Mechanism exploration on effects of cardiac sympathetic anesthesia on cardiac performance of dilated cardiomyopathy

Idiopathic dilated cardiomyopathy（IDC）is a primary myocar－dial disease of unknown cause characterized by cardiac dilatation and impaired myocardial contractil ity．There is increasing incidence of IDC in recent years．Although modern medical technology has developed a lot,IDC' s mortality is still high,which is ab out ２５percent at one year and approximately ５０percent at five years．Therefore,it presents great challe nges in this field ．We just give a report of our five －year st…     

心区交感神经阻滞对扩张型心肌病心功能改善的机制探讨

Objective To explore the mechanism of effects of cardiac sympathetic anesthesia on left ventricular ejection fraction(LVEF) and left cardiac cavity size of patients with dilated cardiomyopathy.Method 121 consecutive patients with dilated cardiomyopathy were divided into cardiac sympathetic nerve blockade group(TEA group) and control group(c group).In TEA group,5％ lidocaine was injected into thoracic epidural cavity for about 4 to 8 weeks in addition with routine therapy.In c group,only routine therapy was used.We observe the changes of LVEF and left cardiac cavity size before and after treatment in both groups. Result In TEA group,after anesthesia,LVEF was increased from(31.3± 12.8) to(47.3± 21.3),P<0.001;left ventricular end－ diastolic diameter was reduced from(69.1± 7.1)to (65.1± 8.0),P<0.001;left atrial diameter was decreased from(44.0± 6.2)to(39.4± 7.2),P< 0.001. Conclusion Cardiac sympathetic anesthesia can effectively improve the ejection performance of dilated cardiomyopathy and make the dilated cardiac cavity turn to normal level.     

超声心动图评价心区交感神经阻滞对扩张型心肌病舒张功能的影响

目的探索心区交感神经阻滞，能否改善扩张型心肌病的舒张功能。方法60例扩张型心肌病患者随机分为治疗组30例和对照组30例。治疗组于胸椎3～4或4～5脊突间隙穿刺留管，0．5％利多卡因每2h推注3～5ml(除夜间睡眠外)，4周为一疗程(加用常规药物)。对照组除不用心区交感神经阻滞，余同治疗组。应用多普勒超声心动图测量每组治疗前后舒张功能指标。结果①治疗组症状体征缓解迅速，而对照组缓解较慢，有的患者无效甚至加重。②治疗组舒张充盈模式改善者13例，加重者1例，其余16例舒张充盈模式未变，但也有模式改善趋势。其中15例限制型充盈模式中6例改善为假性正常模式；9例假性正常充盈模式中4例改善为延迟舒张充盈模式；6例延迟舒张充盈模式中3例改善为正常充盈模式；只有1例由假性正常充盈模式进展为限制型充盈模式。而对照组舒张充盈模式改善者1例，加重者9例，其余20例舒张充盈模式未变。其中1例由延迟舒张充盈模式改善为正常充盈模式，2例由延迟舒张充盈模式进展为假性正常充盈模式，7例由假性正常充盈模式进展为限制型充盈模式。结论心区交感神经阻滞能改善扩张型心肌病的舒张功能，对扩张型心肌病有益。     

心区交感神经阻滞对扩张型心肌病左室重塑的影响

目的　探讨心区交感神经阻滞对扩张型心肌病 (dilatedcardiomyopathy,DCM)左室重塑的影响 ,以寻求DCM治疗新法。方法　 2 0 0 0年 5月至 2 0 0 2年 5月临床诊断为DCM患者 6 0例 (符合WHO标准 ) ,随机分成治疗组和对照组。治疗组实施上胸段硬膜外阻滞 ,4周一疗程 ,适当辅以常规药物。对照组仅给予常规药物治疗。应用彩色多普勒超声诊断仪常规方法测量左室重塑指标。结果　治疗组症状体征缓解迅速 ,而对照组缓解较慢 ,有的患者无效甚至加重。治疗组收缩功能提高 ,左室重塑指标得以改善[LVEDD (71 7± 9 3)mmvs (6 6 2± 8 8)mm ,EF (31 1± 17 0 ) %vs (36 6± 12 0 ) % ,FS (12 0± 1 0 ) %vs(15 0± 3 0 ) % ,LVEDV (393 3± 14 4 8)mlvs (343 2± 137 1)ml,LVESV (2 82 5± 12 1 1)mlvs (2 2 7 3±10 8 6 )ml,LVmass (394 3± 10 0 7)gvs (372 1± 93 2 )g,P <0 0 5 ],而对照组无改善。结论　心区交感神经阻滞治疗DCM能中止并逆转DCM左室重塑。     

