The authors make a number of points concerning the management of atrial fibrillation including de... more The authors make a number of points concerning the management of atrial fibrillation including determining the need for cardioversion, the need for adequate anticoagulation prior to transoesophageal echocardiography and the use of antiarhythmic drug therapy after cardioversion. (non-author abstract)
In recent years, there have been considerable advances in our understanding of the complex pathop... more In recent years, there have been considerable advances in our understanding of the complex pathophysiology of unstable angina. A number of therapeutic options are now available. This article reviews current concepts of pathophysiology and summarises clinical features, natural history and available treatments.
Journal of The American Society of Echocardiography, Jul 1, 1999
The Chiari network is a fenestrated membrane consisting of threads and strands in the right atriu... more The Chiari network is a fenestrated membrane consisting of threads and strands in the right atrium. First described in 1897 by anatomist Hans Chiari, it is a congenital remnant of embryonic development resulting from incomplete resorption of the right valve of the sinus venosus. Found in 2% to 3% of the population, it is generally not of clinical importance. Rarely, however, the network may be associated with serious complications such as thrombus formation, embolus entrapment, arrhythmia, tumor development, and catheter entrapment. We report the entanglement of an Amplatzer septal occluder device catheter in a prominent Chiari network that was herniated into the left atrium. Transesophageal echocardiographic recognition of this before deployment and guidance during disentanglement is described below.
Background The transmitral E wave and the peak velocity of early diastolic mitral annular motion ... more Background The transmitral E wave and the peak velocity of early diastolic mitral annular motion (e`) both decrease with age, but the mechanisms underlying these age-related changes are incompletely understood. This study investigated the possible contributions of blood pressure (BP) and left ventricular end-diastolic length (LVEDL) to age-related reductions in E and e`. Methods The study group were 82 healthy adult subjects <55 years of age who were not obese or hypertensive. Transmitral flow and mitral annular motion were recorded using pulsed-wave Doppler. LVEDL was measured from the mitral annular plane to the apical endocardium. Results Age was positively correlated with diastolic BP and septal wall thickness (SWT), inversely correlated with LVEDL (β =-0.25) after adjustment for sex and body surface area, but was not related to left ventricular end-diastolic diameter (LVEDD). Age was also inversely correlated with E (r =-0.36), septal e`(r =-0.53) and lateral e`(r =-0.53). On multivariable analysis, E was inversely correlated with diastolic BP and LVEDD, septal e`was inversely correlated with diastolic BP and positively correlated with SWT and LVEDL, after adjusting for body mass index, whilst lateral e`was inversely correlated with diastolic BP and positively correlated with LVEDL. Conclusion The above findings are consistent with higher BP being a contributor to age-related reductions in both E and e`and shortening of LVEDL with age being a contributor to the agerelated reduction in e`. An implication of these findings is that slowing of myocyte relaxation PLOS ONE |
The effects of graded intravenous infusions of sodium nitroprusside on resting blood pressure and... more The effects of graded intravenous infusions of sodium nitroprusside on resting blood pressure and heart rate and on the reflex changes in these variables evoked by a standardized Valsalva manoeuvre were studied in six normal subjects. The effects of nitroprusskle on the above variables were also studied after pretreatment with captopril, to allow assessment of the role of angiotensin 11. 2. Nitroprusside given in doses ranging from 7.5 to 150 pg/min elicited dose-related decreases in resting blood pressure and rise in heart rate and in plasma renin activity (PRA). After pretreatment with captopril, nitroprusside could not be given at doses above 60 pglmin without producing an unacceptable fall in blood pressure. The rise in heart rate in response to a given dose of nitroprusside was little altered after captopril. 3. Blood pressure and heart rate were studied during the last 10 s of the Valsalva manoeuvre. Before captopril the normal response (maintenance of blood pressure with tachycardia) was not altered by any dose of nitroprusside. Captopril alone also had no effect on the response but, with captopril plus high dose nitroprusside, mean arterial pressure during the manoeuvre decreased significantly, indicating impairment of reflex constrictor response. 4. These findings support the proposition that the angiotensin I1 response normally limits the fall in blood pressure during vasodilator therapy. We conclude that the greater fall in blood
1. The effects of graded intravenous infusions of sodium nitroprusside on resting blood pressure ... more 1. The effects of graded intravenous infusions of sodium nitroprusside on resting blood pressure and heart rate and on the reflex changes in these variables evoked by a standardized Valsalva manoeuvre were studied in six normal subjects. The effects of nitroprusside on the above variables were also studied after pre-treatment with captopril, to allow assessment of the role of angiotensin II. 2. Nitroprusside given in doses ranging from 7.5 to 150 μg/min elicited dose-related decreases in resting blood pressure and rise in heart rate and in plasma renin activity (PRA). After pretreatment with captopril, nitroprusside could not be given at doses above 60 μg/min without producing an unacceptable fall in blood pressure. The rise in heart rate in response to a given dose of nitroprusside was little altered after captopril. 3. Blood pressure and heart rate were studied during the last 10 s of the Valsalva manoeuvre. Before captopril the normal response (maintenance of blood pressure with ...
