Effects of Different Dialysis Modalities on Cardiac Autonomic Dysfunctions in End‐Stage Renal Disease Patients: One Year Prospective Study

Cardiac autonomic dysfunction (CAD) is a common problem in patients with end-stage renal disease (ESRD) and may contribute to the risk of cardiac mortality. Long-term effects of dialysis modalities on CAD in ESRD patients are not clear. In this one-year prospective study, we studied the effects of different dialysis modalities on CAD in ESRD patients. The study consisted of 20 ESRD patients who had the indications for initiating dialysis therapy (13 hemodialysis and 7 CAPD patients) and 15 healthy controls (M/F: 5/10; age 30 +/- 4). In all the subjects, first at the beginning of study (in patient groups just before initiating dialysis therapy) and then after 12 months, we studied 24 hours ECG-Holter monitoring and heart rate variability parameters (time and frequency domain analysis parameters; SDNN: standard deviations of nn intervals, rMSSD: square root of the median of standard deviation, HRVI: heart rate variability index, LF/HF: low frequency/high frequency). In ESRD patients, before dialysis therapy, all the parameters of time domain analysis were significantly lower compared to control group (p = 0.001). In patient groups, after dialysis therapy (on the 12th month), significant improvement was observed in time domain analysis parameters (p = 0.001). When dialysis modalities were compared, the increase in the time domain analysis parameters was significantly greater in the CAPD group compared to hemodialysis (HD) group. Our findings suggest that CAD is frequent in ESRD patients, a dialysis therapy of 12 months can cause significant improvement on CAD and the ameliorative effect of CAPD is better than HD.

Clinical, echocardiographic, and hemodynamic characteristics of rheumatic mitral valve stenosis and atrial fibrillation

Chronic atrial fibrillation (AF) is associated with an increased frequency of embolic events and negative impact on cardiac function, and therefore, an increased morbidity and mortality risk in patients with rheumatic mitral valve stenosis (RMS). In the present study, the clinical, 2-D and Doppler echocardiographic, and left-and right-heart hemodynamic data were evaluated for 92 patients (68 women) with RMS and AF and compared with data from 118 patients (88 women) with RMS with sinus rhythm. The clinical, echocardiographic, and hemodynamic evaluations were performed within 1 to 7 days of each other. Patients with AF were older (45.7+/-13.4 vs 38.6+/-12.0 years, p < 0.01) and had a longer symptomatic period (108.2+/-117.9 vs 50.6+/-53.1 months, p < 0.01) compared with those with sinus rhythm. Most of the patients with AF were in NYHA functional capacity 3-4 (74% vs 19%), whereas most of the patients with sinus rhythm were in NYHA functional capacity 2. Patients with AF had a higher mitral valve score based on morphologic features ranging from 4 to 16 depending on the severity of disease (8.3+/-2.1 vs 6.5+/-1.9, p < 0.01) and greater left ventricular end-diastolic diameter (LVEDD) (52.3+/-8.7 vs 47.7+/-8.7 mm, p < 0.02), and end-systolic diameter (LVESD) (34.4+/-7.5 vs 30.9+/-7.5 mm, p < 0.01). Organic tricuspid valve involvement was diagnosed more frequently in patients with AF (61% vs 32%, p < 0.01). Mild mitral regurgitation was also more frequent in patients with AF (71%vs 51%, p < 0.03). The mitral valve area was similar in patients with and without AF (1.30+/-0.39 vs 1.39+/-0.41 cm2, p > 0.05). Mean diastolic mitral valve gradient and pulmonary artery pressure did not differ in patients with and without AF. Right atrial pressures were higher in patients with AF (7.6+/-3.3 vs 6.3+/-1.9 mm Hg, p < 0.02). The authors suggest that (1) AF occurred in older patients, who had a longer disease process and more serious symptoms; (2) hemodynamic derangements (mitral valve gradient, pulmonary artery pressure) did not differ in patients with and without AF; (3) greater mitral valve score, more tricuspid valve involvement, higher LVEDD, which are suggestive of greater rheumatic activity process were more frequently seen in patients with AF than in those without AF. These findings support the opinion that AF is a marker of widespread rheumatic damage in patients with RMS.