高位硬膜外阻滞对扩张型心肌病心脏收缩功能的延迟作用

目的　探讨高位硬膜外阻滞 (TEB)治疗停止后扩张型心肌病患者心脏收缩功能是否继续改善。方法　上胸段棘突间穿刺至硬膜外腔 ,留置硬膜外导管 ,0 .5 %利多卡因 3～ 5ml每 2h推注一次 ,持续 4周 ,适当辅以常规治疗。测定并比较TEB治疗停止后 16周及停止初期扩张型心肌病患者射血分数(EF)、缩短分数 (FS)。结果　 16周后EF值由 2 8.2 1%± 7.2 2 %升为 34.5 4%± 6 .16 %(P =0 .0 195 ) ,FS由 10 .5 7%± 2 .98%升为 13.43%± 3.18%(P =0 .0 2 12 )。结论　高位硬膜外阻滞治疗停止后扩张型心肌病患者心脏收缩功能继续改善 ,该方法对扩张型心肌病患者心脏收缩功能改善具有延迟作用。     

组织多普勒超声评价交感神经阻滞对扩张型心肌病左心室心肌收缩力的影响

目的观察心交感神经阻滞对扩张型心肌病左心室心肌收缩力的影响。方法随机选取30例扩张型心肌病患者,分为对照组(16例)和治疗组(14例)。对照组给予常规抗心力衰竭治疗,治疗组在给予对照组治疗的同时,以0.5%利多卡因每2h经硬膜外导管推注一次(夜间睡眠除外),阻滞心区交感神经(胸1-5)。所有患者于治疗前和治疗后1个月行经胸心脏超声检查,测量左心房收缩末期内径(LAD),左心室舒张末期内径(LVEDd),短轴缩短率(FS),射血分数(EF),二尖瓣环后间隔、侧壁、前壁、下壁、前间隔、后壁的组织峰值收缩速度(Sm)和运动距离(D),计算6个位点的峰值收缩速度和运动距离平均值(MSm和MD),比较两组上述指标的差异。结果治疗组LAD和LVEDd均显著缩小,EF和FS明显增加,对照组上述指标无显著改善。同对照组比,治疗组MSm和MD均显著增加[MSm(4.91±0.56)cm/s对(4.09±0.82)cm/s,P<0.05;MD(0.61±0.18)cm对(0.41±0.18)cm,P<0.05]。左心室射血分数改善与MSm和MD的变化显著相关(MSmr=0.576,P=0.001;MDr=0.526,P=0.003)。结论对于扩张型心肌病,心区交感神经阻滞较常规治疗能显著缩小左心腔径,尤为突出的是它能更有力地增强心肌的收缩力,改善左心室收缩功能。     

卡维地洛改善扩张型心肌病心力衰竭的心功能

目的观察卡维地洛对扩张型心肌病 (DCM)、心力衰竭的临床疗效。方法 60例DCM并心力衰竭患者在利尿剂、洋地黄、ACEI及硝酸盐制剂治疗的基础上 ,随机分为卡维地洛治疗组及常规治疗组 (每组 3 0例 )。治疗前及 4月启用超声心动图测左室缩短分数 (FS) ,射血分数 (EF)、左室舒张末内径 (LVDD)、室间隔厚度 (IVS)和左室后壁厚度 (LVPW)。结果治疗 4月后 ,两组心功能明显改善。卡维地洛组LVDD[61.5± 6.6与 67.3± 6.2 ,P <0 .0 5 ]、EF[4 8± 9.7与 40 .3±6.2 ,P <0 .0 5 ]、D/T[4 .1± 0 .7与 4.6± 0 .5 ,P <0 .0 5 ]显著改善。结论卡维地洛能显著改善DCM心力衰竭心功能及心肌重构     

