Epidemiology,Pathogenesis, and Diagnosis of Cardiac Sarcoidosis

Cardiac sarcoidosis (CS) is a widely underdiagnosed yet clinically significant form of granulomatous myocarditis associated with significant morbidity and mortality. Clinical presentation ranges from silent cardiac involvement detected on imaging to cardiomyopathy or sudden cardiac death. Diagnosis of CS remains challenging due to the lack of sensitivity and specificity of any single diagnostic method, underscoring the importance of elevated clinical suspicion and the use of multimodality imaging to guide diagnosis and treatment. In this review, we discuss the epidemiology, pathogenesis, clinical features, and diagnosis of this clinically evading and enigmatic disease.     

A phenomenon of heart-rate turbulence,its evaluation,and prognostic value

Identification of high-risk cardiac patients is crucial for stratification strategies and preventionof cardiovascular events, including death. Single ventricular premature beat triggers some oscillations incardiac cycle duration (the shortening followed by the lengthening of the cycle intervals) inhealthy subjects and low-risk patients with ischaemic heart disease and/or heart failure. This phenomenonis called heart-rate turbulence (HRT). It was shown in retrospective and prospective studies thatthe absence of HRT is associated with increased risk of subsequent mortality in cardiac patients. HRT can bequantified by two variables: turbulence onset (TO), describing an early acceleration phase, andturbulence slope (TS), describing a late deceleration phase of heart rate after ventricularpremature beat. Both TO and TS are independent one from another and from other conventional risk predictors.The combination of TO and TS seems to be the strongest Holter-based risk predictor and has some addictivepredictive value to left ventricular ejection fraction, heart rate variability, and the averaged diurnal heartrate and baroreflex sensitivity. In addition, HRT has a predictive value in patients treated withbeta-blockers and amiodarone. Moreover, it is thought that HRT is mediated by baroreflex and therefore can beused as a non-invasive measure of its sensitivity and autonomic nervous system function. Blunted HRT can beobserved in diabetic patients with autonomic dysfunction and in patients with atropine-blocked vagal nerveactivity. Moreover, it seems that a diurnal variation of HRT exists because it is better expressed duringsleep. However, the use of HRT is limited to patients with dominant sinus rhythm and the presence of singleventricular beat. Nevertheless, the assessment of HRT is an inexpensive and simple method and can be performedwith a routine ambulatory 24-hour ECG recording.     

Plasma big-endothelin levels, cardiac autonomic neuropathy, and cardiac functions in patients with insulin-dependent diabetes mellitus

BACKGROUND: The alteration of endothelin (ET) levels in diabetic patients with cardiac autonomic neuropathy (CAN) has not been studied extensively and its correlation with cardiac function parameters has not been discussed. HYPOTHESIS: The aim of the present study was to discuss the correlation between the degree of cardiac autonomic neuropathy, plasma big-ET levels, and cardiac functions in diabetic patients who were clinically free of cardiovascular disease. METHODS: Twenty subjects (32.1 +/- 7.8 years, 11 men, 9 women) with insulin-dependent diabetes mellitus (IDDM) were studied to evaluate the relationship between circulating big-endothelin (big-ET1) levels, CAN, and cardiac functions. The severity of CAN was scored according to Ewing's criteria. Cardiac functions were assessed using Doppler echocardiography. RESULTS: Left ventricular systolic function in the patient group was within normal limits and comparable with the values of the control group (n = 10). The mean E/A values of diabetics with CAN (1.15 +/- 0.33, p = 0.004) and without CAN (1.34 +/- 0.17) were significantly lower than those of controls (1.57 +/- 0.27). Diabetics with CAN had significantly higher big-ET1 values (81.1 +/- 94 pg/ml) compared with others (12.4 +/- 5.9 and 21.1 +/- 17.7 pg/ml, p = 0.04). Circulating big-ET1 levels showed a significant correlation with E/A values in the control group (p = 0.01, r = -0.7) and with peak A values (p = 0.003, r = 0.64) in diabetics. The CAN score correlated negatively with E/A values (p = 0.01, r = 0.54). CONCLUSIONS: High big-ET levels might have an important role in the pathogenesis or consequences of diastolic dysfunction in diabetics with CAN. Their role in cardiac autonomic neuropathy and diastolic dysfunction should be investigated further.     

