Left Ventricular Ejection Fraction as Criterion for Implantation of an Implantable Cardioverter-Defibrillator in Heart Failure Patients Undergoing Surgical Left Ventricular Reconstruction

Background: Besides implantation of an implantable cardioverter-defibrillator (ICD), a proportion of patients with left ventricular (LV) dysfunction due to ischemic cardiomyopathy are potential candidates for surgical LV reconstruction (Dor procedure), which changes LV ejection fraction (LVEF) considerably. In these patients, LVEF as selection criterium for ICD implantation may be difficult. This study aimed to determine the value of LVEF as criterium for ICD implantation in heart failure patients undergoing surgical LV reconstruction.
Methods: Consecutive patients with end-stage heart failure who underwent ICD implantation and LV reconstruction were evaluated. During admission, two-dimensional (2D) echocardiography (LV volumes and LVEF) was performed before surgery and was repeated at 3 months after surgery. Over a median follow-up of 18 months, the incidence of ICD therapy was evaluated.
Results: The study population consisted of 37 patients (59 ± 11 years). At baseline, mean LVEF was 23 ± 5%. Mean left ventricular end-systolic volume (LVESV) and left ventricular end-diastolic volume (LVEDV) were 175 ± 73 mL and 225 ± 88 mL, respectively. At 3-month follow-up, mean LVEF was 41 ± 9% (P < 0.0001 vs. baseline), and mean LVESV and LVEDV were 108 ± 65 mL and 176 ± 73 mL, respectively (P < 0.0001 vs. baseline). During 18-month follow-up, 12 (32%) patients had ventricular arrhythmias, resulting in appropriate ICD therapy. No significant relations existed between baseline LVEF (P = 0.77), LVEF at 3-month follow-up (P = 0.34), change in LVEF from baseline to 3-month follow-up (P = 0.28), and the occurrence of ICD therapy during 18-month follow-up.
Conclusion: LVEF before and after surgical LV reconstruction is of limited use as criterium for ICD implantation in patients with end-stage heart failure.     

Intracardiac Echocardiography-Guided Cardiac Resynchronization Therapy: Technique and Clinical Application

Background: We undertook a pilot investigation to evaluate the feasibility of a novel technique using intracardiac echocardiography (ICE) for intraoperative assessment of cardiac resynchronization therapy (CRT).
Methods: We evaluated ICE intraoperative imaging of left ventricular (LV) function and aortic valvular flow as well as safety of implementation. ICE was used to guide CRT system lead placement, assess impact of pacing modes, and optimization of device programming.
Results: Twenty-three patients underwent ICE imaging. ICE showed global hypokinesis in six patients, regional wall motion abnormality only in 10 patients, and both in seven patients. Optimized CRT modes included mean atrioventricular (AV) interval of 170 ms and interventricular timing using simultaneous right ventricular (RV)-LV pacing (five patients), LV pacing only (one patient), and sequential LV to RV stimulation (15 patients) or RV to LV stimulation (two patients). ICE-guided CRT acutely improved mean left ventricular ejection fraction (LVEF) from 24 ± 9% to 41 ± 1% (P < 0.00001). During follow-up of 3–24 (mean 11) months, New York Heart Association class improved in all patients from a mean of 3.2 ± 0.4 at implant to 1.6 ± 0.7 (P < 0.0001), with improvement of LVEF from 19 ± 7% to 34 ± 12% (P = 0.0001). Actuarial survival was 83% at 12 months.
Conclusions: (1) ICE imaging is reliable and safe for continuous intraoperative imaging of LV wall motion, and assesses baseline status and impact of CRT interventions. (2) Intraoperative ICE-guided CRT optimization resulted in an increase in LVEF acutely and consistent improvement in heart failure. (3) Sequential biventricular pacing and longer AV interval programming were more often used in ICE-guided CRT.     

