET duration (ET/R-R). Aortic root size (Ao), LV stroke volume (SV) and cardiac output (CO) were calculated as previously described. Results: Acromegaly: mean disease duration was 6.5±6.0 years, LVMI=95±24 g/m², SV = 158±60 mL, Ao = 3.4±0.5 cm, ET/R-R = 0.33±0.03 s. A correlation was found between LVMI and ET/R-R (R=0.34 ; p=0.07) and LVMI and VTI (R=0.58 ; p= 0.002). Hypertension group: LVMI=93±13 g/m², SV = 87±16 mL, Ao = 3.1±0.2 cm, ET/R-R = 0.36±0.03 s. Control group: LVMI = 77±12 g/m², SV = 84±20 mL, Ao = 2.8±0.4 cm. ET/R-R = 0.34±0.04 s. No correlation between LVMI and ET/R-R nor LVMI and VTI was found in the hypertensive or control group. Conclusion: A comparable degree of LVH was found in acromegaly and the hypertensive group, both significantly higher compared to normals. Unlike in hypertension, in the acromegalic hearts this was associated with an increase in outflow together with a shorter relative ejection time suggesting the presence of increased contractility. Additionally, the aortic diameter was increased both in acromegaly and hypertension, although significantly higher in acromegaly. Thus, unlike hypertensive heart disease, acromegalic heart disease at an early stage is associated with a hypertrophic and hypercontractile LV without an additional increase in afterload, leading to a higher grade of aortic dilatation.

Prikaz bolesnika s heparinom induciranom trombocitopenijom, liječenom fondaparinuxom.

A novel aortic score is presented for the quantification of atherosclerosis altered ascending aorta, as assessed by epiaortic ultrasound

Uvod: Gradijent kroz aortni zalistak u teškoj aortnoj stenozi (AS) upućuje na težinu stenoze, ali često ne ukazuje na moguću smanjenju miokardnu funkciju. Nakon početnog hipertrofijskog remodeliranja lijeve klijetke (LK), dolazi do razvoja fibroze miokarda što uzrokuje sistoličku disfunkciju. Pretpostavili smo povezanost oblika spektra brzina aortnog protoka i slabljenja miokardne funkcije zbog fibroze u AS. Metode: Ehokardiografski smo predoperativno (PRE) i 9 mjeseci nakon operacije (POST) istraživali 34 bolesnika podvrgnuta zamjeni aortnog zalistka (AVR-aortic valve replacement) zbog teške AS. 29 zdravih dobrovoljaca služilo je kao kontrolna skupina. Poluautomatska analiza bila je primijenjena na zapise brzine aortnog protoka prikupljene kontinuiranim Dopplerom na temelju kojih je kvantificirana asimetrija spektra kao normalizirana razlika površina ispod krivulje lijeve i desne polovine spektra. Tako se niža asimetrija spektra nalazi u simetričnijem protoku s kasnijim vrškom. U 18 bolesnika predoperativno je učinjena magnetska rezonancija (MR) srca uključujući slike odgođene postkontrastne imbibicije (LE-late enhancement) radi procjene nadomjesne fibroze. Uzorci biopsije LK prikupljeni su radi procjene intersticijske fibroze u 29 bolesnika tijekom AVR. Rezultati: Vrijednosti asimetrije PRE ≥ 0.15 pokazale su 95% specifičnost i 100% senzitivnost u otkrivanju bolesnika s postoperacijskim oporavkom ejekcijske frakcije (EF), bez obzira na srednji transvalvulni gradijent PRE. Znakovi LE prikazani su MR-om u 72% bolesnika u kojih je navedena pretraga izvedena. Jednaki postotak bolesnika imao je znakove fibroze u nalazu biopsije. U podskupini bolesnika s asimetrijom PRE ≥ 0.15 (koji su svi oporavili EF postoperativno), LE je bila prisutna u 50% bolesnika. Suprotno tome, u podskupini bolesnika s asimetrijom PRE < 0.15, LE je prikazana u 90.9% bolesnika. Naposlijetku, nakon AVR, vrijednosti asimetrije porasle su na ≥ 0.15 u svih bolesnika. Međutim, 10 bolesnika zadržalo je asimetriju < 0.25. Predoperativni MR nalazi bili su dostupni u 6/10 bolesnika te su u svih ukazivali na znakove LE. Zaključak: Simetrični spektar aortnog protoka čini se povezan sa smanjenjem funkcije LK kao i s nadomjesnom fibrozom vidljivom na MR. Nadalje, takav zapis s visokom specifičnošću i senzitivnošću predskazuje postoperacijski funkcijski oporavak. Poluautomatska analiza pruža dodatne kliničke podatke o funkcijskom značenju aortne stenoze.