Congenital obstructive lesions involving the major pulmonary veins,left atrium,or mitral valve: A clinical,laboratory, and morphologic survey

The clinical, laboratory, and morphologic features of congenitally obstructive lesions causing pulmonary venous hypertension are reviewed. These lesions are responsible for considerable infant mortality and morbidity, especially in the first weeks of life, are not infrequently encountered in older children, and are occasionally seen in adults. The presence of a malformation causing pulmonary venous hypertension often can be detected clinically, but precise anatomical and physiological diagnoses, usually necessary for optimal patient management, often can be made only by detailed laboratory study. Cardiac catheterization and angiocardiography remain the prime modes of accurate diagnosis in such patients, many of whom have other significant cardiovascular malformations, and echocardiography is an extremely useful adjunct, especially in patients with mitral valvular stenosis, hypoplasia, or atresia. The only definitive treatment in any of these patients is operative relief of the obstruction, and the chances of success depend not only on the skill of the surgeon, but also on the nature of the obstructing lesion, the types of associated malformations, and the precision with which these are defined preoperatively.     

Effects of a new calcium sensitizer, levosimendan, on haemodynamics, coronary blood flow and myocardial substrate utilization early after coronary artery bypass grafting

Aims The aim of the study was to evaluate the effects on systemicand coronary haemodynamics and myocar-dial substrate utilizationof a new calcium sensitizer, levosimendan, after coronary arterybypass grafting. Methods and Results Twenty-three low-risk patients were included in this randomizedand double-blind study. They received placebo (n=8), 8 (n=8)or 24 (n=7) µg.kg^–1of levosimendan after coronaryartery bypass operation. Systemic and coronary sinus haemodynamicswith thermodilution and myocardial substrate utilization weremeasured. The heart rate increased 11 beats.min^–1afterthe higher dose (P<0·05). Cardiac output increasedby 0·7 and 1·6l.min^–1(P<0·05 forboth) after 8 and 24µg.kg^–1of levosimendan, respectively.Systemic and pulmonary vascular resistance decreased significantlyafter both doses. Coronary sinus blood flow increased by 28and 42ml/(P=0·054 for the combined effect) after thelower and higher dose, respectively. Myocardial oxygen consumptionor substrate extractions did not change statistically significantly. Conclusion Despite improved cardiac performance, levosimendan did not increasemyocardial oxygen con-sumption or change myocardial substrateutilization. Thus levosimendan has the potential to treat lowcardiac output states after cardiopulmonary bypass surgery.     

HSP60, Bax, and cardiac apoptosis

HSP60 has long been known as an important chaperonin and as having key folding functions within the mitochondria. However, it has now become evident that significant amounts of HSP60 are found in extra-mitochondrial locations. This extra-mitochondrial HSP60 in the heart has key anti-apoptotic functions. Extra-mitochondrial HSP60 complexes with both bax and bak, but not with bcl-2. Reduction in HSP60 is sufficient to precipitate apoptosis. In the setting of hypoxia and reoxygenation HSP60 decreases with reoxygenation, but the apoptotic cascade has already been triggered by end-hypoxia. Redistribution of cytosolic HSP60 to the plasma membrane during hypoxia appears to contribute to the initiation of the apoptotic cascade with hypoxia and reoxygenation.     