Marked Improvement in Left Ventricular Function and Significant Reverse Left Ventricular Remodeling within 3 Months of Cardiac Resynchronization Therapy in Patients with Dilated Cardiomyopathy

We monitored reverse left ventricular (LV) remodeling and LV function during the first 6 months of cardiac resynchronization therapy (CRT) in 34 patients (mean age = 55.3 ± 13.6 years, 28 men) with dilated cardiomyopathy (DCM), left bundle branch block, in stable New York Heart Association class III, and on fixed drug regimen who underwent implantation of CRT systems with or without cardioverter defibrillator back-up. QRS-complex duration was reduced from 169.69 ± 19.6 ms (SD) to 144.1 ± 23.4 ms during CRT. Parasternal M-mode and apical 2D-echocardiography was performed before and 3 and 6 months after device implantation. LV enddiastolic (EDD) and endsystolic (ESD) diameters were measured, and biplane LV enddiastolic (EDV), and endsystolic (ESV) volumes and ejection fractions (EF) were calculated using a modified Simpson formula. Significant decreases in LVEDD (P = 0.0064 at 3 months and P = 0.021 at 6 months), LVESD (P = 0.023 at 3 months, and P = 0.003 at 6 months), and LVESV (P = 0.006 resp. P = 0.007), and increases in LVEF (P = 0.003 at 3 months and P < 0.001 at 6 months) were observed. Mean LVEF increased from 23% at baseline to 39% at 6 months. CRT induced prominent reverse LV remodeling and significantly increased LVEF within a few months in patients with DCM.     

Survival and Appropriate Device Interventions in Recipients of Cardioverter Defibrillators Implanted for the Primary Versus Secondary Prevention of Sudden Cardiac Death

Background: Implantable cardioverter-defibrillators (ICD) implanted after an episode of ventricular tachyarrhythmia (VTA) or in patients at high risk of VTA lower the long-term mortality. Comparisons of the clinical outcomes of the two indications are scarce.
Methods: The study enrolled 360 consecutive ICD recipients. The device was implanted for secondary prevention in 150 patients, whose mean age was 60 ± 14 years, and mean left ventricular ejection fraction (LVEF) was 40 ± 16%, and for primary prevention in 210 patients, whose mean age was 61 ± 11 years, and mean LVEF was 31 ± 13%. All-cause mortality and time to first appropriate ICD therapy were measured.
Results: The two study groups were similar with respect to age and prevalence of coronary artery disease. Mean LVEF was higher in the secondary prevention group (P = 0.001). Cox regression analysis revealed a significantly shorter time to first appropriate ICD therapy in the secondary prevention group (HR = 0.51, 95% CI = 0.30 – 0.87, P = 0.01). Over a mean follow-up of 37 ± 19 months, the all-cause mortality in the overall population was 12.7%, and was similar in both subgroups (HR = 0.99, 95% CI = 0.55–1.77, P = 0.97).
Conclusions: The long-term mortality in this unselected population of ICD recipients was low. Patients treated for secondary prevention received earlier appropriate ICD therapy than patients treated for primary prevention. Long-term mortality was similar in both groups. The higher VT incidence of VTA was effectively treated by the ICD and was not associated with a higher mortality.     

Long-Term Outcomes of CRT-PM Versus CRT-D Recipients

Objective: To compare the rates of all-cause mortality in recipients of cardiac resynchronization therapy devices without (CRT-PM) versus with defibrillator (CRT-D).
Methods: Between February 1999 and July 2004, 233 patients (mean age = 69 ± 8 years, 180 men) underwent implantation of CRT-PM or CRT-D devices. New York Heart Association (NYHA) heart failure functional class II was present in 11%, class III in 69%, and class IV in 20% of patients; mean left ventricle ejection fraction (LVEF) was 26.5 ± 6.5 %, 48% presented with idiopathic dilated cardiomyopathy and 49% with ischemic heart disease. Cox multiple variable regression analysis was performed in search of predictors of death.
Results: The clinical characteristics of the 117 CRT-PM and 116 CRT-D recipients were similar, except for LVEF (28.2 ± 6.2% vs 25.0 ± 6.5%, respectively; P < 0.001), and ischemic versus nonischemic etiology of heart failure (41% vs 56%, respectively P = 0.02). Over a mean follow-up of 58 ± 15 months, no significance difference in overall mortality rate was observed between the two study groups. Male sex, NYHA functional class IV, and atrial fibrillation at implant were significant predictors of death.
Conclusions: There was no difference in long-term survival rate among patients with CRT-D versus CRT-PM, although CRT-D more effectively lowered the sudden death rate. Male sex, NYHA functional class IV, and atrial fibrillation predicted the worst prognosis.     