Morphological changes of Doppler ultrasound images are an important source of information for diagnosis of cardiovascular diseases. Quantification of these flow profiles requires segmentation of the ultrasound images. In this article, we propose a new model-based method for segmentation of (aortic outflow) velocity profiles. The method is based on a procedure for registration using a geometric transformation specifically designed for matching Doppler ultrasound profiles. Mutual information is used as an image similarity measure, while optimization is performed by a genetic algorithm. The registration method is experimentally validated using an in-silico image phantom. The model based segmentation is evaluated in a series of aortic outflow Doppler ultrasound images from 30 normal volunteers, comparing the automated method to the manual delineation by an expert cardiologist. The experimental results confirm the accuracy of the approach and shows that the method can be used for the segmentation of clinically obtained aortic outflow velocity profiles.

Background: Myocarditis is an inflammatory disease of the myocardium. In its acute phase it can mimic the symptoms of an acute coronary syndrome, induce life-threatening arrhythmias or cardiogenic shock, while in its chronic phase it can lead to dilated cardiomyopathy and heart failure. However, it’ s a disease that is seriously under-diagnosed clinically and usually too late for any specific treatment protocol. In the last two decades, cardiac magnetic resonance has been recognized as a new non-invasive imaging modality for the diagnosis of myocarditis. We would like to present the first two cases of myocarditis confirmed by CMR at the University Hospital Centre Zagreb. The first case is 27-year old male who presented himself in emergency department as an acute coronary syndrome. Alongside clinically typical chest pain, elevation of cardiac Troponin T (cTnT 4.01), ST elevation of 1– 2 mm in inferior leads, he also had echocardiographicaly verified akinesia of the inferoposterior wall with reduced systolic function (EF 45%) and minimal pericardial effusion. Coronary angiography showed a normal coronary angiogram with a slower filling of the left anterior descending artery. The patient had chest pain for several subsequent days after which the symptoms disappeared. The patient temperature rose to 37.7 C while inflammatory parameters remained normal throughout the whole hospital stay (max. CRP 4.5 mg/L, SE 12 mm/h). On the follow-up echocardiographic study after one month only minimal loss of contractility and improval of systolic function were observed. A cardiac magnetic resonance study was performed since the etiology of the incident remained still unclear. To enhance the detection of pathology on CMR, gadolinium-diethylene triamine pentaacetate (DTPA) was used. Contrast-enhanced CMR analysis showed late enhancement in inferior and lateral segments of left ventricle with mid-wall distribution which are typical for the late stage of myocarditis. The second case is 17-year old boy who came in the emergency department because of the fever, sore throat, chest pain and dyspnea. Elevated levels of the inflammatory parameters (CRP 131.2 mg/L, SE 38 mm/h) and cardiac troponin T (cTnT 1.73 mcg/L) were registered, as well as ST elevation in precordial leeds.Right-sided pneumonia was also observed. Echocardiographic exam showed slightly enlarged left ventricle with impaired systolic function (EF 46– 60%) and reduced amplitudes of the wall motion in the posterlateral region. To confirm the diagnosis of myocarditis, CMR was preformed. Oedema of the posterolateral wall was seen, as well as the patchy distribution of contrast enhancement, mostly in the subepicardial segment. In the control period before discharge echocardiographic test results were normal, with EF 70% and the normal contractility of the myocardium. Conclusion: Different LE pattern was observed comparing the acute and chronic phase of myocarditis with the acute phase showing edema in the affected region of the myocardium, while the chronic phase showed a mid-wall pattern. Discussion: Our results correspond with other published series of myocarditis patients that showed high sensitivity of over 90%. Endomyocardial biopsy with histopathology has been used as the gold standard. However, reliance on the Dallas criteria alone has been shown to give false-negative results and the acquisition of myocardial tissue with a bioptome is a painful and not completely risk-free procedure. CMR allows us a non-invasive highly specific method to detect myocarditis both it its acute and chronic phase.