for diabetes. Its prognostic value compared to fasting blood glucose (BSL) in patients with ST-el... more for diabetes. Its prognostic value compared to fasting blood glucose (BSL) in patients with ST-elevation myocardial infarction (STEMI) is unknown. Objectives: Compare HbA1c and fasting BSL for left ventricular (LV) diastolic function and filling pressures after STEMI. Methods: A total of 142 (61.8AE12.1 years, 74.6% male) first STEMI patients were prospectively recruited. LV diastolic function was defined as the mean septal and lateral early diastolic velocities (average e') by pulsed wave tissue Doppler, and filling pressure was the ratio of transmitral early diastolic velocity to average e' (average E/e'). Results: Mean HbA1c and fasting BSL were 6.5AE1.6% and 7.7AE2.8mmol/L respectively. Between diabetics and non-diabetics, there were no differences in the rates of coronary angioplasty (p¼0.50), bypass surgery (p¼0.39), LV end-diastolic volume (EDV, 116AE37 vs. 118AE43mL, p¼0.78), end-systolic volume (ESV, 69AE33 vs. 68AE35mL, p¼0.93), ejection fraction (EF, 42AE12 vs. 44AE11%, p¼0.49). On multivariable analyses, average e' was independently associated with age (b¼-0.283, r¼0.001), LVEF (b¼0.211, r¼0.013) and HbA1c (b¼-0.173, p¼0.034), but not BSL (p¼0.83). Similarly, average E/e' was independently associated with age (b¼0.290, p<0.001), LVEF (b¼-0.201, p¼0.018) and HbA1c (b¼0.240, p¼0.003), but not BSL (p¼0.07). ROC analysis showed that an optimal HbA1c cutoff of 6.4% (AUC¼0.68, p¼0.002) was associated with an elevated LV filling pressure (average E/e' !13). Conclusion: HbA1c, not fasting BSL is independently associated with impaired LV diastolic function and increased filling pressures after STEMI.
Journal of the American Society of Echocardiography, 1999
The Chiari network is a fenestrated membrane consisting of threads and strands in the right atriu... more The Chiari network is a fenestrated membrane consisting of threads and strands in the right atrium. First described in 1897 by anatomist Hans Chiari, it is a congenital remnant of embryonic development resulting from incomplete resorption of the right valve of the sinus venosus. Found in 2% to 3% of the population, it is generally not of clinical importance. Rarely, however, the network may be associated with serious complications such as thrombus formation, embolus entrapment, arrhythmia, tumor development, and catheter entrapment. We report the entanglement of an Amplatzer septal occluder device catheter in a prominent Chiari network that was herniated into the left atrium. Transesophageal echocardiographic recognition of this before deployment and guidance during disentanglement is described below.
