We used transthoracic Doppler echocardiography to evaluate the potential for flow variation in a skeletonized internal thoracic artery (ITA) graftc ipsilateral to an upper-extremity arteriovenous fistula during postoperative hemodialysis.Between October 2008 and May 2009, 7 patients in chronic hemodialysis underwent coronary artery bypass grafting. We selected 5 of these patients according to the following inclusion criteria: patients who were undergoing chronic hemodialysis via a left upper-extremity arteriovenous fistula and in whom the skeletonized left ITA was anastomosed to the left anterior descending artery as an in situ graft; the right ITA was not used as a graft; postoperative multidetector computed tomography evaluation of the coronary artery demonstrated patency of the left ITA. The following parameters were calculated at baseline, after the dialysis pump was on, before the pump was turned off, and after the pump was off: peak systolic velocity, end-diastolic velocity, time-averaged mean velocity, pulsatility index, and ITA diameter. Flow was calculated with the following formula: Flow = Time-Averaged Mean Velocity x (Half the Diameter of the ITA)2 x 60 x pi.When the hemodialysis pump was started, there was a significant reduction in the flow of the left ITA (P = .01), whereas there was no variation in the flow of the right ITA (P = .54). During dialysis, no patients experienced hypotension, arrhythmia, or angina. Just after the end of dialysis, the left ITA flow significantly increased (P = .01).Flow reduction of the ITA graft ipsilateral to an upper-extremity arteriovenous fistula develops during postoperative hemodialysis, even when the skeletonization technique is used.
Background There have been no reports that show significant direct relationship between echocardiographic parameters and B‐type natriuretic peptide ( BNP ) level. This could be due to the heterogeneous pathophysiology of heart failure and a lack of appropriate echocardiographic parameters. We sought to determine the best echocardiographic parameter that described elevated BNP level in patients with heart failure with and without systolic dysfunction. Methods and Results We studied 111 consecutive heart failure patients. They were divided into patients with heart failure and preserved ejection fraction ( HFPEF , n = 61) and that with heart failure and reduced ejection fraction ( HFREF , n = 50). Conventional and new echocardiographic parameters including myocardial strains were measured. BNP did not reflect any single echocardiographic parameter in patients with heart failure in total. The ratio of early diastolic transmitral flow velocity and mitral annular velocity had strong positive correlation with BNP level in the HFPEF group but not in the HFREF group. In the group of HFREF , global longitudinal and circumferential strains were positively correlated. Multivariate analysis revealed that predicted factors for BNP value in HFPEF and in HFREF were different. Conclusion High BNP level may indicate high filling pressure when ejection fraction is preserved and may indicate myocardial dysfunction when it is reduced.
The diagnosis of coronary artery disease (CAD) with nonstress echocardiography remains challenging. Although the assessment of either early systolic lengthening (ESL) or postsystolic shortening (PSS) allows the sensitive detection of CAD, it is unclear whether the integrated analysis of ESL and PSS in addition to the peak systolic strain can improve the diagnostic accuracy. We investigated the incremental value of ESL and PSS in detecting left anterior descending artery (LAD) stenosis using nonstress speckle-tracking echocardiography. Fifty-nine patients with significant LAD stenosis but without visual wall motion abnormalities on echocardiography at rest (30 single-vessel stenosis, 29 multivessel stenosis) and 43 patients without significant stenosis of any vessel were enrolled. The peak systolic strain, the time to ESL (TESL), and the time to PSS (TPSS) were analyzed in all LAD segments, and the incremental values of the TESL and TPSS in detecting LAD stenosis and the diagnostic accuracy were evaluated. In the apical anterior segment, the peak systolic strain was significantly lower and TESL and TPSS were significantly longer in the single-vessel group than in the no stenosis group. In the single-vessel group, the addition of TESL and TPSS to the peak systolic strain significantly increased the model power in detecting stenosis, and the integrated analysis improved diagnostic accuracy compared with the peak systolic strain alone. In contrast, this incremental value was not demonstrated in the multivessel group. The integrated analysis of the peak systolic strain, ESL, and PSS may allow better screening of single-vessel LAD stenosis using nonstress speckle-tracking echocardiography.
