Long-term outcome in diabetic heart failure patients treated with cardiac resynchronization therapy

BACKGROUND: Diabetes mellitus is an independent risk factor for increased morbidity and mortality in heart failure (HF) patients. AIMS: To compare functional and structural improvement, as well as long-term outcome, between diabetic and non-diabetic HF patients treated with cardiac resynchronization therapy (CRT). METHODS: We compared response to CRT in 141 diabetic and 214 non-diabetic consecutive patients. Major events were; death from any cause, urgent heart transplantation and implantation of a left ventricular (LV) assist device. Frequencies of hospitalisation and defibrillator (CRT-D) discharges were also analyzed. RESULTS: CRT was able to significantly improve functional capacity, ventricular geometry and neurohumoral imbalance in both diabetic and non-diabetic patients over a median follow-up time of 34 months. Overall event-free survival was similar in diabetic and non-diabetic patients (HR 1.23, p=0.363), as was survival free from CRT-D interventions (HR 1.72; p=0.115) and hospitalisations (HR 1.12; p=0.500). On multivariable analysis, NYHA class IV (p=0.002), low LV ejection fraction (p=0.002), absence of beta-blocker therapy (p<0.001), impaired renal function (p=0.003), presence of an epicardial lead (p=0.025), but not diabetes (p=0.821) were associated with a poor outcome after CRT. CONCLUSIONS: Diabetic HF patients treated with CRT had a very favourable functional and survival outcome, which was comparable to non-diabetic patients.     

Aberrant left pulmonary artery (pulmonary artery sling): successful repair and 24 year follow-up report

A case of anomalous left pulmonary artery arising from the right and coursing behind the trachea and anterior to the esophagus (pulmonary artery sling) is reported. The therapy currently advocated for this disorder is ligation of the anomalous vessel and performance of a left pulmonary to main pulmonary arterial anastomosis anterior to the trachea. A median sternotomy incision allows total mobilization of the anomalous vessel, minimizes respiratory embarrassment and aids in performance of the anastomosis. In the present case, a postoperative pulmonary angiogram revealed a patent left pulmonary artery, the second reported instance of such patency. The first successful repair of pulmonary artery sling was reported by Potts and colleagues in 1954. After a 24 year follow-up period their patient has normal exercise tolerance and no perfusion to the left lung is evident on ventilation-perfusion scan.     

Disruption of ROCK1 gene attenuates cardiac dilation and improves contractile function in pathological cardiac hypertrophy

The development of left ventricular cardiomyocyte hypertrophy in response to increased hemodynamic load and neurohormonal stress is initially a compensatory response. However, persistent stress eventually leads to dilated heart failure, which is a common cause of heart failure in human hypertensive and valvular heart disease. We have recently reported that Rho-associated coiled-coil containing protein kinase 1 (ROCK1) homozygous knockout mice exhibited reduced cardiac fibrosis and cardiomyocyte apoptosis, while displaying a preserved compensatory hypertrophic response to pressure overload. In this study, we have tested the effects of ROCK1 deficiency on cardiac hypertrophy, dilation, and dysfunction. We have shown that ROCK1 deletion attenuated left ventricular dilation and contractile dysfunction, but not hypertrophy, in a transgenic model of Gαq overexpression-induced hypertrophy which represents a well-characterized and highly relevant genetic mouse model of pathological hypertrophy. Although the development of cardiomyocyte hypertrophy was not affected, ROCK1 deletion in Gαq mice resulted in a concentric hypertrophic phenotype associated with reduced induction of hypertrophic markers indicating that ROCK1 deletion could favorably modify hypertrophy without inhibiting it. Furthermore, ROCK1 deletion also improved contractile response to β-adrenergic stimulation in Gαq transgenic mice. Consistent with this observation, ROCK1 deletion prevented down-regulation of type V/VI adenylyl cyclase expression, which is associated with the impaired β-adrenergic signaling in Gαq mice. The present study establishes for the first time a role for ROCK1 in cardiac dilation and contractile dysfunction.     