Alpha interferon and ribavirin combination therapy of chronic hepatitis D

The success of alpha interferon (IFN-alpha) monotherapy for the treatment of chronic hepatitis D is very limited. In this study, the efficacy of IFN-alpha and ribavirin combination therapy for chronic hepatitis D was investigated. Nineteen patients (15 males; mean age +/- standard deviation, 36.8 +/- 12.8 years) with chronic hepatitis D who were treated with IFN-alpha2b (10 million U, three times/week, subcutaneously) and ribavirin (1,000 to 1,200 mg/day, orally) for 24 months were studied. All patients had compensated liver disease (15 were precirrhotic), elevated transaminase levels, and hepatitis D virus RNA positivity at baseline. Genotypic analyses revealed hepatitis D virus genotype I and hepatitis B virus genotype D. All patients completed the 24 months of treatment and at least 6 months (7 to 19 months) of a follow-up period. Biochemical responses were observed in eight patients (42.1%) at the end of treatment and in seven patients (36.8%) at the end of follow-up. Eight patients (42.1%) at the end of treatment and four patients (21%) at the end of follow-up had virological responses. In conclusion, combination treatment of IFN-alpha and ribavirin for chronic hepatitis D is not able to induce virological responses at a sufficient rate, despite its partial effectiveness in improving biochemical responses, and is not superior to IFN-alpha monotherapy.     

Time course of effects of cardiac resynchronization therapy in chronic heart failure: benefits in patients with preserved exercise capacity

Objectives: To assess in patients with chronic heart failure the effect of cardiac resynchronization therapy (CRT) over 12 months' follow-up the time course of the changes in functional and neurohormonal indices and to identify responders to CRT.
Methods: Eighty-nine patients (74.1 ± 1 years, left ventricular ejection fraction [LVEF] < 35%), QRS complex duration >150 ms, in stable New York Heart Association (NYHA) class III or IV on optimal medical treatment were prospectively randomized either in a control (n = 45) or CRT (n = 44) group and underwent clinical evaluation, cardiopulmonary exercise testing (CPET), 2D-Echo, heart rate variability (HRV), carotid baroreflex (BRS), and BNP assessments before and at 6- and 12-month follow-up.
Results: In the CRT group, improvement of cardiac indices and BNP concentration were evident at medium term (over 6 months) follow-up, and these changes persisted on a longer term (12 months) (all P < 0.05). Instead CPET indices and NYHA class improved after 12 months associated with restoration of HRV and BRS (all P < 0.05). We identified 26 responders to CRT according to changes in LVEF and diameters. Responders presented less depressed hemodynamic (LVEF 25 ± 1.0 vs 22 ± 0.1%), functional (peak VO₂ 10.2 ± 0.2 vs 6.9 ± 0.3 ml/kg/min), and neurohormonal indices (HRV 203.6 ± 15.7 vs 147.6 ± 10.ms, BRS 4.9 ± 0.2 vs 3.6 ± 0.3 ms/mmHg) (all P < 0.05). In the multivariate analysis, peak VO₂ was the strongest predictor of responders.
Conclusions: Improvement in functional status is associated with restoration of neurohormonal reflex control at medium term. Less depressed functional status (peak VO₂) was the strongest predictor of responders to CRT.     

Cardiac Stimulation Threshold in Familial Amyloidosis with Polyneuropathy

It has been suggested that a higher cardiac stimulation threshold reduces the applicabilty of pacemaker therapy in cardiac amyloidosis. We therefore reviewed threshold data in patients with familial amyloidosis with polyneuropathy (FAP), which is an inherited type of systemic amyloidosis, invariably involving the heart. Fourteen FAP patients treated with a pacemaker were studied. The mean (±SD) voltage stimulation threshold during implantation was 1.0 ± 0.5 V, and noninvasive follow-up 6 months later revealed a mean Vario threshold of 1.9 ± 0.5 V. Beyond this time, the threshold tended to be stable, and high threshold exit block did not occur in any patient. Several FAP patients did show a moderately elevated threshold, and a multiprogrammable pulse generator with a high output capability is recommended when pacemaker therapy is considered in these patients.     