Severe aortic stenosis (AS) shows higher, often prolonged LV outflow velocities. The gradient measured over a stenotic valve is indicative of stenosis severity, but often does not relate to myocardial function. We hypothesize a relation between the profile of the aortic outflow velocity and myocardial function. 35 patients undergoing aortic valve surgery for severe AS were studied by echocardiography pre- (PRE) and 1 year postoperatively (POST). 29 healthy volunteers served as controls. Ejection fraction (EF), aortic valve area (AVA) and mean aortic gradient (PG mean) were measured while model-based analysis was applied to aortic CW velocity traces. The asymmetry (asymm) was quantified as the normalized difference of area under the curve of left and right half of the spectrum so that a lower asymm corresponds to more symmetrical, later peaking flow. A significant correlation was found between asymm PRE and change in EF POST-PRE (r=0.66, P0.05). Asymm PRE did not correlate significantly with PG mean PRE (r=0.18), while the patients with higher values of asymm PRE all showed improvement in EF POST-PRE (positive delta EF), regardless of PG_mean PRE (figure 1, right). A symmetrical aortic outflow profile might reflect not only higher grade AS, but seems related to a reduction in LV function and predicts its recovery after surgery with higher confidence than preoperative mean gradient. Automated model-based analysis provides additional clinical information on the functional impact of AS.

This article presents series report and one center experience in artificial valve thrombosis management and fybrinolysis.

The authors describe a case of a patient presenting with pulmonary edema. Further diagnostic work-up led to the diagnosis of myocardial bridging and apical ballooning syndrome.

U uvodniku se predstavljaju i detaljno objašnjavaju smjernice Europskog društva za hipertenziju i Europskog kardiološkog društva (ESH/ESC) za dijagnosticiranje i liječenje arterijske hipertenzije prilagođeno uvjetima i organizaciji zdrastvene službe u Hrvatskoj. Smjernice imaju temeljnu svrhu pridonošenja kvalitetnijoj kontroli hipertoničara u Hrvatskoj. Ovaj dokument službeni je stav stručnih društava i institucija koje su sudjelovale u njegovoj izradi.

Introduction: In LV failure, it has been observed that a lower velocity is often combined with a slower increase in velocity, a more rounded curve form and peak velocity later in systole. From isolated cells, it was suggested that chronic ischemia decreases but prolongs contraction. Additionally, severe aortic stenosis shows, higher but often prolonged outflow velocities. Outflow velocities represent the pressure gradient between LV and aorta and thus influenced by either of them. However, a dynamically increasing resistance in the vessel tree reduces late velocities while late increases should be related to prolonged contraction. We assumed a relationship between the morphology and duration of aortic outflow velocities and myocardial function in coronary artery disease (CAD). Methods: We studied 85 patients (pts) undergoing routine dobutamine stress echo (DSE) (40 male, 45 female, mean age 62.4± 9.6 years). Pts were divided in 2 groups: group A: 37 pts without evidence of CAD and/or normal DSE, group B: 48 pts with angiographically proven CAD and/or positive DSE. 37 sex and age matched healthy volunteers with no signs or symptoms of cardiovascular disease served as a control group. Automated analysis using modeling was applied on digitally stored aortic CW traces. Time from onset of aortic flow to peak flow (Tmax) and ejection time (ET) were calculated both directly from the CW traces as well as from the modeled signal (Tmax_mat, ET_mat). The asymmetry measure (asymm) was measured from the modeled signal and was defined as the the difference between the areas of the right and left half of the signal. A normal curve was more triangular in shape, with an early peak, while curves of pts with CAD showed typical broadening with a much more rounded shape and later peak. *p