Decreased intercellular coupling improves the function of cardiac pacemakers derived from mouse embryonic stem cells

The aim of this study was to determine if embryonic stem cell derived cardiomyocyte aggregates (ESdCs) can act as pacemakers in spontaneously active cardiomyocyte preparations when their connexin isoform expression is tuned toward a more sinus nodal phenotype. Using microelectrode array recordings (MEAs), we demonstrate that mouse ESdCs establish electrical coupling with spontaneously active cardiomyocyte preparations (HL-1 monolayer) and obtain pacemaker dominance. WT- and Cx43(−/−)-ESdCs comparably established intercellular coupling with cardiac host tissue (Cx43(−/−): 86% vs. WT: 91%). Although both aggregates had a 100% success rate in pacing quiescent cardiac preparations, Cx43(−/−)-ESdCs had an increased likelihood of gaining pacemaker dominance (Cx43(−/−): 40% vs. WT: 13%) in spontaneously active preparations. No differences in size, beating frequency, V_m, or differentiation were detected between WT- and Cx43(−/−)-ESdCs but the intercellular coupling resistance in Cx43(−/−)-ESdCs was significantly increased (Cx43(−/−): 1.2nS vs. WT: 14.8nS). Lack of Cx43 prolonged the time until Cx43(−/−)-ESdCs established frequency synchronization with the host tissue. It further hampered the excitation spread from the cardiomyocyte preparation into the ESdC. However rectifying excitation spread in these co-cultures could not be unequivocally identified. In summary, ESdCs can function as dominant biological pacemakers and Cx43 expression is not a prerequisite for their electrical integration. Maintenance of pacemaker dominance depends critically on the pacemaker's gap junction expression benefiting those with increased intercellular coupling resistances. Our results provide important insight into the design of biological pacemakers that will benefit the use of cardiomyocytes for cell replacement therapy.     

Recreational drug overdose-related cardiac arrests: Break on through to the other side

IntroductionThe annual rate of recreational overdose (OD)-related death is increasing exponentially, making unintentional overdose the leading cause of injury-related death in America. Unfortunately, little attention in the resuscitation community has focused on the post-arrest care of this rapidly growing population.MethodsWe included patients presenting between January 2009 and February 2014 after out-of-hospital cardiac arrest (OHCA) and abstracted baseline clinical characteristics and neurological outcomes. We considered an arrest to be an OD OHCA if toxicology screens were positive and not explained by therapeutic medication administration or home medications; or if there was a history strongly suggestive of OD. We compared the baseline clinical characteristics and outcomes between the OD and non-OD cohorts.ResultsIn total, 591 OHCA patients were admitted, of which 85 (14%) arrests were OD-related. OD OHCA patients were significantly younger, had fewer medical comorbidities, were more likely to present with non-shockable rhythms and had worse baseline neurological function. However, overall survival, neurological outcomes and length of stay did not vary between groups. OD OHCA patients who survived to discharge had a significantly higher rate of favorable discharge dispositions (83% of OD OHCA survivors discharged to home or acute rehabilitation vs 62% of non-OD OHCA (P = 0.03)).ConclusionPatients who have suffered an OD OHCA make up a significant proportion of the overall OHCA population. Despite poor baseline prognostic factors, survival after OD OHCA was no worse than after non-OD OHCA, and among survivors a majority had a good neurological outcome.     

Cardiac arrest in the workplace and its outcome: a systematic review and meta-analysis

IntroductionOut-of-hospital cardiac arrest (OHCA) in the workplace appears to be managed more effectively than OHCA occurring in other places. A systematic review and meta-analysis of the available epidemiological data was performed, comparing the rate of survival for OHCA in the workplace, versus survival in other locations.MethodsFour databases (Pub-Med, Scopus, Web of science, “Base de Données de Santé Publique”, BDSP, i.e. the French Public Health Database) were searched from 01/2000 to 03/2015, using the key words: (”Cardiac arrest”) and (“occupational” OR “workplace” OR “public location”). A two stage process with two independent readers was used to select relevant papers. Numbers of subjects who suffered from OHCA in the workplace versus other locations were extracted when possible, as well as their respective outcomes (admitted alive to the hospital, discharged alive, good neurological outcome). Metarisks were calculated using the generic variance approach (meta-odds ratios metaOR).ResultsAfter full-text reading, 17 papers were included, from 9 countries, mostly published after 2005, and coming mostly from prospective registers. “Workplace” was defined differently in different studies, mostly in terms of industrial sites and offices. The workplace was an exceptional location for occurrences of OHCA (from 0.3% to 4.7% of all OHCA, from 1.3 to 23.8 events per million people per year), based on 2077 OHCA. In the quantitative analyses (survival available, 10 studies), MetaOR were found to be relatively consistent and high (from 1.9 (1.5–2.3) to 5.9(2.7–13.0)). When OHCA occurring at workplaces were compared to other public sites, no significant differences were found.ConclusionThere is sufficient evidence to support the view that there will be better outcomes for OHCA cases that occur in the workplace than for those occurring elsewhere. Requirements for occupational health and safety should include prevention of such major (albeit rare) events.     