阿托伐他汀对扩张型心肌病患者细胞因子及心功能的影响

目的研究阿托伐他汀对扩张型心肌病患者血清细胞因子水平及心功能的影响，探讨他汀类药物应用于非缺血性心肌病的可行性。方法69例心功能NYHAⅠ、Ⅱ级的扩张型心肌病患者随机分为2组。阿托伐他汀组（35例）每日口服立普妥20mg，对照组（34例）不服用降脂药物。于实验开始及6个月结束时采用酶联免疫吸附法测定血清肿瘤坏死因子-α（TNF—α）、白细胞介素石（IL-6）水平；采用全自动免疫分析系统测定血清超敏C-反应蛋白（hs—CRP）水平，并测定血清总胆固醇（TC）、低密度脂蛋白胆固醇（LDL-C）、甘油三酯（TG）等水平的变化；通过超声心动图评价左心室舒张末期内径（LVEDD）、短轴缩短率（FS）、左心室舒张末期容积（LVEDV）、左心室收缩末期容积（LVESV）及射血分数（EF）。结果①阿托伐他汀组较对照组TNF—α、IL-6、hs—CRP、TC、LDL-C水平及TC／HDL—C明显降低（均P〈0．01）；②阿托伐他汀组较对照组LVESV明显减低（P〈0．05），而FS、EF明显增高（均P〈0．01）。结论短期应用阿托伐他汀可以改善扩张型心肌病患者的心功能，降低血清炎性细胞因子和炎症标志物的水平。阿托伐他汀很可能成为治疗非缺血性心肌病的又一有效药物。     

Genetics of dilated cardiomyopathy

Dilated cardiomyopathy (DCM) is a myocardial disease characterized by dilatation and impaired systolic function of the left or both ventricles. The etiology of DCM is multifactorial, and many different clinical conditions can lead to the phenotype of DCM. During recent years it has become evident that genetic factors play an important role in the etiology and pathogenesis of idiopathic DCM. The genetics of DCM have been under intensive investigation lately, and thereby the knowledge on the genetic basis of DCM has increased rapidly. The genetic background of the disease seems to be relatively heterogeneous, and the disease-associated mutations concern mostly single families and only few affected patients. Disease-associated mutations have been detected e.g. in genes encoding sarcomere, cytoskeletal, and nuclear proteins, as well as proteins involved with regulation of Ca(2+) metabolism. The mechanisms, by which mutations eventually result in clinical heart failure, are complex and not yet totally resolved. DCM causes considerable morbidity and mortality. Better knowledge of the genetic background and disease-causing mechanisms would probably help us in focusing early treatment on right subjects and potentially also developing new treatment modalities and improving cardiac outcome in the affected patients. This review deals with DCM of genetic origin.     

Epidemiology of dilated cardiomyopathy and hypertrophic cardiomyopathy

Epidemiological study in Akita City revealed that the Japanese prevalence of dilated cardiomyopathy was 12.5 per 100,000 population at the end of 1994, and the mean age of patients with dilated cardiomyopathy was 63 +/- 12 years. The prevalence was comparable with that of 9.03 per 100,000 population in Niigata Prefecture and with that of 15 per 100,000 population by the echocardiographic mass screening in 2,673 subjects from 12 Japanese rural areas. The prevalence of hypertrophic cardiomyopathy in Japan was 170 to 574 per 100,000 population by mass screening. In future, the genetic analysis may compensate the limitation of morphological diagnosis of cardiomyopathies and also reveal new aspects of these disorders.     

三维斑点追踪成像对扩张型心肌病患者再同步化治疗后疗效的评价

目的 探讨三维斑点追踪成像(3D-STI)技术评价扩张型心肌病患者心脏再同步化治疗(CRT)后左心功能及心肌非同步运动变化的价值.方法 应用3D-STI对25例正常人及21例扩张型心肌病(DCM)患者行CRT术前后左心功能及心肌非同步运动指标进行检测,指标包括左室平均长轴应变(MLS)、平均圆周应变(MCS)、平均径向应变(MRS)、射血分数(3D-LVEF)及左室16节段面积应变达峰时间最大差(A-MaxTs)和标准差(A-Ts-SD),并与放射性核素测量的左室射血分数(ECT-LVEF)及左心室相角程(LVW)进行相关分析.结果 与正常人比较,DCM患者MLS、MCS、MRS、3D-LVEF减低,AMaxTs、A-Ts-SD延长.CRT术后1周,DCM患者MRS、ECT-LVEF较术前稍有改善(P＜0.05),其余参数较术前差异无统计学意义(P＞0.05).术后6个月MLS、MCS、MRS、A-MaxTs、A-Ts-SD、3D-LVEF较术前及术后1周均有所改善(P＜0.05).相关分析显示DCM患者MLS、MCS、MRS、3D-LVEF与ECTLVEF相关,A-MaxTs、A-Ts-SD与LVW相关.结论 3D-STI简便、准确,可用于评价DCM患者CRT后左心功能及心肌非同步运动的变化,为临床提供有价值参考.     