Because it improves endocardial definition, the use of tissue harmonic imaging (THI) is increasin... more Because it improves endocardial definition, the use of tissue harmonic imaging (THI) is increasing rapidly in clinical echocardiographic practice. With its increasing use, there is a perception that structures imaged with THI appear thicker than those obtained using the fundamental (FND) mode. However, the corollary that quantitative differences may exist between these two modalities has not been formally tested. Thus, the aim of this study was to determine if differences exist between standard aurtic root, left atria1 and left ventricular measurements derived from the FND and THI modes. Methods: Routine transthoracic echocardiography was performed in 50 unselected patients (26 females, 24 males, mean age 54 yrs), using a Hewlett Packard Sonos 5500 ultrasound machine. Standard 2D and M-mode images were digitally acquired and then analysed offline by 2 independent observers. Measurements were averaged over 3 cardiac cycles, M-mode measurements comprised aortic root diameter (Ao) and let? atria1 diameter (LA), as well as let? ventricular internal diastolic diameter (LVIDd), septal thickness (IVS) and posterior wall thickness (PW). Left ventricular outflow tract diameter (LVOT) and planimetered LA area (LAA) were obtained from the 2D echo image. Results: A0 LA LVIDd IVS PW LVOT LAA(cmrl 1
Catheterization and Cardiovascular Interventions, 2001
During deployment of an Amplatzer atrial septal occluder device to close a secundum ASD, the righ... more During deployment of an Amplatzer atrial septal occluder device to close a secundum ASD, the right atrial disk and waist of the device twisted, resulting in the cobrahead malformation. Postulated mechanisms for this complication include twisting of the device during loading into the delivery catheter and catching of leading edge of the device on the LA free wall or appendage, causing twisting during deployment. Retrieval of the device into the catheter and even removal of the device from the patient to allow manual untwisting may be required to allow the device to return to its original conformation for successful redeployment.
Optimal therapy for diastolic heart failure (DHF), the most common form of heart failure in older... more Optimal therapy for diastolic heart failure (DHF), the most common form of heart failure in older persons, is unclear. To determine the effect of aldosterone antagonism in DHF, we conducted an open-label preliminary trial of spironolactone 25mg/day in 11 women with DHF. Cardiopulmonary exercise testing, Doppler-echocardiography, and a quality of life (QOL) survey were administered at baseline and after 4-months. Peak exercise VO 2 increased by 8.3% (p=0.001), the ratio of Doppler diastolic early filling velocity to mitral annulus velocity decreased by 25% (p=0.02), QOL score improved by 21% (p=0.16 for trend), and median NYHA class improved from class III to class II (p=0.004). Findings from this preliminary study confirm the role of aldosterone in the pathophysiology of DHF and suggest that aldosterone antagonism may benefit such patients. These hypotheses are currently being tested in two separated NIH-funded, randomized trials, the Spironolactone For Failure in the Elderly (SPIFFIE) and the Treatment Of Preserved Cardiac Function Heart Failure with an Aldosterone antagonist (TOPCAT) trials.
The authors make a number of points concerning the management of atrial fibrillation including de... more The authors make a number of points concerning the management of atrial fibrillation including determining the need for cardioversion, the need for adequate anticoagulation prior to transoesophageal echocardiography and the use of antiarhythmic drug therapy after cardioversion. (non-author abstract)
In recent years, there have been considerable advances in our understanding of the complex pathop... more In recent years, there have been considerable advances in our understanding of the complex pathophysiology of unstable angina. A number of therapeutic options are now available. This article reviews current concepts of pathophysiology and summarises clinical features, natural history and available treatments.
Journal of The American Society of Echocardiography, Jul 1, 1999
The Chiari network is a fenestrated membrane consisting of threads and strands in the right atriu... more The Chiari network is a fenestrated membrane consisting of threads and strands in the right atrium. First described in 1897 by anatomist Hans Chiari, it is a congenital remnant of embryonic development resulting from incomplete resorption of the right valve of the sinus venosus. Found in 2% to 3% of the population, it is generally not of clinical importance. Rarely, however, the network may be associated with serious complications such as thrombus formation, embolus entrapment, arrhythmia, tumor development, and catheter entrapment. We report the entanglement of an Amplatzer septal occluder device catheter in a prominent Chiari network that was herniated into the left atrium. Transesophageal echocardiographic recognition of this before deployment and guidance during disentanglement is described below.