A tourniquet assisted cardiopulmonary resuscitation augments myocardial perfusion in a porcine model of cardiac arrest

ObjectiveDuring cardiopulmonary resuscitation (CPR), myocardial blood flow generated by chest compression rarely exceeds 35% of its normal level. Cardiac output generated by chest compression decreases gradually with the prolongation of cardiac arrest and resuscitation. Early studies have demonstrated that myocardial blood flow during CPR is largely dependent on peripheral vascular resistance. In this study, we investigated the effects of chest compression in combination with physical control of peripheral vascular resistance assisted by tourniquets on myocardial blood flow during CPR.MethodsVentricular fibrillation was induced and untreated for 7 min in ten male domestic pigs weighing between 33 and 37 kg. The animals were then randomized to receive CPR alone or a tourniquet assisted CPR (T-CPR). In the CPR alone group, chest compression was performed by a miniaturized mechanical chest compressor. In the T-CPR group, coincident with the start of resuscitation, the thin elastic tourniquets were wrapped around the four limbs from the distal end to the proximal part. After 2 min of CPR, epinephrine (20 μg/kg) was administered via the femoral vein. After 5 min of CPR, defibrillation was attempted by a single 150 J shock. If resuscitation was not successful, CPR was resumed for 2 min before the next defibrillation. The protocol was continued until successful resuscitation or for a total of 15 min. Five minutes after resuscitation, the elastic tourniquets were removed. The resuscitated animals were observed for 2 h.ResultsT-CPR generated significantly greater coronary perfusion pressure, end-tidal carbon dioxide and carotid blood flow. There was no difference in both intrathoracic positive and negative pressures between the two groups. All animals were successfully resuscitated with a single shock in both groups. There were no significant changes in hemodynamics observed in the animals treated in the T-CPR group before-and-after the release of tourniquets at post-resuscitation 5 min.ConclusionsT-CPR improves myocardial and cerebral perfusion during CPR. It may provide a new and convenient method for augmenting myocardial and cerebral blood flow during CPR.     

Measuring and improving cardiopulmonary resuscitation quality inside the emergency department

Aim of studyTo evaluate CPR quality during cardiac resuscitation attempts in an urban emergency department (ED) and determine the influence of the combination of scenario-based training, real-time audiovisual feedback (RTAVF), and post-event debriefing on CPR quality.MethodsCPR quality was recorded using an R Series monitor-defibrillator (ZOLL Medical) during the treatment of adult cardiac arrest patients. Phase 1 (P1; 11/01/2010-11/15/2012) was an observation period of CPR quality. Phase 2 (P2; 11/15/2012-11/08/2013) was after a 60-min psychomotor skills CPR training and included RTAVF and post-event debriefing.ResultsA total of 52 cardiac arrest patients were treated in P1 (median age 56 yrs, 63.5% male) and 49 in P2 (age 60 yrs, 83.7% male). Chest compression (CC) depth increased from 46.7 ± 3.8 mm in P1 to 61.6 ± 2.8 mm in P2 (p < 0.001), with the percentage of CC ≥ 51 mm increasing from 30.6% in P1 to 87.4% in P2 (p < 0.001). CC release velocity increased from 314 ± 25 mm/s in P1 to 442 ± 20 mm/s in P2 (p < 0.001). No significant differences were identified in CC fraction (84.3% P1 vs. 88.4% P2, p = 0.1), CC rate (125 ± 3 cpm P1 vs. 125 ± 3 cpm P2, p = 0.7), or pre-shock pause (9.7 s P1 vs. 5.9 s P2, p = 0.5), though CC fraction and pre-shock pause were within guideline recommendations.ConclusionImplementation of the bundle of scenario-based training, real-time audiovisual CPR feedback, and post-event debriefing was associated with improved CPR quality and compliance with CPR guidelines in this urban teaching emergency department.     

产前超声诊断中晚孕期胎儿心脏畸形48例应用分析

目的探讨产前超声在胎儿心脏畸形诊断中的应用价值。方法回顾性分析2012年9月至2013年9月于陕西中医学院第二附属医院产前超声筛查中诊断的心脏畸形胎儿48例的临床资料及声像图表现,并分析总结3例漏诊的原因。结果 37例胎儿心脏畸形于中孕期检出,占总数的77.1%;晚孕期检出11例,占22.9%,其中1例室间隔缺损胎儿于孕晚期复查时缺损完全愈合,漏诊3例均于出生后经超声心动图确诊。结论产前常规超声检查可提高胎儿心脏畸形的检出率,并减少漏诊、误诊的发生。