Baroreflex Sensitivity and Heart Rate Variability in Coronary Disease Compared to Dilated Cardiomyopathy

This study was designed to compare baroreceptor sensitivity and heart rate variability as measures of cardiac autonomic tone in patients with coronary disease (CAD, n = 49) and idiopathic dilated Cardiomyopathy (IDC, n = 130). Time domain heart rate variability, including SDNN, SDANN, and pNN50, was determined during 24-hour Holter ECG. Baroreflex sensitivity was analyzed nonivasively using the phenylephrine method. Baroreflex sensitivity and heart rate variability were comparable between patients with CAD versus IDC (baroreflex sensitivity: 6.1 ± 3 vs 6.9 ± 5 ms/mmHg; SDNN: 97 ± 40 vs 114 ± 41 ms; SDANN: 83 ± 33 vs 99 ± 41 ms; pNNSO: 3.9 ± 4 vs 9.6 ± 13 ms, P = NS for all comparisons). Likewise, a subgroup analysis of patients with a left ventricular ejection fraction (LVEF) ≤ 30% showed no significant difference in baroreceptor sensitivity and heart rate variability between IDC and CAD patients. Patients with CAD and an LVEF > 30% had a decreased heart rate variability but not a decreased baroreflex sensitivity compared to patients with IDC and LVEF > 30 % (baroreflex sensitivity: 6.4 ± 4 vs 8.3 ± 6 ms/mmHg, P = NS; SDNN: 98 ± 19 vs 128 ± 42 ms, P < 0.05; SDANN: 86 ± 21 vs 112 ± 43 ms, P < 0.05; pNN50: 4.2 ± 3 vs 12.3 ± 8 ms, P < 0.05). Patients with a markedly depressed LVEF show comparable alterations in cardiac autonomic tone whether they have CAD or IDC. Patients with CAD and preserved LV function, however, have a decreased heart rate variability compared to patients with IDC and preserved LV function. The prognostic significance of these findings will be determined prospectively in a large patient cohort at our institution.     

Cardiac Resynchronization Therapy in Patients with Right Ventricular Pacing-Induced Cardiomyopathy

Background: It is not known whether patients with normal baseline left ventricular (LV) function who develop right ventricular (RV) pacing-induced cardiomyopathy as a result of dual-chamber pacing can benefit from cardiac resynchronization therapy (CRT). We retrospectively assessed the effect of a CRT upgrade on RV pacing-induced cardiomyopathy.
Methods and Results: We reviewed the charts of patients who received a CRT device for RV pacing-induced cardiomyopathy. We assessed the effects of CRT on LV function, recovery, and other response parameters. From September 2005 through February 2009, 21 patients (13 men; aged 63 ± 9 years) underwent a treatment upgrade to a CRT system. Before the dual-chamber pacemaker was implanted, the LV ejection fraction (LVEF) was 53 ± 2.3%. After pacing, the LVEF was 31.2 ± 3.8%, the LV end-diastolic dimension (LVEDD) was 5.8 ± 0.5 cm, and B-type natriuretic peptide (BNP) levels were 426 ± 149 pg/mL. The duration of pacing before documentation of pacing-induced cardiomyopathy was 3.8 ± 1.5 months. All the patients had been on a stable medical regimen for at least 2 months. After the upgrade to CRT, the follow-up time was 4.9 ± 0.9 months. Sixteen patients (76%) reported a significant improvement in their symptoms. After the CRT upgrade, the LVEF increased to 37.4 ± 9.0% (P < 0.01 vs pre-CRT). The LVEDD decreased to 5.0 ± 1.0 cm (P = 0.03 vs pre-CRT), and BNP levels decreased to 139 ± 92 pg/mL (P = 0.08 vs pre-CRT).
Conclusion: A CRT upgrade is an effective treatment for RV pacing-induced cardiomyopathy and should be implemented as soon as the diagnosis is established. Unfortunately, about 24% of our patients did not respond to the upgrade. (PACE 2010; 37–40)     

IFN combined cyclosporin A therapy

Current therapy of chronic hepatitis C with a 6 months course of alpha interferon shows limited effectiveness for patients with chronic hepatitis C. In particular more effective therapy is needed to treat patients who have high serum level of group 1-HCV RNA. We previously reported that a combination of interferon and cyclosporin A was more effective than interferon monotherapy. We also examined whether CsA has an antiviral effect on HCV using cultured human hepatocyte cell line. Propagation of HCV seems to be inhibited by CsA in a dose dependent manner. Further study is needed to clarify the action of cyclosporin A.     