From isolated cells, it was suggested that chronic ischemia decreases, but prolongs contraction. Additionally, severe aortic stenosis shows, besides higher, often prolonged outflow velocities. Outflow velocities represent the pressure gradient between LV and aorta, thus are influenced by either of them. However, a dynamically increasing resistance in the vessel tree would reduce late velocities while high late velocities should be related to prolonged contraction. Thus, we assumed a relationship between the morphology and duration of aortic outflow velocities and myocardial function in coronary artery disease (CAD). We studied 126 pts who underwent a routine dobutamine stress echo (DSE). At baseline and peak stress, CW Doppler traces of aortic flow were acquired. All traces were visually divided into 2 groups: normal and broadened. Fig 1 middle shows a typical normal trace, triangular in shape, with the peak occurring early. Left shows typical broadening with a much more rounded shape and later peak. Traces with a clear dynamic intra-cavity gradient at peak stress were omitted ; peak dose could not be reached in 45/126 pts. 53/126 pts had an angiographically confirmed stenosis in at least one coronary. 25/53 (47%) showed a broad outflow trace. This did not change at peak stress. Of 12/126 patients with unconfirmed CAD and positive DSE, 2 (17%) had a broad spectrum. At peak stress 4/8 (50%) were broad. 61/126 pts had no evidence of CAD and normal DSE. Of these, 7/61 (11%) were broad which increased to 12/26 (46%) at peak stress. The broadening in these apparently normal pts was often induced by a (small) dynamic gradient (fig 1 right). Thus, in the presence of CAD, there seems to be a broadening of the aortic outflow profile. This might be related to a reduction in global myocardial contractility.

Heart involvement in acromegaly is mostly recognized by the presence of LV hypertrophy (LVH), often accompanied by diastolic dysfunction (DD). Although it is known that patients (pts) with active disease have more pronounced LVH than pts in remission, the impact of pituitary adenoma size might also be important. We sought to analyze the degree of LVH and DD in acromegaly with regard to adenoma size. The diagnosis of acromegaly was based on clinical characteristics, failure to suppress serum GH level below 1 µ g/L after a glucose tolerance test and a high serum IGF1 level. 32 pts with acromegaly (49± 11 years) and normal systolic function were distributed in 2 groups by adenoma size (measured from MRI images of the hypothalamo-pituitary region). MACRO: 11 pts with macroadenoma (>10 mm in diameter) ; MICRO: 21 pts with microadenoma (

Patients undergoing routine dobutamine stress echo were analyzed. This study analyzes the prevalence of left ventricular cavity/outflow pressure gradient induced by dobutamine stress echocardiography and its relation to myocardial geometry.

Purpose: In patients with acromegaly, due to chronic GH and IGF-I excess a specific cardiomyopathy, associated with myocardial hypertrophy and diastolic dysfunction, develops. The first stage of acromegalic cardiomyopathy is characterized by a visually hyperkinetic LV but normal ejection fraction (EF). We sought to analyze whether this was associated with signs of increased contractility in acromegaly patients. Methods: 32 patients with acromegaly (49.5± 10.6 years) and normal EF were compared to 26 healthy sex and age matched normals. Patients in both groups underwent a complete echocardiographic exam. LV mass was calculated and indexed by body surface area to obtain the LV mass index (LVMI). The outflow velocity time integral (VTI) and ejection time (ET) were measured from PW Doppler traces of transaortic flow. ET was indexed by heart cycle duration (R-R) to obtain the relative ET duration (ET/R-R). Results: Acromegaly: mean disease duration was 6.6± 6.0 years, LVMI=93.9± 25.3 g/m² , VTI = 23.4± 5.2 cm, ET/R-R = 0.35± 0.04 s. A correlation was found between LVMI and ET/R-R (R=0.34 ; p=0.07) and LVMI and VTI (R=0.58 ; p= 0.002). These correlations are presented in Fig 1 (right). Normals: LVMI=86.5± 15.7 g/m² , VTI = 24.4± 3.4 cm, ET/R-R = 0.35± 0.04 s. No correlation between LVMI and ET/R-R nor LVMI and VTI was found (Fig 1, left). Conclusion: A significantly higher degree of LVH was found in acromegaly patients compared to normals. This was associated with an increase in outflow together with a shorter relative ejection time suggesting the presence of increased contractility in the acromegalic hearts. Thus acromegalic heart disease, at an early stage, might be considered as a model of a hypertrophic and hypercontractile LV without an additional increase in afterload.