Effects of late regain of sinus rhythm on pulmonary artery pressure and functional status in patients with mitral valve replacement surgery and atrial fibrillation

BACKGROUND AND AIM OF THE STUDY

The study aim was to evaluate the effects of regaining sinus rhythm (SR) on pulmonary artery pressure (PAP) and NYHA class in patients undergoing mitral valve replacement (MVR) surgery and in atrial fibrillation (AF).

METHODS

Forty patients (mean age 50.7+/-8.2 years) with previous MVRS and chronic AF were included in the study; the mean postoperative interval was 54.7+/-31.8 months. Among these 40 patients, 22 (the study group) were treated with amiodarone (600 mg/day) and direct current (DC) cardioversion (CV), while 18 (control group) underwent normal treatment.

RESULTS

In the study group, two patients regained SR with amiodarone loading, while 20 proceeded with DC CV at 21 days after amiodarone loading. SR was regained in 20 patients. The amiodarone dosage was lowered to 200 mg/day in the sixth postoperative week. Patients were followed for a mean of 18.0+/-4.4 months (range: 12-22 months). In the study group, recurrence of AF occurred in only one patient, at four months after DC CV. SR was maintained in 19 patients. At a clinical control examination, the mean NYHA class of study patients was decreased from 2.6+/-0.5 to 1.8+/-0.6 in two months, and to 1.5+/-0.6 in 12 months (p <0.01). Doppler echocardiographic follow up in the study group showed PAP to be significantly reduced, from 44.2+/-12.3 mmHg to 32.8+/-8.1 mmHg (p <0.01).

CONCLUSION

In patients with MVR and AF, amiodarone treatment and DC CV achieved good early and mid-term success in regaining and maintaining SR. Regulation of rhythm was concomitant with a reduction in PAP and improved NYHA functional class. Hence, a special effort should be made to correct arrhythmia in patients with MVR and AF.

Pericardial tamponade and large pericardial effusions: causal factors and efficacy of percutaneous catheter drainage in 50 patients

In 50 patients treated from January 1998 through March 2002 for pericardial effusion and tamponade, we retrospectively investigated the efficacy of percutaneous placement of an indwelling pericardial catheter guided by 2-dimensional echocardiography and fluoroscopy. We also investigated causation. In 80% of the patients, we were able to determine specific causes through clinical, serologic, and cytologic investigation: cancer in 15 patients, chronic renal failure in 11, systemic lupus erythematosus in 2 rheumatoid arthritis in 2, Dressler syndrome in 2, tuberculosis in 1, blunt chest trauma in 1, purulent pericarditis in 1, and probably viral pericarditis in 5. No specific cause could be determined in 10 patients (20%). We did not observe any complication due to the procedure. Two patients died during hospitalization. After hospitalization, 9 patients with metastatic cancer died within 3 months. A 2nd percutaneous drainage procedure was required in 2 cancer patients. Recurrence of pericardial effusion and tamponade and the requirement of pericardiectomy occurred in 2 patients with perfusion of unknown cause and in 1 patient with perfusion due to rheumatoid arthritis. Histologic examination of pericardial tissue in patients with idiopathic disease showed fibrinous pericarditis but no causal factor. In the group with idiopathic pericardial effusion, 2 patients with multiple mediastinal lymphadenopathy underwent mediastinal exploration; biopsy revealed nonspecific lymphadenitis and fibrinous pericarditis. In patients with large pericardial effusions and tamponade, the specific cause was in most cases already known or obtained by initial clinical and laboratory investigation. Sufficient cardiac decompression was achieved by percutaneous pigtail catheter drainage.