Early Benefit of Implantable Cardioverter Defibrillator Therapy in Patients Waiting for Cardiac Transplantation

The ICD can effectively recognize and treat ventricular arrhythmias that can lead to sudden death. Sudden death is a major problem in patients awaiting heart transplantation. We reviewed our experience with the ICD in patients with malignant ventricular arrhythmias waiting for cardiac transplantation. Nineteen patients were included. Seventeen were men, mean age was 54 ±11 years (range 17–66) and the left ventricular ejection fraction was 22%± 10% (range 9%–46%). After a mean follow–up of 6 ± 5 months (range 1–20 months), 17 patients reached heart transplantation. One patient died and the other is waiting for a transplant. Before transplantation 71 % of patients received an appropriate discharge. The mean time to the first appropriate discharge was 2 ± 2 months (range < 1–6 months), which was significantly shorter than the mean time to first discharge in the other patients (n = 182) receiving a defibrillator in our center (11 ±10 months; range 1–58 months) (P < 0.0004). In conclusion, cardiac transplantation candidates with life–threatening ventricular arrhythmias can effectively be protected against sudden arrhythmic death by ICD. These patients have a high incidence of appropriate shocks occurring very early after implantation.     

急性心肌梗死缺血后处理对患者发生心肌梗死后心力衰竭的影响

目的探讨缺血后处理对急性心肌梗死后患者心力衰竭的影响。 方法选取2014年1月至2015年12月于吉林大学附属吉林医院心血管诊治中心第二疗区住院患者200例,起病时间在12 h内,并急诊行经皮冠状动脉介入(PCI)治疗的患者,根据随机数字表法随机分为两组,对照组(100例,常规PCI治疗)和缺血后处理组(IPTC组)(100例,给予缺血后处理)。比较两组患者的血清同工酶(CK-MB)、肌钙蛋白I(cTnI)、脑钠肽(BNP)水平和心脏彩超中的左室射血分数(LVEF)和左室舒张末内径(LVEDD)值。 结果心肌梗死后3 d时,对照组cTnI为(40.40±3.85)ng/ml,IPTC组为(23.12±2.36)ng/ml,两组间比较差异有统计学意义(t＝7.30,P<0.05),对照组显著高于IPTC组。心肌梗死后14 d时,对照组BNP为(2 595±239)pg/mL,IPTC组为(1 391±154)pg/mL,两组间比较差异有统计学意义(t＝6.54,P<0.05),对照组显著高于IPTC组。在随访3个月时,对照组LVEF值为(48.16±4.62)mm,IPTC组LVEF值为(57.11±4.43)mm,两组间比较差异有统计学意义(t＝21.50,P<0.05),对照组显著低于IPTC组。在6个月时随访复查LVEF值,对照组为(49.78±6.22)mm,IPTC组为(60.41±3.94)mm,两组间比较差异有统计学意义(t＝4.67,P<0.05),对照组显著低于IPTC组。在6个月时随访复查LVEDD值,对照组为(52.19±6.42)mm,IPTC组为(44.24±5.47)mm,两组间比较差异有统计学意义(t＝7.70,P<0.05),对照组显著高于IPTC组。 结论缺血后处理可以改善急性心肌梗死后患者的心功能,减少急性期心肌梗死损伤。     

Neurocognitive changes in patients with hepatitis C receiving interferon alfa-2b and ribavirin