Purpose: Doppler echocardiography of the mitral valve and pulmonary veins inflow often reveals global diastolic dysfunction in hypertensive patients. The assessment of regional diastolic function is crucial in understanding the pathophysiological process and diagnosing subclinical myocardial changes. Therefore, we sought to analyze segmental myocardial relaxation using Color Doppler Myocardial Imaging (CDMI) in hypertensive patients without fulfilled criteria for first grade diastolic dysfunction in conventional Doppler. Methods: The study comprised 32 treated hypertensive pts. (48± 7.3 years, normal myocardial thickness and normal systolic function) with well regulated blood pressure according to values from previous 24h BP monitoring and 11 healthy age matched normals. All subjects underwent DMI (E’ , A’ at annulus, base and middle segment (s.) of each wall (w.) in longitudinal views) as well as Doppler echocardiography (IVRT, PFVE, PFVA, DtE, Adur, PVA, PVAdur) at baseline, 3- and 6-month follow up. The non-parametric Mann-Whitney test was used for statistical analysis. P value

From isolated cells, it was suggested that chronic ischemia decreases but prolongs contraction. Additionally, severe aortic stenosis shows, higher but often prolonged outflow velocities. Outflow velocities represent the pressure gradient between LV and aorta and thus influenced by either of them. However, a dynamically increasing resistance in the vessel tree reduces late velocities while late increases should be related to prolonged contraction. We assumed a relationship between the morphology and duration of aortic outflow velocities and myocardial function in coronary artery disease (CAD). We studied 109 pts undergoing routine dobutamine stress echo (DSE). Pts were divided in 2 groups: group A: 61 pts without evidence of CAD and/or normal DSE, group B: 48 pts with angiographically proven CAD and/or positive DSE. Automated analysis using modelling was applied on digitally stored aortic CW traces and deceleration time (TF: from peak to end of spectrum) and symmetry measure (symm: ratio of area under the curve of left and right half of the spectrum). Figure 1 left shows a CW trace and curve analysis of a normal: triangular in shape, with an early peak, while right (CAD) shows typical broadening with a much more rounded shape and later peak. Group A: symm=0, 34± 0, 07 ; TF=79, 90± 11.58 ms. Group B: symm=0, 31± 0, 08* ; TF=73, 10± 12, 71 ms* (*p

Regional diastolyc disfunction measured by Color Doppler myocardial imaging was the first sign of myocardial dysfunction due to arterial hypertension.

In acromegaly, left ventricular hypertrophy (LVH) and diastolic dysfunction can be revealed by echocardiography. Using new method Color Doppler Myocardial Imaging (CDMI) and by measuring myocardial velocities we can detect changes in myocardial function earlier than conventional echocardiography (PWE). We sought to analyze myocardial relaxation using CDMI in acromegalic patients with and without diastolic dysfunction according to PWE parameters. 26 patients with acromegaly (50.27± ; 11.25 yrs) with normal systolic function and initial LVH present in 23% of pts were distributed in 2 groups according to disease activity. Group A: 14 patients in remission ; group B: 12 patients with active disease. All patients and 11 healthy age matched normals underwent CDMI (E’ , A’ , AtA’ , DtA’ ) at the lateral mitral annulus and PWE (IVRT, PFVE, PFVA, DtE, Adur, PVA, PVAdur). The Student’ s T-test was used for statistical analysis. P value

A 72-year-old gentleman was admitted to the cardiovascular service with unstable angina from an outside facility after four days of heparin therapy. On the second day of hospitalization hemoglobin dropped from 11.7 to 9.4 g/dL. Physical exam revealed stable vital signs and a III/VI aortic stenosis murmur. Ecchymoses in the periumbilical (Cullen’ s sign) , groin (Fox’ s sign) and loin (Gray-Turner’ s sign) areas were noted. This was consistent with retroperitoneal hemorrhage. CT scanning confirmed this finding. We report this unusual case of all three physical signs in a single patient with retroperitoneal hemorrhage while on heparin therapy. Cullen was the first to describe an umbilical discoloration in a case of ruptured extrauterine pregnancy. In 1919, Turner described a “ dirty green” loin discoloration associated with acute pancreatitis. Fox’ s sign was first described in 1966 as upper thigh discoloration with a characteristic sharp upper margin. The largest study addressing Cullen’ s and Gray-Turner’ s sign presented 770 patients with acute pancreatitis. 3% incidence and 37% mortality was associated with appearance of one or both signs. We stress that though most commonly described in hemorrhagic pancreatitis, none of these signs are specific for this condition.

