Correlation between left ventricular contractility and relaxation in patients with idiopathic dilated cardiomyopathy

Background and hypothesis: It is not fully understood whether alterations in left ventricular (LV) relaxation in patients with idiopathic dilated cardiomyopathy (DCM) precede or follow alterations in LV systolic function. Accordingly, we investigated the relationship between LV systole and diastolic relaxation in patients with DCM using LV pressure-volume analysis. Methods: Hemodynamic data were collected for 38 consecutive patients with DCM in normal sinus rhythm and in the resting steady state (New York Heart Association functional class II to III). Continuous simultaneous pressure-volume relationships were obtained by conductance catheter. Left ventricular end-systolic elastance (Ees) was determined during transient occlusion of the inferior vena cava. Results: Left ventricular ejection fraction, peak negative dP/dt, and peak positive dP/dt were depressed (31 ± 11%, - 1242 ± 351 mmHg/s, and 1118 ±253 mmHg/s, respectively ). The LV end-diastolic volume index, the time constants of isovolumic LV pressure decay Tl and Td were increased (141 ±38 ml/m², 54+14 ms, and 69 ± 17 ms, respectively). Ees was markedly depressed (0.9 ± 0.5 mmHg/ml) and was not correlated with established systolic or diastolic indices except for peak positive dP/dt. Our results showed that abnormalities of relaxation were not correlated with contractile dysfunction in patients with DCM in the resting steady state however, most patients (79%) had both prolonged relaxation and extremely depressed contractility. Abnormal relaxation may have been transient or compensated in some patients (21%) with DCM who had preserved relaxation despite severely depressed contractility.     

Effect of arotinolol on right ventricular function in patients with dilated cardiomyopathy

Objective Dilated cardiomyopathy (DCM) is generally considered to be accompanied by both left and right ventricular dysfunction,but most studies only analyze the left ventricular function. In this study, we evaluated the effect of arotinolol on right ventricular function in patients with DCM. Methods Right ventricular ejection fraction (RVEF) and right ventricular diameter (RVD) were measured by two-dimensional echocardiography (2-DE) in 33 DCM patients; RVEF measured by first-pass radionuclide angiography (FPRA) was compared with that by 2-DE. Results The treatment with arotinolol for one year resulted in a reduction in the right ventricular diameter (baseline, 23.0 ± 8.3 mm vs after one-year treatment, 20.7 ± 5.4 mm; P=0.004 ) and an associated increase in ejection fraction (baseline, 36.9 ± 10.3% vs after one-year treatment, 45.8 ± 9.6%; P ＜ 0.001 ); there is a high correlation between the 2-DE method and radionuclide ventriculographic method. The correlation coefficient is 0.933 (P＜0.001). Conclusion Arotinolol therapy could not only improve left ventricular function, but also improve right ventricular function in DCM patients.     

Pathophysiologic significance of left ventricular hypertrophy in dilated cardiomyopathy

Background and hypothesis: Patients with dilated cardiomyopathy (DCM) with left ventricular hypertrophy (LVH) have been found to have a better prognosis than patients without LVH. However, the pathophysiologic mechanism for that has not been investigated. We sought to clarify the pathophysiologic significance of LVH in DCM. Methods: We performed isoproterenol infusion echocar-diography (0.02 m?g/kg/min) in 17 patients with DCM, and measured plasma epinephrine and norepinephrine levels at rest and at the end of ergometer exercise in 14 of the 17 patients. Patients were classified into groups according to the presence (9 patients) (LVH+) or absence (8 patients) (LVH-) of LVH. Left ventricular hypertrophy was defined as an inter-ventricular thickness or posterior wall thickness ≥13 mm. Results: Although there was no significant difference between groups in fractional shortening at rest during isoproterenol infusion, fractional shortening was significantly higher in the LVH (+) group than in the LVH (-) group (29 ± 9 vs. 17 ± 8%;p<0.025). Although there was no significant difference in plasma norepinephrine level, it was significantly lower in the LVH (+) group than in the LVH (-) group (233 ± 169 vs. 519 ± 258 pg/ml;p<0.05) at the end point of the exercise. Conclusion: Systolic reserve, represented by the response to isoproterenol, is greater in patients with DCM with LVH than in those without LVH, and a lower plasma level of norepinephrine is needed to activate the myocardium during ex ercise in patients with DCM with LVH. This pathophysiologic characteristic could be one of the mechanisms which explain a better prognosis in patients with DCM with LVH.     