BACKGROUND: During antiviral therapy of chronic hepatitis C, patients frequently report impairment of concentration or memory. Therefore we prospectively investigated neurocognitive performance in patients receiving interferon alfa and ribavirin. METHODS: Repeated computer-based testing of neurocognitive function was performed in 70 patients with chronic hepatitis C receiving interferon alfa-2b (pegylated or conventional) and ribavirin. In addition, depression scores were obtained (Hospital Anxiety and Depression Scale). RESULTS: Reaction times were significantly increased during treatment (mean reaction time increase after 3 months of therapy: alertness, 46.76 ms [95% confidence interval (CI)], 26.86-66.66 ms), P < .001; divided attention, 47.04 ms [95% CI, 26.44-67.64 ms], P < .001; vigilance, 60.78 ms [95% CI, 29.24-92.32 ms], P < .001; and working memory, 38.53 ms [95% CI, 1.22-75.83], P = .34). Accuracy measures (number of false reactions) were affected for the working-memory task exclusively. Cognitive performance returned to pretreatment values after the end of therapy. Cognitive impairment was not significantly correlated with the degree of concomitant depression (0.04 < r [absolute value] < 0.10, P > .390). CONCLUSIONS: Interferon-based combination therapy of chronic hepatitis C causes significant but reversible impairment of neurocognitive performance. Consequences for the requirements of an active life in patients with chronic hepatitis C receiving antiviral therapy need to be assessed.     

Complete remission of cryoglobulinemic glomerulonephritis (HCV-positive) after high dose interferon therapy

We report the case of a 64-year old woman with hepatitis C virus infection, mixed cryoglobulinemia type II (IgG + IgM kappa) and cryoglobulinemic glomerulonephritis. The patient was treated with the standard dose of recombinant interferon alpha-2b (3 million units 3 times a week) for one year, resulting in complete clinical remission and undetectable levels of serum hepatitis C virus RNA. AST and ALT normalized and proteinuria decreased from 2.78 to 0.98 g/day. However, a relapse occurred when therapy was stopped. Additional therapy with interferon-alpha (5 million units 3 times a week for 9 months) resulted again in quick and prolonged remission. The clinical course of our patient showed sustained clinical and virologic response after high-dose interferon-alpha treatment confirming the usefulness of interferon alpha in treatment of patients with cryoglobulinemic glomerulonephritis. Our observation is in agreement with others, suggesting that recommended standard dosage and duration of initial treatment with interferon alpha should be re-evaluated. Although our patient had sustained virologic and clinical response after interferon alpha monotherapy, recent studies clearly support combination therapy of interferon alpha and ribavirin for treatment of chronic HCV infections.     

Serial Changes in Right Ventricular Apical Pacing Lead Impedance Predict Changes in Left Ventricular Ejection Fraction and Functional Class in Heart Failure Patients

Pacing impedance has been proposed to monitor the clinical status of patients with congestive heart failure (CHF). This study examined whether changes in right ventricular (RV) pacing impedance correlate with changes in left ventricular ejection fraction (LVEF) and New York Heart Association (NYHA) functional class during long-term follow-up in pacemaker recipients with CHF. The study included 67 patients, 70 ± 12 years of age, in NYHA class II or III, and with a mean LVEF = 29 ± 8% at implant. LVEF, NYHA class, and bipolar pacing impedance at the RV outflow tract (RVOT) and apex (RVA) were measured at implant and at 3, 6, 9, and 12 months of follow-up. At implant, impedance was similar in RVOT (548 ± 115 Ω) and RVA (571 ± 174 Ω). Between implant and 3 months, mean impedance decreased (P < 0.0001) at both the RVOT (472 ± 62 Ω) and RVA (488 ± 86 Ω), LVEF increased (43 ± 14%, P < 0.0001), and the NYHA class decreased from 2.4 ± 0.5 to 2.1 ± 0.6 (P = 0.0001). Changes in RVA impedance correlated with changes in LVEF (r = 0.45, P = 0.002). A 50 Ω decrease in RVA impedance corresponded to a 3% decrease in LVEF. RVA impedance decreased significantly as NYHA class increased from I to IV (P = 0.04). There was no correlation between impedance measured at the RVOT and LVEF or NYHA class. A decrease in bipolar pacing impedance at the RVA was associated with worsening LVEF and the NYHA class. The use of pacing impedance to monitor the clinical status in CHF is dependent on the RV pacing site.     

