Objective: We aimed to evaluate the subclinical left ventricular (LV) systolic dysfunction with the automated function imaging method (AFI) based on speckle tracking echocardiography (STE) in obstructive sleep apnea patients (OSA) with normal left ventricular ejection fraction (LVEF) and without any confounding disease that can cause myocardial dysfunction. Methods: Twenty-one healthy individuals and 58 OSA patients were included in this observational cross-sectional study. According to the severity of disease, OSA patients were examined in three groups; mild, moderate and severe OSA. Apical 2-, 3-and 4-chamber images were obtained for AFI evaluation. The global systolic longitudinal strain (GL S ) values were determined for each view, and averages of these were used in comparison of the patient groups. One-way ANOVA, Kruskal-Wallis, Pearson correlation tests and linear regression analysis were used for statistical analysis. Results: The GL S values of the OSA patients were lower than of the healthy individuals and these values were decreased along with the OSA severity (Healthy:-25.58±-2.16%, Mild:-23.93±-3.96%, Moderate:-21.27±-2.60%, Severe:-16.94±-2.66%, respectively). The difference was significant between moderate OSA patients and healthy individuals, and significant between severe OSA patients and all other groups (p<0.03). The apnea-hypopnea index was found to be correlated with the GL S (β=-0.659, 95% CI: 0.09-0.17, p<0.001). Conclusion: Longitudinal LV mechanics in OSA patients with normal LVEF are deteriorated in the subclinical stage being associated with the severity of disease. AFI can be used as an effective and safe method in the determination of subclinical myocardial dysfunction in OSA patients, because it is semi-automated and easy to use with a short analysis time.(Anadolu Kardiyol Derg 2012; 12: 320-30) Key words: Obstructive sleep apnea, speckle tracking echocardiography, myocardial strain, regression analysis 320 ÖZET Amaç: Sol ventrikül ejeksiyon fraksiyonu normal ve miyokart fonksiyonlarını etkileyecek ek hastalığı bulunmayan, obstrüktif uyku apneli (OUA) hastalarda, subklinik sol ventrikül sistolik disfonksiyonunu, iki boyutlu benek izleme ekokardiyografi tekniğine dayanan, otomatik fonksiyonel görün-tüleme yöntemi (OFG) ile değerlendirmeyi amaçladık. Yöntemler: Gözlemsel enine-kesitli çalışmamıza 21'i sağlıklı, 58'i OUA hastası olan toplam 79 kişi alındı. OUA'lı hastalar hastalığın ciddiyetine göre hafif, orta ve ağır olarak 3 gruba ayrıldı. OFG değerlendirmesi için sol ventrikülün apikal 2-, 3-, 4-boşluk görüntüleri kullanıldı. İlgili boşluk-lara ait sistolik longitüdinal deformasyon değerlerinin aritmetik ortalaması olan, global longitüdinal deformasyon değerleri gruplar arasında karşılaştırıldı. İstatistiksel analiz için tek -yönlü ANOVA, Kruskal-Wallis, Pearson korelasyon testleri ve doğrusal regresyon analizi kullanıldı. Bulgular: Sağlıklı gruba göre hafif OUA grubundan itibaren hastalığın ciddiyeti ile global longitüdinal deformasyon değerleri azalmaktaydı (Sağlıklı: -%25...

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.

Noninvasive pulmonary artery systolic pressure (PASP) is calculated by summing the right ventricular systolic pressure obtained from Doppler velocity of regurgitant flow through the tricuspid valve and the right atrial (RA) pressure. The RA pressure is generally assumed from different formulas. An accurate RA pressure estimation will add precision to PASP calculation. One of the methods to estimate RA pressure is the inferior vena cava collapsibility index (IVCCI). In 45 patients referred for right heart catheterization, the authors tested a formula for the calculation of PASP based on the estimation of RA pressure from IVCCI and compared this method with two other formulas. The first method (method 1) assumed a constant RA pressure of 10 mm Hg irrespective of right ventricular pressure. The formula used was Doppler gradient + 10 (mm Hg). In the second method (method 2), a clinical estimate of RV pressure was made from the formula: right ventricular-right atrial Doppler gradient x 1.1 + 14. In the third method (method 3), the patients were classified into three groups on the basis of IVCCI: group A, IVCCI greater than 45%; group B, IVCCI between 35% and 45%; and group C, IVCCI less than 35%. The formula used was Doppler gradient + 6, 9, or 16 mm Hg in the presence of normal (group A), moderately reduced (group B), or markedly reduced (group 3) IVCCI. A good correlation between Doppler and catheter measurements of PASP was found for methods 1, 2, and 3, respectively (r=0.8933, SEE=6.4, r=0.8921, SEE=7.0, and r=0.8989, SEE=6.7). Correlation between invasive and noninvasive PASP was similar with the three methods, but correlation in method 2 was less satisfactory than with the other two methods. The mean difference between Doppler-derived and hemodynamic PASP was also high in method 2. In conclusion, the result of this study validates a relatively new, simple echo-Doppler formula for Doppler estimation of PASP based on a noninvasive evaluation of RA pressure through the IVCCI. However, this method is not better than the traditional method 1 for noninvasive PASP estimation.

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.

SUMMARYAtrial fibrillation (AF) has been treated with DC shocks delivered transthoracically, but in 5-30% of patients, the procedures fail to restore sinus rhythm (SR). We hypothesized that applying high energy shock waves to the chest may overcome the inadequate penetration of electrical shock to the atrium. The aim of this study was to evaluate the efficacy of higher energy external DC shock for the treatment of refractory AF coexisting with cardiovascular disease using a synchronized double external defibrillator.Fifteen patients (mean age 65 ± 8) with refractory AF to standard DC cardioversion (CV) underwent higher energy DC shock using a double external defibrillator. Concomitant heart disease was present in all patients. Warfarin and amiodarone (600 mg/day), were administered for at least three weeks duration before DC CV. Sedation was performed with IV midazolam. Two defibrillator paddles were positioned on the anterior and posterior chest wall in a right lateral decubitus position. Defibrillators were synchronized to the R waves and simultaneously 720 joules of energy was administered to the patients. Amiodarone (200 mg/day) was continuously administered after DC shock to maintain SR.Sinus rhythm was obtained in 13 patients. Sinus rhythm was persistent in 11 patients for six months duration. Creatine kinase MB fractions were normal at 4 (22 ± 4 IU/L) and 12 hours (18 ± 4 IU/L). None of the patients developed significant hemodynamic compromise or congestive heart failure, higher AV block, stroke, or transient ischemic cerebral events.The results indicate that higher energy DC shock application using a double external defibrillator is an effective and safe method for the cardioversion of refractory AF. We believe this procedure should be performed before internal atrial cardioversion. (Jpn Heart J 2004; 45: 929-936)