阿罗洛尔对扩张型心肌病心力衰竭患者右心室功能的影响

目的 评价扩张型心肌病(DCM)心力衰竭患者阿罗洛尔治疗前后右心室功能的改善情况.方法 采用二维超声心动图(2-DE)、核素心血池显像2种方法对2000年9月至2004年12月中国医学科学院阜外心血管病医院收治的33例DCM心力衰竭患者的右室射血分数(RVEF)等指标进行右心室功能评价.结果 DCM患者经阿罗洛尔治疗1年后,RVEF由治疗前的(36.9±10.3)%增至治疗后的(45.8±9.6)%(P＜0.001);右心室内径(RVD)由治疗前的(23.0±8.3)mm缩小至治疗后(20.7±5.4)mm(P＜0.01).2-DE测量的RVEF与核素心血池显像法的测量结果 高度相关,相关系数r=0.933(P＜0.001).结论 阿罗洛尔在增加DCM心力衰竭患者左室射血分数(LVEF)的基础上,可增加RVEF、缩小RVD,逆转右心室重构,对DCM心力衰竭患者右心室功能有一定的改善作用.     

Effect of xamoterol on exercise capacity and left ventricular function in angina pectoris and in dilated cardiomyopathy

The present study evaluates the effect of the beta 1 partial agonist xamoterol in patients with coronary artery disease compared to the effect in patients with dilated cardiomyopathy. Nineteen patients with angina pectoris and nine patients with dilated cardiomyopathy received xamoterol 200 mg b.i.d. for 4 weeks in a placebo-controlled double-blind study. The effect was evaluated with a standardized exercise test and radionuclide angiocardiography with determination of global and regional ejection fraction. At rest xamoterol caused no significant changes among the angina patients while global and regional ejection fraction increased among the cardiomyopathy patients. During exercise, when the drug exerts a beta 1-antagonist effect, xamoterol increased the exercise performance among the angina pectoris patients. Fourteen out of 19 patients with angina pectoris were unable to increase their ejection fraction from rest to work due to coronary ischaemia. These 14 patients improved their global ejection fraction during work after xamoterol treatment.     

A 17-year-old Male with Duchenne muscular dystrophy complicated with dilated cardiomyopathy and large left ventricular mural thrombosis

Background Heart failure is one of the main causes of death due to progressive muscular dystrophy of Duchenne muscular dystrophy (DMD) in the majority of the cases. There is high incidence of arterial thromboembolism in DMD patients with severe heart failure. However, it has been receiving little attention whether anticoagulative therapy in DMD patients with severe heart failure in sinus rhythm should be performed. Herein we present a case of DMD patients, with severe heart failure in sinus rhythm, who pres...     

Prognostic value of pulsed tissue Doppler imaging for the assessment of left ventricular systolic function in patients with nonischemic dilated cardiomyopathy