Background: Impaired relaxation during early diastole is very well known in hypertensive heart disease. By standard Doppler echocardiography (PWE) global diastolic dysfunction is easily measured. It is not clear whether structural changes of myocardium induce other functional disturbances during diastole apart from the relaxation. By measuring myocardial velocities using high temporal resolution Tissue Doppler Imaging (TDI) we are enable to analyze regional myocardial function particularly fine diastolic dysfunction of each segment (s.). In order to evaluate late diastolic function we sought to measure TDI parameters in hypertensive pts. Methods: treated hypertensive pts (48&plusmn ; 7.3 yrs, EF2D 58&plusmn ; 12%) with normal exercise test were randomised in 2 groups according to blood pressure (BP) control. Group A -uncontrolled BP (27 pts) ; group B-well control BP (30 pts). Both groups and 13 healthy age match normals (n.) underwent TDI and PWE at baseline and at 3-month follow-up. Following parameters were measured: 1.TDI: peak early diastolic velocity-E’ , peak late diastolic velocity-A’ , acceleration time A’ -AcctA’ , deceleration time A’ - DtA’ from annulus, base and middle (s.) of each wall and basal posterior s. in short (SAX) and long axis (LAX)) 2. PWE Doppler parameters (p.): E/A, DtE, Adur, Pulmonary vein A (PVA) and PVAdur. For statistical analysis the non-parametric Mann-Whitney test was used. p

Tkivni Doppler je modificirana tehnika pulsnog Dopplera koja omogućuje izoliranje malih brzina gibanja stijenki ventrikula od signala velikih brzina nastalih protokom krvi. Ta tehnika omogućava analizu gibanja LK po pojedinim segmentima uzduž duge i kratke osi (11). U našem radu pokazali smo da je regionalna dijastolička disfunkcija koju smo mjerili TDI prvi znak oštećenja miokarda uslijed arterijske hipertenzije, dok su parametri globalne dijastoličke funkcije mjereni konvencionalnim Dopplerom kao i TDI još nepromijenjeni. Osim toga, u bolesnika s nereguliranom arterijskom hipertenzijom koji imaju već izraženu globalnu dijastoličku disfunkciju registrirali smo i promjenu parametara u kasnoj dijastoli. Naši rezultati ukazuju na potencijalno veliki značaj TDI u dijagnozi i ranom otkrivanju hipertenzivnog oštećenja funkcije miokarda kao i u praćenju uspješnosti liječenja hipertenzivnih bolesnika.

Background: Global left ventricular diastolic dysfunction measured by Doppler mitral and pulmonary veins inflow is usual in hypertensive patients. In order to better understand the pathophysiological process and to diagnose subclinical myocardial changes it is necessary to assess regional diastolic function. We sought to analyze segmental myocardial relaxation using Tissue Doppler Imaging (TDI) in hypertensive patients (pts) with and without global diastolic dysfunction by conventional Doppler parameters. Methods: treated hypertensive pts (48&plusmn ; ; ; 7.3 yrs) with normal myocardial thickness and normal systolic function, were randomised in 2 groups according to blood pressure (BP) control from previous 24h BP monitoring. Group A: 28 pts with well control BP ; group B: 30 pts with uncontrolled BP. Pts and 11 healthy age match normals (n.) underwent TDI (E’ , A’ at annulus, base and middle segment (s.) of each wall in longitudinal views and basal posterior segments in short (SAX) and long axis (LAX)) and Doppler echocardiography (IVRT, PFVE, PFVA, DtE, Adur, PVA, PVAdur). For statistical analysis the non-parametric Mann-Whitney test was used. P value