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1.  Role of Serotoninergic Pathways in Drug-induced Valvular Heart Disease and Diagnostic Features by Echocardiography 
Serotonin plays a significant role in the development of carcinoid heart disease, which primarily leads to fibrosis and contraction of right-sided heart valves. Recently, strong evidence has emerged that the use of specific drug classes such as ergot alkaloids (for migraine headaches), 5-hydroxytryptamine (5-HT or serotonin) uptake regulators/inhibitors (for weight reduction), and ergot-derived dopamine agonists (for Parkinson’s disease) can result in left-sided heart valve damage that resembles carcinoid heart disease. Recent studies suggest that both right- and left-sided drug-induced heart valve disease involves increased serotoninergic activity and in particular activation of the 5-HT receptors, including the 5-HT2B receptor subtype, which mediate many of the central and peripheral functions of serotonin. G-proteins that inhibit adenylate cyclase activity mediate the activity of the 5-HT2B receptor subunit which is widely expressed in a variety of tissues including liver, lung, heart, and coronary and pulmonary arteries; and it has also been reported in embryonic mouse heart, particularly on mouse heart valve leaflets. In this review we discuss the salient features of serotoninergic manifestations of both carcinoid heart disease and drug-induced cardiac valvulopathy with an emphasis on echocardiographic diagnosis.
PMCID: PMC3808845  PMID: 19553085
Carcinoid heart disease; Serotonin; Echocardiography
2.  Relationships Among HIV Infection, Metabolic Risk Factors, and Left Ventricular Structure and Function 
AIDS Research and Human Retroviruses  2013;29(8):1151-1160.
Our objective was to determine if the presence of metabolic complications (MC) conveyed an additional risk for left ventricular (LV) dysfunction in people with HIV. HIV+ and HIV− men and women were categorized into four groups: (1) HIV+ with MC (43±7 years, n=64), (2) HIV+ without MC (42±7 years, n=59), (3) HIV− with MC (44±8 years, n=37), or (4) HIV− controls without MC (42±8 years, n=41). All participants underwent two-dimensional (2-D), Doppler, and tissue Doppler echocardiography. Overall, the prevalence of systolic dysfunction (15 vs. 4%, p=0.02) and LV hypertrophy (9 vs. 1%, p=0.03) was greater in HIV+ than in HIV− participants. Participants with MC had a greater prevalence of LV hypertrophy (10% vs. 1%). Early mitral annular velocity during diastole was significantly (p<0.005) lower in groups with MC (HIV+/MC+: 11.6±2.3, HIV−/MC+: 12.0±2.3 vs. HIV+/MC−: 12.4±2.3, HIV−/MC−: 13.1±2.4 cm/s) and tended to be lower in groups with HIV (p=0.10). However, there was no interaction effect of HIV and MC for any systolic or diastolic variable. Regardless of HIV status, participants with MC had reduced LV diastolic function. Although both the presence of MC and HIV infection were associated with lower diastolic function, there was no additive negative effect of HIV on diastolic function beyond the effect of MC. Also, HIV was independently associated with lower systolic function. Clinical monitoring of LV function in individuals with metabolic risk factors, regardless of HIV status, is warranted.
PMCID: PMC3715767  PMID: 23574474
3.  Central Aortic Pressure is Independently Associated With Diastolic Function 
American heart journal  2010;159(6):1081-1088.
Studies investigating the association between central aortic pressures and diastolic function have been limited.
Consecutive ambulatory patients (n=281, mean age 49±13 yrs, 49% male) with normal LV systolic function were included. LV filling pressure (E/Em) was estimated by Doppler-derived ratio of mitral inflow velocity [E] to septal [Em] by tissue Doppler, LV relaxation by Em, central aortic pressures by radial tonometry. Central aortic systolic (cSBP), diastolic (cDBP), mean (cMAP), and pulse pressure (cPP) were entered individually into stepwise linear regression models to determine their association with E/Em or Em.
In univariate analysis, cPP correlated most strongly with E/Em (Spearman’s rho=0.45, p<0.001), while cSBP correlated most strongly with Em (Spearman’s rho=−0.51, p<0.001). Multivariate analysis demonstrated that the pulsatile component of afterload, cPP, contributed most to E/Em (partial r2=23%); meanwhile the nonpulsatile components (cDBP and cMAP), were significant but small contributors (partial r2 of 6% and 5% respectively) of LV relaxation (Em).
The nonpulsatile components of aortic afterload (central mean aortic pressure (cMAP) and central aortic diastolic blood pressure cDBP), exhibited a weak but significant association with LV relaxation, while the pulsatile component of afterload, central aortic pulse pressure (cPP), exhibited strong association with LV filling pressure.