组织同步显像技术在扩张型心肌病心脏同步化治疗的临床应用

目的 探讨常规超声心动图及组织同步显像（TSI）技术在扩张型心肌病心脏同步化治疗（CRT）前、后的临床应用价值.方法 53例CRT治疗的扩张型心肌病患者,于CRT术前3d、术后1周、3个月和6个月在超声心动图指导下进行个体化参数程控,观察CRT前后不同起搏参数时各指标变化.结果 CRT治疗后左心室发生逆重构,其中术后3个月及6个月左心室舒张末期内径、左心室舒张末期容积明显小于术前（P＜0.01,P＜0.05）,左心室舒张充盈时间增加,二尖瓣反流量减少,LVEF明显提高（P＜0.01）,重度延迟节段数减少,节段数量由术前的3.1±1.3减少至6个月的1.5±1.4（P ＜0.01）,左心室起搏电极所在节段的达峰时间有的回复到正常范围,收缩峰值速度亦有改善,但仍没有到正常水平,12节段达峰时间标准差（Ts-SD）由术前的（139±33）ms缩短至（110±40）ms,差异有统计学意义（P＜o.01）.结论 常规超声心动图和TSI技术是预测评价CRT疗效的临床应用最简便有效的方法,是参与CRT全程的一种无创、准确的检查手段.     

氟伐他汀对扩张型心肌病患者血炎症介质及心功能的影响

目的研究氟伐他汀对扩张型心肌病患者血清细胞因子水平及心功能的影响。方法心功能Ⅱ、Ⅲ级的扩张型心肌病患者随机分为2组．氟伐他汀组（n=32例）每日口服氟伐他汀40mg，对照组（30例）不用降脂药物：于研究开始及6个月结束时监测血清肿瘤坏死因子d（TNF—d1、白细胞介素-6（IL-6）、血清超敏C反应蛋白（hs—CRP）水平．监测肝酶及肌酶变化及左心室射血分数（LVEF）。结果氟伐他汀组及对照组治疗后的LVEF均较治疗前明显改善．差异有统计学意义（t分别=5．75、6．78，P均〈0．05）；两组的血TNF—a、IL-6及hs—CRP水平在治疗前后比较，差异均无统计学意义（t分别=1．37、O．46、1．73、0.37、0．63、0．46，P均〉0．05）；但对于心功能Ⅲ级患者氟伐他汀组能显著降低血TNF—a、IL-6水平（t分别=2，55、2．77，P均〈0．05），与对照组治疗后比较，差异也有统计学意义（t分别=2．13、2．05，P均〈0．05）。治疗后的氟伐他汀组LVEF较对照组明显提高（t=2．80，P〈0．05）。结论对心功能Ⅲ级的扩张型心肌病患者使用氟伐他汀治疗有一定的治疗价值，但对扩张型心肌病患者中常规缺乏依据。     

扩张型心肌病行心脏再同步化治疗的护理体会

目的 探讨扩张型心肌病行心脏再同步化治疗的护理.方法 选取14例扩张型心肌病行心脏再同步化治疗的住院患者,对其护理方法进行探讨和总结.结果 本组病例均安全度过围术期,心衰症状改善,生活质量明显提高.结论 充分的术前准备、严密的术后观察、有效的护理及随访是扩张型心肌病行心脏再同步化治疗成功的关键.     

Genetics of dilated cardiomyopathy

Dilated cardiomyopathy (DCM) is a myocardial disease characterized by dilatation and impaired systolic function of the left or both ventricles. The etiology of DCM is multifactorial, and many different clinical conditions can lead to the phenotype of DCM. During recent years it has become evident that genetic factors play an important role in the etiology and pathogenesis of idiopathic DCM. The genetics of DCM have been under intensive investigation lately, and thereby the knowledge on the genetic basis of DCM has increased rapidly. The genetic background of the disease seems to be relatively heterogeneous, and the disease‐associated mutations concern mostly single families and only few affected patients. Disease‐associated mutations have been detected e.g. in genes encoding sarcomere, cytoskeletal, and nuclear proteins, as well as proteins involved with regulation of Ca²⁺ metabolism. The mechanisms, by which mutations eventually result in clinical heart failure, are complex and not yet totally resolved. DCM causes considerable morbidity and mortality. Better knowledge of the genetic background and disease‐causing mechanisms would probably help us in focusing early treatment on right subjects and potentially also developing new treatment modalities and improving cardiac outcome in the affected patients. This review deals with DCM of genetic origin.     