A 12-month course of combination therapy with interferon-alfa and lamivudine in patients with chronic hepatitis delta virus: A single-center, prospective, open-label, uncontrolled study

Background: Chronic hepatitis delta virus (HDV) is a severe and rapidly progressive liver disease for which no therapy has been proved to be effective.Objective: The aim of this study was to investigate the efficacy and tolerability of long-term therapy with a combination of recombinant interferon (IFN)-alfa and lamivudine.Methods: In this single-center, prospective, open-label, uncontrolled study, patients aged 18 to 60 years with chronic HDV were eligible. Patients were treated with a combination of 10 million units of IFN-alfa-2b subcutaneously 3 times weekly and lamivudine 100 mg once daily for 12 months. The primary outcome measures were biochemical and histologic response at the end of treatment and at least 12 months thereafter.Results: Twelve patients (10 men, 2 women; mean age, 33.9 years [range, 19-49 years]) were enrolled (6 treatment-naive patients, 6 previously treated patients). Normalization or decrease of >50% from baseline in serum alanine aminotransferase (ALT) level occurred in 8 (66.7%) of 12 patients at month 12 of treatment. Of the 12 patients, 10 (83.3%) completed the trial; 1 (8.3%) was withdrawn because of severe leukopenia and 1 (8.3%) was lost to follow-up. Relapses occurred in 5 of 8 (63.3%) initial responders shortly after the cessation of therapy. In 3 (25%) patients whose ALT levels became normal at the end of the therapy, the complete biochemical responses persisted for up to 3 years (mean, 31 months). The treatment was associated with a marked improvement in histologic activity.Conclusions: In this study, combination therapy with IFN-alfa and lamivudine was well tolerated and reduced hepatic inflammation was found. Further controlled trials are needed to show possible beneficial effects of this model of therapy and to determine the optimal dose and duration of therapy for chronic HDV.     

Perihepatic lymph nodes and antiviral response in chronic HCV-associated hepatitis

To identify predictive factors of response to interferon alpha (IFN-alpha) plus ribavirin therapy in patients with chronic hepatitis C (CHC), the presence of lymphadenopathy (LyA) of the hepatoduodenal ligament and other variables were investigated. A total of 110 patients with histologically proven CHC were enrolled in this study. Ultrasound (US) was performed at the start and end of therapy and 6 months after stopping therapy. At baseline, LyA was present in 35 (43.7%) of 80 patients with alanine aminotransferase (ALT) values and grading was significantly higher than in the LyA-negative group. LyA was more frequent in nonresponders (nonR) than in relapsers (relR) or sustained responders (susR). Lymph node volume (LyV) was significantly lower in susR than in nonR or relR (p < 0.05). Under antiviral treatment, the reduction in LyV was significantly higher in nonR (p < 0.01); in susR and relR, it was not significantly reduced. LyA totally disappeared in two patients of the susR group. Logistic regression analysis confirmed only a positive association of susR with grading and a negative association with staging (p < 0.02 and p < 0.006). In conclusion, this study suggests that US evidence of LyA is useful in evaluating the severity of a given chronic hepatitis C, but it cannot be proposed as a predictive index of response to antiviral treatment.     

Noninvasive Arrhythmia Risk Stratification in Idiopathic Dilated Cardiomyopathy: Design and First Results of the Marburg Cardiomyopathy Study

The Marburg Cardiomyopathy Study (MACAS) is a prospective, observational study designed to determine the value of the following potential noninvasive arrhythmia risk predictors in at least 200 patients with idiopathic dilated Cardiomyopathy (IDC) over a 5-year follow-up period: NYHA-class, left ventricular ejection fraction (LVEF), left ventricular end-diastolic diameter, left bundle branch block and atrial fibrillation on ECG, QT/JT dispersion on 12-lead ECG, signal-averaged ECG, ventricular arrhythmias and heart rate variability (HRV) on 24-hour Hotter ECG, baroreflex sensitivity, and microvolt T wave alternans during exercise. This article describes the findings among the first 159 patients with IDCs enrolled in MACAS until May 1998 (40 women, 119 men;age:49 ± 12 years; LVEF: 32 ± 10%). Twenty-nine patients (18%) had atrial fibrillation and 130 patients (82%) were in sinus rhythm. Patients with sinus rhythm were further stratified according to LVEF < 30% (n = 54) versus LVEF ≥ 50% (n = 76). Compared to patients with LVEF ≥ 30%, patients with LVEF < 30% more often had left bundle branch block (43% vs 25%, P < 0.05), nonsustained VT (44% vs 22%, P < 0.05), decreased HRV (SDNN: 95 ± 39 vs 128 ± 42 ms, P < 0.01), decreased baroreflex sensitivity (5.6 ± 4 vs 8.3 ± 6 ms/mmHg, P < 0.01), and T wave alternans (59% vs 37%, P < 0.05). The prognostic significance of these findings will be determined by multivariate Cox analysis at the end of a 5-year follow-up. Primary endpoints in MACAS are overall mortality and arrhythmic events (i.e., sustained VT or VF, or sudden cardiac death).     