Reversible,Complete Atrioventricular Block Caused by Primary Cardiac Lymphoma in a Nonimmunocompromised Patient

PCL in a Nonimmunocompromised Patient Primary cardiac lymphoma (PCL) is a rare entity that commonly presents as a heart rhythm disorder. We describe a previously healthy, immunocompetent patient presenting with complete atrioventricular block (AVB). The patient was found to have a cardiac mass on magnetic resonance imaging and underwent percutaneous biopsy eventually diagnosing PCL. After pacemaker implantation, the patient's tumor responded rapidly to chemotherapy and the AVB completely resolved. In otherwise healthy patients presenting with AV block, cardiac tumor should be considered. Additionally, if PCL is diagnosed and the patient is clinically stable with AVB, it may be reasonable to delay pacemaker implantation until the clinical response to chemotherapy is evaluated. (J Cardiovasc Electrophysiol, Vol. 23, pp. 1386‐1389, December 2012)     

罗文琦 欧阳小康 甄文俊 王怀斌 谭洁 马玉健 王子 卫生部北京医院心血管外科

目的 回顾性分析≥80岁接受心脏手术的高龄患者的临床特点,评价手术方式、围术期管理和治疗结果。方法 我院2012年6月至2014年5月,25例高龄患者接受心脏手术,男性19例,女性6例,年龄80~91岁,平均82.6±3.0岁,其中冠心病患者17例,瓣膜病6例,瓣膜病合并冠心病2例。结果 高龄患者合并症多,冠心病患者绝大多数为不稳定心绞痛,多数有心肌梗死病史,瓣膜病变多为老年退行性变。本组围手术期死亡1例。术后最常见的并发症为房颤和心功能不全,急性肾损伤(AKI)、慢性贫血、低蛋白血症等发生率较高。结论 接受心脏外科手术治疗的高龄患者具有其自身特点,高龄不是手术禁忌,但需进行细致评估,根据个体特点选择个体化手术策略,围手术期尤其需要精细的管理,出院后适当增加随诊频率。     

ISCHEMIC HEPATITIS: CLINICAL FEATURES, DIAGNOSIS AND PROGNOSIS

Nineteen episodes of ischemic hepatitis were diagnosed by hepatitic liver function tests and characteristic liver pathology in 17 patients. All patients had an acute illness associated with a likely fall in cardiac output although only five episodes were associated with documented hypotension. Right ventricular failure was severe in only four, mild in six, and absent in nine whilst left ventricular failure was clinically apparent in 16. The hepatitic illness was usually mild. No patient died as a direct result of hepatic damage, prognosis depending on the underlying cardiac or systemic disease. Liver function tests were characterised by a marked rise in serum transaminase levels with a parallel increase in serum lactic dehydrogenase of hepatic origin and a short time course of the enzyme elevation lasting 3 to 11 days. It is concluded that ischemic hepatitis (a) is' caused by poor hepatic perfusion associated with an acute fall in cardiac output; (b) is usually a subclinical illness with little influence on prognosis, and (c) may be accurately differentiated from viral hepatitis on clinical and biochemical criteria alone.     

心力衰竭患者血清基质金属蛋白酶及骨桥蛋白、cTnI、cTnT与心室重构的关系

目的研究及观察心力衰竭患者血清基质金属蛋白酶(matrix metalloproteinase,MMP)及骨桥蛋白(osteopontin,OPN)、心肌肌钙蛋白(cardiac troponin,c Tn)I、c Tn T与心室重构的关系。方法选取2012年8月至2014年3月四川省阆中市人民医院收治的70例心力衰竭患者为观察组;另外选择同时期的70名健康人为对照组。将两组的血清MMP及OPN、c Tn I、c Tn T浓度分别进行检测及比较,然后比较观察组不同左心室舒张末期容积指数(left ventricular end-diastolic volume index,LVEDVI)及左心室体积指数(left ventricular mass index,LVMI)患者的上述指标,并以Logistic分析处理上述血清指标与心室重构的关系。结果观察组的血清MMP及OPN、c Tn I、c Tn T浓度均高于对照组,差异有统计学意义(P<0.05);且观察组中不同ΔLVEDVI和LVMI患者上述指标比较,差异有统计学意义(P<0.05)。Logistic分析结果显示,血清MMP及OPN、c Tn I、c Tn T浓度与心室重构均有密切的关系(P<0.05)。结论心力衰竭心室重构患者的血清MMP及OPN、c Tn I、c Tn T浓度呈现异常的状态,上述指标对于心室重构均有较高的反映价值。     

Association Between Obesity,Age, and Functional Decline in Survivors of Cardiac Surgery

Background/Objectives

Little is known about the effect of obesity on functional decline after cardiac surgery, especially in elderly adults. Our goal was to determine the association between obesity and functional decline in the 2 years after cardiac surgery and the interaction between obesity and age.

