P800 Effect of Valsalva Maneuver on echocardiographic systolic and diastolic parameters in patients with acute coronary syndrome, a comparison between normal and high ventricular filling pressures

Funding Acknowledgements

Nil

OnBehalf

Nil

Introduction

Echocardiography is used as a useful and common method for the assessments of left and right ventricular (LV & RV) systolic and diastolic functions. Valsalva Maneuver (VM) with the increase in the intra-thoracic and intra-abdominal pressure is often used as a simple, inexpensive and non-invasive method to diagnose some clinical conditions such as heart murmurs. However, in terms of echocardiography, the use of VM is limited to a few parameters for many years. On the other hand, blood level of N-Terminal Pro–B-Type Natriuretic Peptide (NT Pro–BNP) indirectly discriminates normal or high ventricular filling pressure (FP).

Purpose

The purposes of this research is to provide a comprehensive review of the technique and to compare the effect of VM in ACS patients, with and without elevated FP on either RV and LV diastolic and systolic echocardiographic parameters.

Methods

Thirty-eight patient, who were diagnosed with possible ACS; Unstable Angina Pectoris, NSTEMI and STEMI, underwent coronary angiography enrolled in this double–blinded clinical trial study. The mild Coronary Artery Disease (CAD) with normal levels of NT Pro–BNP were included in study group one and patients with significant CAD and high level of NT Pro–BNP who underwent PCI were included in study group two. All the systolic and diastolic indicators of both ventricles, totally twenty-four parameters those had mentioned in the academic literature previously, have been evaluated; once before Valsalva and once during stage 2 of the maneuver. Echocardiography is performed by an advanced echo machine and by an expert cardiologist- echocardiographer, which the recorded images were reviewed by the second echocardiographer separately.

Results

Between the two groups, LV parameter analysis showed significant difference in LV EF pre and post VM. However, there was statistically insignificant difference regarding other systolic as well as diastolic parameters. Between the two groups, RV parameters analysis showed no significant difference in systolic and diastolic parameters pre and post VM.

Conclusion

To the best of our knowledge, this is the first report assessing post VM changes in four chambers as well as mitral and tricuspid valves parameters in ACS patients with normal versus high level of FP. Previously, LV diastolic dysfunction and Doppler mitral inflow pattern correlation with VM were approved. In the present study, in addition to those known findings from before, except the LV ejection fraction (LVEF) that showed there was statistically significant difference in pre– and post-VM, other systolic parameters, as well as diastolic indicators in either RV and LV, were identical.

Therefore, we do not recommend conducting Valsalva maneuver on the rest of the other parameters to diagnose systolic and diastolic dysfunction in ACS patients with mild versus significant CAD who were assumed to have normal or elevated filling pressures.

Brucella endocarditis of pseudoaneurysm of an aortic composite graft

The occurrence of Brucella endocarditis following Bentall operation is a rare and life threatening condition, particularly when it is complicated by development of a pseudoaneurysm. Here we present a 40-year-old veterinarian with bicuspid aortic valve, who developed type A aortic root dissection and required Bentall operation. His past medical history was positive for an episode of treated brucellosis. Four months after the operation, he developed signs, symptoms and serological findings of brucellosis for the second time and was treated with antibiotics. Then after he was well untill about 14 days prior to his recent admission, when he again developed hip pain, fever, shortness of breath, profound fatigue and weakness. His transthoracic echocardiography was suggestive of endocarditis. A transesophageal echocardiogram revealed detachment of valve-conduit from the annulus and the mitral-aortic intervalvular fibrosa and the presence of a large aortic pseudoaneurysm with multiple vegetations attached to its Dacron walls. A huge pseudoaneurysm was detected at surgery and the whole valve-conduit was replaced with a 25 mm homograft. Blood and vegetation cultures turned to be positive for Brucella melitensis. Early echocardiographic diagnosis and prompt surgical intervention were helpful for survival of our patient who had aortic pseudoaneurysm complicated by Brucella endocarditis.

5,10-methylene tetrahydrofolate reductase C677T gene polymorphism, homocysteine concentration and the extent of premature coronary artery disease in southern Iran

Elevated level of plasma homocysteine (Hcy) has been identified as an independent risk factor for coronary artery disease (CAD). Furthermore, numerous studies have documented the influences of a common polymorphism (C677T) of methylenetetrahydrofolate reductase (MTHFR) on homocysteine levels. However the relationship between this mutation and cardiovascular diseases (CVD) has remained as a controversial issue. The present study was undertaken to investigate the relationship between C677T polymorphism of MTHFR gene, plasma total Hcy levels and the number of affected vessels as a criterion for the extent of CAD. MTHFR genotypes and plasma homocysteine (HCY) concentrations were examined in 231 patients and 300 healthy subjects who underwent diagnostic coronary angiography. A multiple linear regression analysis was performed to identify the predictors of Hcy levels whereas logistic regression model was built to determine the association of Hcy quartiles with the risk of CAD adjusted for risk factors. The prevalence of MTHFR genotypes was similar between CAD patients and non-CAD individuals while the geometric mean of Hcy values was significantly higher in patient group (14.13 ± 4.11 μmol/l) than in control group (10.19 ± 3.52 μmol/l) (P < 0.001). Moreover, unlike the MTHFR polymorphism, Hcy concentration increased with increasing number of stenosed vessels and the CAD risk increased about 2 folds in the top two Hcy quartiles (≥ 17.03 and 13.20-17.02 μmol/l) compared with the lowest quartile (≤ 9.92 μmol/l) after controlling for conventional risk factors (P<0.001 for both). Our data suggest that hyperhomocysteinaemia (HHcy) is significantly associated to CAD risk increase as well as to the extent of coronary atherosclerosis.

