Cardiovascular Diseases & Diagnosis

Intravascular Ultrasound (IVUS) has emerged as the first clinical imaging method to visualize atherosclerosis and other pathologic conditions within vessel wall. It is of paramount importance in clarifying situations in which angiography is equivocal or difficult to interpret, choosing the appropriate intervention, and optimizing the results. It is an important tool providing several unique insights into plaque burden, remodeling, and restenosis. In percutaneous coronary intervention (PCI) with drug-eluting stents (DES), IVUS guidance may reduce stent thrombosis. IVUS guidance appears to be most beneficial in complex lesion subsets, such as left main coronary artery (LMCA) and bifurcations. In this review, the author examines the clinical applications of IVUS in current PCI era dominated by use of DES.

Intravascular Ultrasound (IVUS) has emerged as the first clinical imaging method to visualize atherosclerosis and other pathologic conditions within vessel wall. It is of paramount importance in clarifying situations in which angiography is equivocal or difficult to interpret, choosing the appropriate intervention, and optimizing the results. It is an important tool providing several unique insights into plaque burden, remodeling, and restenosis. In percutaneous coronary intervention (PCI) with drug-eluting stents (DES), IVUS guidance may reduce stent thrombosis. IVUS guidance appears to be most beneficial in complex lesion subsets, such as left main coronary artery (LMCA) and bifurcations. In this review, the author examines the clinical applications of IVUS in current PCI era dominated by use of DES.

Objectives: The purpose of this study was to evaluate the immediate and short term follow up impact of Percutaneous Transvenous Mitral Commissurotomy (PTMC) on Right Ventricular (RV) function using twodimensional and tissue Doppler echocardiographic indices.

Background: In patients with Mitral Stenosis (MS) RV function may be affected due to myocardial and hemodynamic factors. Previous studies using echocardiography have shown discordant results as regards to improvement of RV function immediately after PTMC. Only few studies have evaluated RV function at 6 months follow up.

Methods: A total of 90 patients with severe symptomatic MS, all in sinus rhythm, who got admitted for PTMC to author’s institute, were prospectively enrolled. RV function was evaluated by conventional and Tissue Doppler Imaging (TDI) echocardiography before, 48 hours after PTMC, and at 6 months follow up. Results: All patients underwent successful PTMC. The mitral valve area was significantly increased (0.80 ± 0.13 cm2 versus 1.73 ± 0.14 cm2, p=0.0001) immediately after PTMC, while the mean transmitral gradient (21.6 ± 8.0 mm Hg versus 5.9 ± 1.6 mm Hg, p < 0.0001) and systolic pulmonary artery pressure (52.3 ± 23.4 mm Hg versus 41.7 ± 16.9 mm Hg, p < 0.0001) were significantly decreased. There was significant improvement in RV function immediately after PTMC (RV outflow tract fractional shortening (RVOTfs): 54.1 ± 8.7% versus 70.4 ± 5.0%, p < 0.001, Tricuspid Annular Plane Systolic Excursion (TAPSE): 16.0 ± 1.5 mm versus 18.6 ± 1.7 mm, p < 0.0001, TEI INDEX: 0.51 ± 0.04 to 0.34 ± 0.04, p < 0.001). Myocardial velocities measured at lateral tricuspid annulus were not improved significantly immediately after PTMC but improved significantly at 6 months follow up (Myocardial velocity during isovolumic contraction (IVCv); 10.2 ± 0.6 cm/s to 12.0 ± 1.3 cm/s, p < 0.001, systolic myocardial velocity (Sv): 11.7 ± 0.9 cm/s to 13.2 ± 0.9 cm/s , p < 0.001 , myocardial acceleration during isovolumic contraction(IVA): 3.0 ± 0.5 cm/s2 to 3.9 ± 0.3 cm/s2 , p < 0.001).

Conclusion: Immediately after successful PTMC, significant improvement in RV function was observed. TDI myocardial velocities and IVA showed gradual improvement in RV function at 6 months follow up. Prognostic value and clinical significance of this improvement deserve further investigation.

Background: Diabetes mellitus (DM) reduces life expectancy by a third, principally because of cardiovascular disease and endothelial dysfunction is considered to be one of the first manifestations of vascular disease. Photoplethysmography is a non-invasive technique to evaluate endothelial dysfunction based on the emission of infra-red light on the skin.

Objective: To evaluate endothelial function by photoplethysmography in patients with type 2 DM without evidence of vascular disease.

Methods: A cross-sectional study of patients with and without DM was undertaken. Endothelial function was evaluated using photoplethysmographic waves taking into consideration the shape of the curve and time of maximum amplitude/total time of the curve (TMA/TT) before and after ischemia induced by arterial obstruction.

Results: In 174 subjects included, a greater basal TMA/TT index was found in diabetics, even after adjusting for age, hypertension, dyslipidemia and hypothyroidism. The percent change in amplitude post-ischemia compared to basal value was diminished in diabetics (p=0.030). Persons with diabetes, with and with not endothelial dysfunction, had comparable HbA1c concentrations; but diabetics with endothelial dysfunction, had lower serum concentration of HDL-C. (p=0.05) Conclusions: More endothelial dysfunction was found in patients with diabetes. While the control of diabetes did not influence endothelial dysfunction, it was associated with HDL cholesterol.