Design

Retrospective cohort study.

Setting

The Health and Retirement Study, 2004–2014.

Participants

U.S. adults aged 50 and older who indicated having cardiac surgery and had a body mass index (BMI) of 18.5 kg/m² or greater (N = 1,731).

Measurements

BMI was classified as normal or overweight (18.5–29.9 kg/m²) and obese (≥30 kg/m²). Primary outcome was decline in ability to perform an activity of daily living (ADL) after surgery.

Results

Respondents had a median age of 71, 59.3% were female, and 34.3% were obese. Obese respondents had a higher incidence of ADL decline (22.4%) than those who were not obese (17.1%) (P = .007). In the multivariable analysis of our full cohort, obesity was not associated with ADL decline (odds ratio (OR)=1.20, 95% confidence interval (CI)=0.90–1.59, P = .21) after cardiac surgery, although obese respondents aged 50 to 79 had greater odds of ADL decline (OR=1.45, 95% CI=1.06–2.00, P = .02). Obese respondents aged 80 and older had nonstatistically significantly lower odds of ADL decline (OR=0.61, 95% CI=0.30–1.24, P = .18) compared to non‐obese respondents.

Conclusion

The association between obesity and postoperative functional decline in survivors of cardiac surgery differed according to age. Additional research is needed to identify interventions to improve outcomes in groups of older adults in whom obesity may increase the risk of postoperative functional decline.     

La mort subite cardiaque chez la femme,registre du nord de la Tunisie

BackgroundSudden cardiac death is a major public health problem. Epidemiological and clinical differences according to gender have been described in sudden cardiac death. The aim of this study was to examine the gender differences between autopsy findings and circumstance of occurrence associated with sudden cardiac death.MethodsWe prospectively collected epidemiological and autopsy data of victims of sudden cardiac death occurring in the northern governorates of Tunisia between January 2013 and December 2019. Symptoms preceding death, circadian, weekly and seasonal variations of sudden death were also analyzed.ResultsThe study population included 1834 men and 468 women with a mean age of 56.5 ± 14.2 years. All cardiovascular risk factors except smoking were significantly more frequent among women but ischemic heart disease was the most common cause of death in men (51.3 %, versus 28 %, P < 0.001). Women were more likely to have a negative macroscopic autopsy than men (34 % versus 23.6 %, P < 0.001). Chest pain preceding sudden death was more frequent in male (24 % versus 13.2 %, P < 0.001). In contrast, women were more likely to have dyspnea (8.1 % versus 15.6 %, P < 0.001). Sudden death in women occurred indoors more often than in men (63.9 % versus 54.5 %, P < 0.001) and also more often during night (midnight to 6 am). We also recorded an excess cardiac mortality in winter in both sexes.ConclusionsWomen had considerably more cardiovascular risk factors and more commonly negative macroscopic autopsy. Death occurred indoors and during night more often than in men.     

Current perspectives in hypertrophic cardiomyopathy: diagnosis, clinical management, and prevention of disability and sudden cardiac death

Hypertrophic cardiomyopathy is a rare primary myocardial disease known for its dramatic morphologic and clinical manifestations. Sudden cardiac death and functional cardiac symptoms are common. However, differing pathologic mechanisms may be responsible for similar clinical symptoms and make a unified approach to therapy impossible. This review will discuss the genetics, criteria for diagnosis, relationship among pathophysiologic abnormalities and clinical symptoms, and management of hypertrophic cardiomyopathy.