Background The transmitral E wave and the peak velocity of early diastolic mitral annular motion ... more Background The transmitral E wave and the peak velocity of early diastolic mitral annular motion (e`) both decrease with age, but the mechanisms underlying these age-related changes are incompletely understood. This study investigated the possible contributions of blood pressure (BP) and left ventricular end-diastolic length (LVEDL) to age-related reductions in E and e`. Methods The study group were 82 healthy adult subjects <55 years of age who were not obese or hypertensive. Transmitral flow and mitral annular motion were recorded using pulsed-wave Doppler. LVEDL was measured from the mitral annular plane to the apical endocardium. Results Age was positively correlated with diastolic BP and septal wall thickness (SWT), inversely correlated with LVEDL (β =-0.25) after adjustment for sex and body surface area, but was not related to left ventricular end-diastolic diameter (LVEDD). Age was also inversely correlated with E (r =-0.36), septal e`(r =-0.53) and lateral e`(r =-0.53). On multivariable analysis, E was inversely correlated with diastolic BP and LVEDD, septal e`was inversely correlated with diastolic BP and positively correlated with SWT and LVEDL, after adjusting for body mass index, whilst lateral e`was inversely correlated with diastolic BP and positively correlated with LVEDL. Conclusion The above findings are consistent with higher BP being a contributor to age-related reductions in both E and e`and shortening of LVEDL with age being a contributor to the agerelated reduction in e`. An implication of these findings is that slowing of myocyte relaxation PLOS ONE |
The effects of graded intravenous infusions of sodium nitroprusside on resting blood pressure and... more The effects of graded intravenous infusions of sodium nitroprusside on resting blood pressure and heart rate and on the reflex changes in these variables evoked by a standardized Valsalva manoeuvre were studied in six normal subjects. The effects of nitroprusskle on the above variables were also studied after pretreatment with captopril, to allow assessment of the role of angiotensin 11. 2. Nitroprusside given in doses ranging from 7.5 to 150 pg/min elicited dose-related decreases in resting blood pressure and rise in heart rate and in plasma renin activity (PRA). After pretreatment with captopril, nitroprusside could not be given at doses above 60 pglmin without producing an unacceptable fall in blood pressure. The rise in heart rate in response to a given dose of nitroprusside was little altered after captopril. 3. Blood pressure and heart rate were studied during the last 10 s of the Valsalva manoeuvre. Before captopril the normal response (maintenance of blood pressure with tachycardia) was not altered by any dose of nitroprusside. Captopril alone also had no effect on the response but, with captopril plus high dose nitroprusside, mean arterial pressure during the manoeuvre decreased significantly, indicating impairment of reflex constrictor response. 4. These findings support the proposition that the angiotensin I1 response normally limits the fall in blood pressure during vasodilator therapy. We conclude that the greater fall in blood
1. The effects of graded intravenous infusions of sodium nitroprusside on resting blood pressure ... more 1. The effects of graded intravenous infusions of sodium nitroprusside on resting blood pressure and heart rate and on the reflex changes in these variables evoked by a standardized Valsalva manoeuvre were studied in six normal subjects. The effects of nitroprusside on the above variables were also studied after pre-treatment with captopril, to allow assessment of the role of angiotensin II. 2. Nitroprusside given in doses ranging from 7.5 to 150 μg/min elicited dose-related decreases in resting blood pressure and rise in heart rate and in plasma renin activity (PRA). After pretreatment with captopril, nitroprusside could not be given at doses above 60 μg/min without producing an unacceptable fall in blood pressure. The rise in heart rate in response to a given dose of nitroprusside was little altered after captopril. 3. Blood pressure and heart rate were studied during the last 10 s of the Valsalva manoeuvre. Before captopril the normal response (maintenance of blood pressure with ...
for diabetes. Its prognostic value compared to fasting blood glucose (BSL) in patients with ST-el... more for diabetes. Its prognostic value compared to fasting blood glucose (BSL) in patients with ST-elevation myocardial infarction (STEMI) is unknown. Objectives: Compare HbA1c and fasting BSL for left ventricular (LV) diastolic function and filling pressures after STEMI. Methods: A total of 142 (61.8AE12.1 years, 74.6% male) first STEMI patients were prospectively recruited. LV diastolic function was defined as the mean septal and lateral early diastolic velocities (average e') by pulsed wave tissue Doppler, and filling pressure was the ratio of transmitral early diastolic velocity to average e' (average E/e'). Results: Mean HbA1c and fasting BSL were 6.5AE1.6% and 7.7AE2.8mmol/L respectively. Between diabetics and non-diabetics, there were no differences in the rates of coronary angioplasty (p¼0.50), bypass surgery (p¼0.39), LV end-diastolic volume (EDV, 116AE37 vs. 118AE43mL, p¼0.78), end-systolic volume (ESV, 69AE33 vs. 68AE35mL, p¼0.93), ejection fraction (EF, 42AE12 vs. 44AE11%, p¼0.49). On multivariable analyses, average e' was independently associated with age (b¼-0.283, r¼0.001), LVEF (b¼0.211, r¼0.013) and HbA1c (b¼-0.173, p¼0.034), but not BSL (p¼0.83). Similarly, average E/e' was independently associated with age (b¼0.290, p<0.001), LVEF (b¼-0.201, p¼0.018) and HbA1c (b¼0.240, p¼0.003), but not BSL (p¼0.07). ROC analysis showed that an optimal HbA1c cutoff of 6.4% (AUC¼0.68, p¼0.002) was associated with an elevated LV filling pressure (average E/e' !13). Conclusion: HbA1c, not fasting BSL is independently associated with impaired LV diastolic function and increased filling pressures after STEMI.