Effect of omega-3 on brain natriuretic peptide and echocardiographic findings in heart failure: Double-blind placebo-controlled randomized trial

BACKGROUND

Possible beneficial effects of dietary omega-3 supplementation on patients with congestive heart failure (CHF) were investigated.

METHODS AND RESULTS

100 patients with CHF who had a tri-chamber pacemaker and automated defibrillator were initially recruited, and 70 agreed to participate.38 patients received 2 g/day of omega-3 and 32 received placebo capsules. BNP level, 6-min walk test and echocardiographic parameters were recorded at baseline and after 6 months of treatment. BNP levels decreased significantly after 6 months in the omega-3 group, from 1766.2 ± 1978.1 pg/mL to 1159.4 ± 1430.9 pg/dL (P < 0.005). Tei index and late diastolic velocity index were significantly improved in treated group. Mortality and hospitalization rates did not differ.

CONCLUSION

The beneficial effects of omega-3 supplementation in patients with CHF were not as clear as hypothesized; however, omega-3 fatty acids can result in small changes in plasma BNP levels and modest improvements in echocardiographically assessed diastolic function (Clinical trial.gov registration: NCT01227837).

Brucellosis relapse causing prosthetic valve endocarditis and aortic root infective pseudoaneurysm

We report a previously treated case of brucellosis and aortic root replacement, which became complicated by prosthetic valve endocarditis and a massive aortic root pseudoaneurysm. Preoperative blood and intraoperative pseudoaneurysm wall cultures were positive for Brucella, and the patient was managed successfully with a combination of surgical and medical treatment. Brucella endocarditis is further discussed.

Patent foramen ovale in patients with tension headache: is it as common as in migraineurs? An age- and sex-matched comparative study

The association of patent foramen ovale (PFO) and atrial septal aneurysm (ASA) with migraine headache attack (MHA) has been clearly shown. The same findings have been recently demonstrated also in cluster headache. Although tension-type headaches (TTH) are the most common kind of headache, their association with these atrial septal abnormalities has never been studied before. The study was conducted to clarify whether there was a significant association between the presence of such atrial septal abnormalities and tension headache, when compared with migraineurs. One hundred consecutive patients with migraine and 100 age- and sex-matched subjects with TTH and 50 healthy volunteers with no headache were enrolled in the study and underwent a complete transesophageal echocardiographic study with contrast injections at rest and with the Valsalva maneuver. There was no significant difference between the age and the sex of the participants of the three groups. The overall prevalence of PFO was 23% in patients with TTH and that of large PFOs was only 11%. The 23% prevalence of PFO in patients with TTH was not statistically different from 16% found in our normal control group. Furthermore, we found a significantly higher prevalence of PFO in migraineurs (50%) when compared with patients with tension headache (p < 0.001). This was also true for the collective presence of large PFOs and ASAs (35%) (p < 0.001). Although atrial septal anomalies have an association with MHA, they do not have a significant association with TTH.

Acquired accessory left atrium

The patient was a 61-year-old woman brought to our hospital due to dyspnea and lower extremity swelling in shock state three weeks after mitral valve replacement due to rheumatic mitral regurgitation. Cardiothoracic examination revealed bilateral diffuse rales, metallic first heart sound and a loud holo systolic murmur in apex with radiation to axilla. Transesophageal echocardiography revealed a large echo lucent area representing a separate chamber in the lateral part of left atrium which communicates with left ventricle through a relatively large orifice far from normal functioning prosthesis. In operation left atrial dissection was confirmed but the patient did not wean from cardiopulmonary bypass and died on the operating table.

Flash Pulmonary Edema Heralding Renal Artery Spasm

Flash pulmonary edema is a condition characterized by sudden and recurrent episodes of dyspnea resulting from acute pulmonary venous congestion in the presence of normal or well-preserved left ventricular systolic function. This is usually associated with bilateral renal artery stenosis or stenosis of a single surviving kidney. We describe a patient with clinical presentation of flash pulmonary edema due to renal artery spasm. To the best of our knowledge, this is the first reported case of flash pulmonary edema due to renal artery spasm.

A current problem in cardiology: very late thrombosis after implantation of sirolimus eluting stent

Discontinuation of antiplatelet medications has been strongly associated with coronary stent thrombosis. The first reported cases have been documented at 6 h to 6 weeks after stent implantation. This article presents a case of very late stent thrombosis 24 months after sirolimus eluting stent implantation and 18 months after clopidogrel discontinuation, despite aspirin continuation, and argues in favor of prolonging dual antiplatelet medication including clopidogrel in this setting, at least until data from randomized trials address this important issue.