应用组织运动二尖瓣环位移自动追踪技术评价经皮冠状动脉介入治疗后左心室整体收缩功能改变

目的探讨采用组织运动二尖瓣环位移自动追踪技术（TMAD）评价冠状动脉粥样硬化性心脏病（CAD）患者经皮冠状动脉介入术（PCI）后6个月左心室整体收缩功能改变的价值。 方法选择2012年11月至2013年12月首都医科大学附属北京天坛医院心内科住院CAD患者22例,全部经冠状动脉造影证实前降支狭窄程度≥70%、成功行PCI术、并成功追踪6个月。其中男性16例,女性6例,年龄39～67岁,平均年龄（52.8±5.5）岁;健康对照组35例,其中男性25例,女性10例,年龄33～59岁,平均年龄（50.2±9.1）岁。在心尖四腔心和两腔心切面应用双平面Simpson′s法测量左心室射血分数（LVEF）。于标准的心尖四腔心、三腔心、两腔心切面,选择连续3～5个心动周期存储动态图像（CAD患者于术前及术后6个月存储图像）,用Qlab 7.0软件进行脱机分析。测量二尖瓣环6个位点收缩期最大位移（Ds）,瓣环连线中点最大位移（D-mid）,左心室长轴缩短率（FSL）,计算6个位点Ds均值,3个切面D-mid均值、FSL均值。比较对照组与CAD组术前、后上述指标是否存在差异,分析二尖瓣环位移指标与LVEF的相关性。 结果与健康对照组比较,CAD组术前常规超声测量指标左心房前后径（LAd）、左心室舒张末内径（LVd）、左心室舒张末容积（LVEDV）、左心室收缩末容积（LVESV）增加[（3.43±0.17）cm vs（3.66±0.21）cm,（4.60±0.23）cm vs（4.89±0.43）cm,（82.51±6.22）ml vs（88.47±9.71）ml,（25.81±3.81）ml vs（38.90±7.24）ml];与健康对照组比较,左心室射血分数（LVEF）降低[（64.75±3.43）% vs （56.41±7.17）%] ,差异均有统计学意义（t=-3.24、-2.67、-2.60、-6.50、5.53,P均<0.05）。PCI术后6个月,LAd、LVd、LVEDV、LVESV降低[（3.57±0.18）cm、（4.76±0.31） cm、（86.86±8.69）ml、（37.08±8.31）ml],LVEF升高（58.85±6.19） %,与术前比较差异均有统计学意义（t=2.33、2.79、2.48、3.18、-2.12,P均<0.05）。健康对照组、CAD组术前、CAD组术后二尖瓣环6个位点Ds均值分别为（13.09±1.34） mm、（10.78±1.59） mm、（13.57±1.19）mm;3个切面D-mid均值分别为（13.75±1.59）mm、（11.36±2.63）mm、（14.23±1.48）mm;FSL均值分别为（17.32±2.41）%、（13.56±2.52）%、（16.29±1.77）% 。与对照组相比,CAD组术前二尖瓣环6个位点Ds均值、3个切面D-mid均值、FSL均值均减低,差异均有统计学意义（t值分别为4.19、4.47、4.72,P均<0.05） 。与CAD组术前比较,PCI术后6个月二尖瓣环6个位点Ds均值、3个切面D-mid均值、FSL均值均增加,差异均有统计学意义（t值分别为-7.55、-7.48、-6.82,P均<0.05） 。CAD组术后二尖瓣环6个位点Ds均值与对照组相比差异无统计学意义（t值分别为-1.47、-1.10、-1.44,P>0.05） 。CAD组PCI术后Ds均值、D-mid均值及FSL均值与LVEF均呈正相关（r值分别为0.72、0.71,0.83,P<0.001）。 结论CAD患者PCI术后左心室整体收缩功能较术前明显改善;TMAD技术可用于评估CAD患者PCI术后左心室整体功能。