PMCID: PMC2913412  PMID: 20569723
diastolic function; pulse pressure; aortic blood pressures
4.  A cross-sectional study of differences in 6-min walk distance in healthy adults residing at high altitude versus sea level 
We sought to determine if adult residents living at high altitude have developed sufficient adaptation to a hypoxic environment to match the functional capacity of a similar population at sea level. To test this hypothesis, we compared the 6-min walk test distance (6MWD) in 334 residents living at sea level vs. at high altitude.
We enrolled 168 healthy adults aged ≥35 years residing at sea level in Lima and 166 individuals residing at 3,825 m above sea level in Puno, Peru. Participants completed a 6-min walk test, answered a sociodemographics and clinical questionnaire, underwent spirometry, and a blood test.
Average age was 54.0 vs. 53.8 years, 48% vs. 43% were male, average height was 155 vs. 158 cm, average blood oxygen saturation was 98% vs. 90%, and average resting heart rate was 67 vs. 72 beats/min in Lima vs. Puno. In multivariable regression, participants in Puno walked 47.6 m less (95% CI -81.7 to -13.6 m; p < 0.01) than those in Lima. Other variables besides age and height that were associated with 6MWD include change in heart rate (4.0 m per beats/min increase above resting heart rate; p < 0.001) and percent body fat (-1.4 m per % increase; p = 0.02).
The 6-min walk test predicted a lowered functional capacity among Andean high altitude vs. sea level natives at their altitude of residence, which could be explained by an incomplete adaptation or a protective mechanism favoring neuro- and cardioprotection over psychomotor activity.
PMCID: PMC3909455  PMID: 24484777
Six-minute walk test; High altitude adaptation; Hypoxia; Functional capacity
5.  Effect of moderate diet-induced weight loss and weight regain on cardiovascular structure and function 
The objective of this prospective, single-site, two-year dietary intervention study was to evaluate the effects of moderate weight reduction and subsequent partial weight regain on cardiovascular structure and function.
Obesity is associated with adverse cardiac and vascular structural and functional alterations.
Sixty obese subjects (age: 46±10 years, body mass index: 37±3 kg/m2) were evaluated during their participation in a weight loss study. Cardiac and vascular ultrasound studies were performed at baseline and at 3, 6, 12, and 24 months after start of intervention.
Forty-seven subjects (78%) completed the entire two-year follow-up. Average weight loss was 7.3±4.0, 9.2±5.6, 7.8±6.6 and 3.8±7.9% at 3, 6, 12, and 24 months, respectively. Age- and sex- adjusted mixed linear models revealed that the follow-up time was significantly associated with decreases in weight (p<0.0001), left ventricular (LV) mass (p=0.001), and carotid intima-media thickness (p<0.0001); there was also significant improvement in LV diastolic (E’, p≤0.0001) and systolic (S’, p=.001) function. Partial weight regain diminished the maximal observed beneficial effects of weight loss, however cardiovascular parameters measured at two years still showed a net benefit compared with baseline.
Diet-induced moderate weight loss in obese subjects is associated with beneficial changes in cardiovascular structure and function. Subsequent weight regain is associated with partial loss of these beneficial effects.
PMCID: PMC2818984  PMID: 20082927
obesity; echocardiography; hypertrophy; carotid arteries; diastolic function
6.  Effects of Sodium Thiosulfate on Vascular Calcification in End-Stage Renal Disease: A Pilot Study of Feasibility, Safety and Efficacy 
American Journal of Nephrology  2011;33(2):131-138.
Background and Objectives
Vascular calcification is a major contributor to morbidity and mortality in hemodialysis. The objective of this pilot study was to determine the feasibility, safety and efficacy of sodium thiosulfate (STS) in the progression of vascular calcification in hemodialysis patients.
Chronic hemodialysis patients underwent a battery of cardiovascular tests. Those with coronary artery calcium (Agatston scores >50) received intravenous STS after each dialysis for 5 months (n = 22) and the tests were repeated. Changes in MDCT-determined calcification were assessed as the mean annualized rate of change in 3 vascular beds (coronary, thoracic and carotid arteries) and in L1-L2 vertebral bone density.
Although individual analyses showed coronary artery calcification progression in 14/22 subjects, there was no progression in the mean annualized rate of change of vascular calcification in the entire group. The L1-L2 vertebral bone density showed no changes. There were no correlations between rates of progression of vascular calcification and phosphorus, fetuin or C-reactive protein levels. Changes in coronary artery calcification scores correlated with those of the thoracic aorta.
STS treatment is feasible, appears safe and may decrease the rate of progression of vascular calcification in hemodialysis patients. A large, randomized, controlled trial is warranted.