Journal of the American Society of Echocardiography, 1999
The Chiari network is a fenestrated membrane consisting of threads and strands in the right atriu... more The Chiari network is a fenestrated membrane consisting of threads and strands in the right atrium. First described in 1897 by anatomist Hans Chiari, it is a congenital remnant of embryonic development resulting from incomplete resorption of the right valve of the sinus venosus. Found in 2% to 3% of the population, it is generally not of clinical importance. Rarely, however, the network may be associated with serious complications such as thrombus formation, embolus entrapment, arrhythmia, tumor development, and catheter entrapment. We report the entanglement of an Amplatzer septal occluder device catheter in a prominent Chiari network that was herniated into the left atrium. Transesophageal echocardiographic recognition of this before deployment and guidance during disentanglement is described below.
Because it improves endocardial definition, the use of tissue harmonic imaging (THI) is increasin... more Because it improves endocardial definition, the use of tissue harmonic imaging (THI) is increasing rapidly in clinical echocardiographic practice. With its increasing use, there is a perception that structures imaged with THI appear thicker than those obtained using the fundamental (FND) mode. However, the corollary that quantitative differences may exist between these two modalities has not been formally tested. Thus, the aim of this study was to determine if differences exist between standard aurtic root, left atria1 and left ventricular measurements derived from the FND and THI modes. Methods: Routine transthoracic echocardiography was performed in 50 unselected patients (26 females, 24 males, mean age 54 yrs), using a Hewlett Packard Sonos 5500 ultrasound machine. Standard 2D and M-mode images were digitally acquired and then analysed offline by 2 independent observers. Measurements were averaged over 3 cardiac cycles, M-mode measurements comprised aortic root diameter (Ao) and let? atria1 diameter (LA), as well as let? ventricular internal diastolic diameter (LVIDd), septal thickness (IVS) and posterior wall thickness (PW). Left ventricular outflow tract diameter (LVOT) and planimetered LA area (LAA) were obtained from the 2D echo image. Results: A0 LA LVIDd IVS PW LVOT LAA(cmrl 1
Catheterization and Cardiovascular Interventions, 2001
During deployment of an Amplatzer atrial septal occluder device to close a secundum ASD, the righ... more During deployment of an Amplatzer atrial septal occluder device to close a secundum ASD, the right atrial disk and waist of the device twisted, resulting in the cobrahead malformation. Postulated mechanisms for this complication include twisting of the device during loading into the delivery catheter and catching of leading edge of the device on the LA free wall or appendage, causing twisting during deployment. Retrieval of the device into the catheter and even removal of the device from the patient to allow manual untwisting may be required to allow the device to return to its original conformation for successful redeployment.
Optimal therapy for diastolic heart failure (DHF), the most common form of heart failure in older... more Optimal therapy for diastolic heart failure (DHF), the most common form of heart failure in older persons, is unclear. To determine the effect of aldosterone antagonism in DHF, we conducted an open-label preliminary trial of spironolactone 25mg/day in 11 women with DHF. Cardiopulmonary exercise testing, Doppler-echocardiography, and a quality of life (QOL) survey were administered at baseline and after 4-months. Peak exercise VO 2 increased by 8.3% (p=0.001), the ratio of Doppler diastolic early filling velocity to mitral annulus velocity decreased by 25% (p=0.02), QOL score improved by 21% (p=0.16 for trend), and median NYHA class improved from class III to class II (p=0.004). Findings from this preliminary study confirm the role of aldosterone in the pathophysiology of DHF and suggest that aldosterone antagonism may benefit such patients. These hypotheses are currently being tested in two separated NIH-funded, randomized trials, the Spironolactone For Failure in the Elderly (SPIFFIE) and the Treatment Of Preserved Cardiac Function Heart Failure with an Aldosterone antagonist (TOPCAT) trials.
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Papers by john Gelman