Objective: To compare clinical and echocardiographic data before and after transcatheter closure of patent ductusarteriosus (PDA) with occluder device.

Methods: The study population consisted of 30 children with PDA who were subjected to history taking and clinical examination to detect symptoms and signs suggestive of significant shunting. Doppler, two-dimensional echocardiography studies with measurement of mitral inflow velocities in early and late diastole (E and A wave), early and late diastolic mitral annular velocity (É and Á) by DTI, Tei index, and standard chamber dimensions. All children were studied before and 3 months after percutaneous closure of PDA that done using the Amplatzer device.

Results: Transcatheter closure of PDA produced marked improvement of patients’ symptoms and signs postclosure, significant reduction in heart rate and respiratory rate while there was no significant change in blood pressure or temperature. Also there was significant reduction in LV systolic and diastolic dimensions and volumes, LV ejection fraction, left atrial diameter, E wave, A wave, É wave and Á wave while there was significant increase in LV Tei index and no significant change in aortic root diameter, E/A or E/É. Conclusion: Haemodynamic effects of PDA and changes in LV dimensions and function caused by it are reversible after transcatheter closure of PDA.

The term cardiorenal syndrome (CRS) implies acute or chronic injury to the heart and kidneys that often involves a temporal sequence of disease initiation and progression. The classification of CRS is divided into five subtypes. Types 1 and 2 involve acute and chronic cardiovascular disease (CVD) scenarios leading to acute kidney injury (AKI) or accelerated chronic kidney disease (CKD). Types 3 and 4, describe AKI and CKD, respectively, leading primarily to heart failure, although, it is possible that acute coronary syndromes, stroke, and arrhythmias could be CVD outcomes in these forms of CRS. Finally, CRS type 5 describes a systemic insult to both heart and the kidneys, such as sepsis, where both organs are injured simultaneously in persons with previously normal heart and kidney function at baseline. This manuscript will summarize key issues and future opportunities in challenging patients with CRS. Because most CRS occur in patients with pre-existing myocardial disease or chronic kidney disease, we will emphasize the chronic condition which puts individuals at risk for acute events. In the setting of a hospitalization, acute CRS can occur which have been consistently associated with inpatient complications, longer lengths of intensive care unit and hospital stay, need for renal replacement therapy, rehospitalization and death. While there are several common diagnostic and therapeutic targets for the heart and kidney, there remains considerable opportunity for both in-vitro diagnostics and medicinal therapy to favorably influence the occurrence and natural history of CRS.

For several decades, coronary artery bypass grafting (CABG) has been considered as the gold standard treatment of unprotected left main coronary artery (LMCA) disease. However, because of large vessel caliber and anatomic accessibility, percutaneous coronary intervention (PCI) for LMCA has been attractive option for interventional cardiologists. With the marked improvement in technique and technology, PCI has been shown to be feasible for patients with unprotected LMCA stenosis. The recent introduction of drug-eluting stents (DESs), together with advances in pre procedural and post procedural adjunctive pharmacotherapies, has improved outcomes of PCIs of these lesions. The available current evidence comparing efficacy and safety of PCIs using DES and CABG revealed comparable results in terms of safety and a lower need for repeat revascularization for CABG. Still the management can be challenging in high risk anatomic subsets involving LMCA bifurcation lesions and, therefore, an integrated approach combining advanced devices, tailored techniques, adjunctive support of physiologic evaluation, and adjunctive pharmacologic agents should be reinforced to improve clinical outcome.

As the years go by, the physiology of the human body becomes ever better understood. But because venous tone cannot easily be measured it is no wonder the physiology of veins has been consistently overlooked. The author describes his experiences suggesting the key role it appears to play in vasovagal syncope, the regulation of cardiac output, high altitude pulmonary edema, beri-beri, and in those with cardiac arrest.

Kommerell diverticulum (KD) with left aberrant subclavian artery is a rare congenital variation of vascular structure, and it can be asymptomatic or symptomatic owing to mass effect. Surgical intervention is recommended in symptomatic patients or asymptomatic patients with a large diverticulum because of possible dissection and rupture of Kommerell diverticulum. We report a case of right-sided aorta, KD, and left aberrant subclavian artery in a 74- year-old man. He had no symptoms with KD.

Introduction: D Dimer has been shown to be elevated in abdominal aortic aneurysms (untreated).

Report: An 80 year old man presented with left calf swelling. During the investigations to exclude deep vein thrombosis a very high level of D Dimer was noted. This prompted evaluation of his previous endovascular aneurysm repair (EVAR) graft when the duplex scan of the left lower extremity was normal. A large Type II endoleak was found. A further two patients with endoleaks had elevated D Dimers. In one of them the D Dimer level came down with resolution of endoleak.

Conclusion: D Dimer may play an important role in the follow up after EVAR. This new observation needs to be studied further in this setting.