There is still some debate regarding the prognostic significance of left ventricular longitudinal systolic dysfunction as assessed by tissue Doppler (TD) imaging in patients with chronic heart failure (HF), since previous studies have included patients with postischemic wall motion abnormalities. Thus, this study was designed to ascertain whether TD-derived longitudinal systolic dysfunction may influence the outcome of patients with nonischemic chronic HF. In 200 consecutive patients with chronic HF secondary to dilated cardiomyopathy and no history of ischemic heart disease, peak systolic mitral annular velocity (S(m) ) was measured by pulsed TD at the septal and lateral annular sites. The end points were cardiac death or hospitalization for worsening HF. Mean follow-up duration was 30 months. In a time independent analysis, averaged S(m) calculated as the average of septal and lateral S(m) , resulted to be a significant predictor of outcome in the study population (area under receiver-operator characteristic curve: cardiovascular death, 0.69, P < 0.0001; cardiovascular events, 0.64, P = 0.0005). In a time-dependent analysis, average S(m) was associated with both cardiovascular death (hazard ratio 0.832, P = 0.0019) and cardiovascular events (hazard ratio 0.904, P = 0.039), independently of other clinical risk factors and echocardiographic parameters of systolic function. Septal S(m) but not lateral S(m) was independently associated with the outcome measures. In conclusion, the assessment of systolic mitral annular velocity by pulsed TD is a useful indicator for prognostic stratification of patients with nonischemic dilated cardiomyopathy and chronic HF.     

Cardioprotective effects of trimetazidine on patients with dilated cardiomyopathy and left bundle branch block

Background The effects of trimetazidine on patients with dilated cardiomyopathy(DCM) and left bundle branch block(LBBB) are not clear. Methods Sixty consecutive patients with DCM, LBBB and heart dysfunction(35% ≤ LVEF ≤ 45%) were randomly allocated to heart failure therapy plus trimetazidine group(20 mg three times a day; 30 patients) or heart failure therapy alone group(30 patients). During follow-up of 6months, QRS morphology, plasma NT-proBNP, 6-minute walk test(6MWT) and echocardiographic indexes were measured. Results At the 6th month, a significant functional improvement was noted in patients receiving trimetazidine added to heart failure treatment. In patients from the trimetazidine group, an increase of left ventricular ejection fraction(LVEF) was noted(from 38 ± 5.5% to 47 ± 7.1%, P = 0.020). The increase of LVEF in the trimetazidine group was associated with a more significant reduction of the left ventricular endsystolic diameter(LVESD) compared with the control group at 6-month follow-up. The NT-pro BNP levels decreased significantly in the trimetazidine group(3.11 ± 0.47 at baseline and 2.77 ± 0.45 at 6-month followup, P 0.01) and the 6MWT increased significantly in the trimetazidine group(325 ± 44 m at baseline and419 ± 56 m at 6-month follow-up, P 0.01). The differences in NT-pro BNP levels(2.77 ± 0.45 vs 2.96 ±0.46, P = 0.036) and 6MWT(419 ± 56 m vs 366 ± 54 m, P = 0.032) between the two groups were significant at 6-month follow-up. Conclusions Trimetazidine can improve LV function caused by DCM and LBBB. The positive effects of trimetazidine on LV function are especially evident in patients with optimization of drug therapy for heart failure, which strongly suggests an additive effect of these therapy modalities.     

Comparison of noninvasive measures of contractility in dilated cardiomyopathy

Left ventricular performance is usually quantified by ejection phase indices such as ejection fraction, cardiac output, and fractional shortening. The load-dependence of these measures may result in inaccurate estimation of intrinsic myocardial contractility in states of chronic pressure or volume overload. End-systolic and stress-shortening relations have been proposed as measures of contractile state insofar as they are theoretically independent of preload and incorporate afterload. This article examines the behavior of these relations in response to changes in loading conditions and contractile state and reviews their application utilizing noninvasive methodology, particularly in the setting of dilated cardiomyopathy.     

Myocardial histological changes in dilated cardiomyopathy during a long-term left ventricular assist device support

Summary As the myocardium in patients with dilated cardiomyopathy (DCM) is deteriorating progressively, resulting in a decrease in left ventricular function, patients with end-stage DCM may require implantation of a left ventricular assist device (LVAD) unless they undergo heart transplantation. Although LVAD has been reported to provide excellent hemodynamic support, no data are currently available about the effects of long-term LVAD support on the myocardium in patients with DCM. We describe two patients with end-stage DCM who underwent LVAD implantation and were supported with LVAD for 524 and 245 days, respectively. Serial myocardial biopsies showed increases in myocardial cell diameter and intercellular fibrosis, despite excellent hemodynamic support by LVAD. These data suggest that the myocardium in patients with end-stage DCM deteriorates progressively, even if the preload of the left ventricle is reduced by LVAD.     