PMCID: PMC3064860  PMID: 21242673
Hemodialysis; Sodium thiosulfate; Vascular calcification
7.  Effects of human immunodeficiency virus and metabolic complications on myocardial nutrient metabolism, blood flow, and oxygen consumption: a cross-sectional analysis 
In the general population, peripheral metabolic complications (MC) increase the risk for left ventricular dysfunction. Human immunodeficiency virus infection (HIV) and combination anti-retroviral therapy (cART) are associated with MC, left ventricular dysfunction, and a higher incidence of cardiovascular events than the general population. We examined whether myocardial nutrient metabolism and left ventricular dysfunction are related to one another and worse in HIV infected men treated with cART vs. HIV-negative men with or without MC.
Prospective, cross-sectional study of myocardial glucose and fatty acid metabolism and left ventricular function in HIV+ and HIV-negative men with and without MC. Myocardial glucose utilization (GLUT), and fatty acid oxidation and utilization rates were quantified using 11C-glucose and 11C-palmitate and myocardial positron emission tomography (PET) imaging in four groups of men: 23 HIV+ men with MC+ (HIV+/MC+, 42 ± 6 yrs), 15 HIV+ men without MC (HIV+/MC-, 41 ± 6 yrs), 9 HIV-negative men with MC (HIV-/MC+, 33 ± 5 yrs), and 22 HIV-negative men without MC (HIV-/MC-, 25 ± 6 yrs). Left ventricular function parameters were quantified using echocardiography.
Myocardial glucose utilization was similar among groups, however when normalized to fasting plasma insulin concentration (GLUT/INS) was lower (p < 0.01) in men with metabolic complications (HIV+: 9.2 ± 6.2 vs. HIV-: 10.4 ± 8.1 nmol/g/min/μU/mL) than men without metabolic complications (HIV+: 45.0 ± 33.3 vs. HIV-: 60.3 ± 53.0 nmol/g/min/μU/mL). Lower GLUT/INS was associated with lower myocardial relaxation velocity during early diastole (r = 0.39, p < 0.001).
Men with metabolic complications, irrespective of HIV infection, had lower basal myocardial glucose utilization rates per unit insulin that were related to left ventricular diastolic impairments, indicating that well-controlled HIV infection is not an independent risk factor for blunted myocardial glucose utilization per unit of insulin.
Trial Registration
NIH Clinical Trials NCT00656851
PMCID: PMC3258269  PMID: 22151886
insulin resistance; cardiac metabolism and function; PET-imaging
8.  Relation of Serum Fetuin-A Levels to Coronary Artery Calcium in African-American Patients on Chronic Hemodialysis 
Vascular calcium deposition in end-stage renal disease occurs commonly, however its relationship to cardiovascular risk factors and fetuin-A levels in African-Americans is not known. Compliant African-American HD patients (n=17) agreed to undergo a 64-slice multidetector computed tomography for the assessment of coronary artery calcium score (CACS). The relationship between traditional cardiovascular risk factors (i.e., age, gender, dialysis vintage, history of diabetes, means of the previous 3 years of the weekly pre-dialysis blood pressure and hemoglobin, means of monthly values of calcium, phosphorus, alkaline phosphatase, uric acid and albumin, and means of quarterly measures of parathyroid hormone and lipids), and fetuin-A levels and CACS was explored by univariate analyses. Serum phosphorus levels over the previous 3 years were well controlled. The CACS range was 0-3,877 Agatston units (mean: 996; median :196). Among the tested variables, only fetuin-A was significantly and inversely associated with CACS (standardized β = -0.64 [95% confidence limits [CL]: -18.09, -3.62], p=0.006). There was no association between age and fetuin-A level (standardized β = -0.02 [95%CL: -0.10, 0.23]). In conclusion, African-American patients on long-term HD and with good phosphorus control exhibit a strong inverse correlation between fetuin-A levels and CACS which is independent of age.
PMCID: PMC2631229  PMID: 19101228
Fetuin-A; Hemodialysis; Coronary artery calcium score; African-American
9.  Doppler Echocardiographic Methods for Optimization of the Atrioventricular Delay during Cardiac Resynchronization Therapy 
Echocardiography (Mount Kisco, N.Y.)  2008;25(9):1047-1055.
Cardiac resynchronization therapy (CRT) is beneficial for a majority of patients with medically-refractory heart failure due to severe left ventricular (LV) systolic dysfunction and prolonged interventricular conduction to improve symptoms and LV performance. An optimally programmed atrioventricular delay (AVD) during CRT can be also important to maximize the response in left ventricular function. Several Doppler-echocardiographic methods have been reported to be useful for determination of the optimal AVD. This review will discuss the various Doppler-based approaches to program the AVD in patients that receive CRT.
PMCID: PMC2649785  PMID: 18986435
Doppler Echocardiography; Heart Failure; Cardiac Pacing

Results 1-9 (9)