Features of mildly dilated congestive cardiomyopathy compared with idiopathic restrictive cardiomyopathy and typical dilated cardiomyopathy

Congestive cardiomyopathy was recognized in eight patients with only mildly dilated ventricles (an echocardiographic ventricular diastolic dimension index of less than 10% to 15% above the normal range) but with other features typical of end-stage congestive cardiomyopathy. Such patients with mildly dilated cardiomyopathy (MDCM) represented 5% of heart transplant recipients with cardiomyopathy, who were analyzed by us. The clinical, echocardiographic, and hemodynamic data, as well as the gross and microscopic pathologic findings of the hearts in this group were compared with similar data in five patients with idiopathic restrictive cardiomyopathy (IRCM) and 10 patients with typical dilated cardiomyopathy (DCM). Compared with IRCM and DCM, patients with MDCM had a higher incidence of familial cardiomyopathy (p less than 0.009). The echocardiographic features of patients with MDCM and DCM were virtually identical, showing globular hearts with predominant left ventricular dilation and diffuse poor left ventricular contraction. Patients with IRCM had marked atrial dilation but less abnormality of left ventricular size and contraction parameters. On the basis of echocardiographic data, patients with IRCM and MDCM could be well segregated. Cardiac index and light microscopic examinations were similar in the three groups. However, electron microscopy showed a lack of myofibrillar loss in patients with IRCM, little or no myofibrillar loss in those with MDCM, and almost total myofibrillar loss in those with DCM. Patients with MDCM have a high prevalence of familial cardiomyopathy. Absolute heart size and electron microscopic features of the MDCM group were intermediate between IRCM and DCM, but other clinical, echocardiographic and hemodynamic findings were similar to typical DCM.     

Amplified effects of d,l-sotalol in canine dilated cardiomyopathy

Despite the presence of well-described cardiac repolarization abnormalities in heart failure, d,l-sotalol effects on cardiac repolarization have not been evaluated in animal models of CHF. The authors hypothesized that the d,l-sotalol effects on cardiac repolarization are altered in canine dilated cardiomyopathy when compared to controls. Effects of d,l-sotalol were compared in seven dogs with tachycardia induced cardiomyopathy (CHF) and six control animals. In an open-chest model, contact monophasic action potential recordings were obtained from RV and LV endocardium/epicardium during and after two doses of d,l-sotalol (1 mg/kg and 3 mg/kg, each over 20 minutes). Effects of d,l-sotalol on action potential duration at 90% repolarization (APD90) were examined at pacing cycle lengths of 300-1,000 ms. Plasma d,l-sotalol levels were measured at baseline, 10, and 40 minutes following each dose. Prolongation of APD90 by d,l-sotalol, was significantly exaggerated in CHF animals versus controls (P < 0.05, ANOVA). These differences were magnified at slow heart rates (P < 0.05, ANOVA). There were no significant differences in plasma d,l-sotalol levels between the two groups. Effects of d,l-sotalol on cardiac repolarization are exaggerated in CHF without significant alterations in plasma drug levels. While using d,l-sotalol in heart failure, independent additional effects due to ventricular electrical remodeling may be a consideration.     

速度向量成像技术对扩张型心肌病心脏扭转运动的研究

目的 应用速度向量成像技术定量分析扩张型心肌病(DCM)患者左心室扭转运动,探讨该技术在心脏扭转运动研究中的应用价值.方法 应用速度向量成像技术测量27例DCM患者与60例正常对照者左室内径及心功能,并于心底部与心尖部短轴观分别获取两个切面心内膜与心外膜旋转角度、旋转速度曲线.结果 DCM组心功能明显低于对照组(P＜0.01),心底部与心尖部旋转角度和旋转速度、心内膜与心外膜旋转角度和旋转速度DCM组均明显低于对照组(P＜0.01).结论 速度向量成像可快速、无创、定量评价DCM患者左室扭转运动,为了解DCM心脏运动特征提供了新的方法 .