曲美他嗪治疗扩张型心肌病患者左心功能不全的疗效观察

目的评价曲美他嗪对扩张型心肌病患者左心功能不全的治疗效果。方法选择冠状动脉造影正常的78例患者，左室射血分数（LVEF）％40％，左室扩大、左心室舒张末期左室内径（LVDD）在（63．61±10．32）mm，心功能Ⅱ～Ⅳ级（NYHA）。随机将患者分为治疗组40例，对照组38例，治疗组在常规治疗基础上加用曲美他嗪20mg3次／d，服用6个月，对照组仅用常规治疗。治疗前、治疗后1个月、6个月观察患者临床情况及多普勒超声指标的变化。结果LVEF由（31．8±6．1）％上升至（41．3±10．3）％，较治疗前明显提高（P〈0．01），与对照组比较也有显著提高（P〈0．05），运动耐量（NYHA分级）较治疗前明显改善（P〈0．001），与对照组比差异显著（P〈0．01）。LVDD两组都较治疗前明显下降（P〈0．01），组间差异不显著（P〉0．05）。结论在常规治疗基础上加用曲美他嗪长期治疗，可明显改善扩张型心肌病患者的左心功能，增加患者运动耐量。     

Partial left ventriculectomy improves left ventricular end systolic elastance in patients with idiopathic dilated cardiomyopathy

OBJECTIVE: To assess the effect of partial left ventriculectomy (PLV) on estimate of left ventricular end systolic elastance (Ees), arterial elastance, and ventriculoarterial coupling. PATIENTS: 11 patients with idiopathic dilated cardiomyopathy before and two weeks after PLV, and 11 controls. INTERVENTIONS: Single plane left ventricular angiography with simultaneous measurements of femoral artery pressure was performed during right heart pacing before and after load reduction. RESULTS: PLV increased mean (SD) Ees from 0.52 (0.27) to 1.47 (0.62) mm Hg/ml (p = 0.0004). The increase in Ees remained significant after correction for the change in left ventricular mass (p = 0.004) and end diastolic volume (p = 0.048). As PLV had no effect on arterial elastance, ventriculoarterial coupling improved from 3.25 (2.17) to 1.01 (0.93) (p = 0.017), thereby maximising left ventricular stroke work. CONCLUSION: It appears that PLV improves both Ees and ventriculoarterial coupling, thus increasing left ventricular work efficiency.     

扩张型心肌病血清Ⅰ型、Ⅲ型前胶原水平与左室结构及收缩功能的关系

目的研究扩张型心肌病（IDCM）血清Ⅰ型、Ⅲ型前胶原（PCⅠ、PCⅢ）水平与左室结构及收缩功能的关系。方法IDCM患者53例,健康人32例为对照组,应用放射免疫法测定血清PCⅠ、PCⅢ,应用超声心动仪测量左室结构指标及左室射血分数（LVEF）。分析IDCM血清PCⅠ、PCⅢ与左室结构指标、LVEF关系。结果IDCM组血清PCⅠ、PCⅢ高于对照组（P<0.01）。简单线性相关分析揭示IDCM血清PCⅠ、PCⅢ分别与舒张末期左室内径、左室质量指数（LVMI）正相关（P<0.05）,与LVEF负相关（P<0.01）。多元逐步回归分析显示血清PCⅠ、PCⅢ分别与LVEF负相关,与左室结构指标无相关性（P>0.05）。结论IDCM血清PCⅠ、PCⅢ升高;反映左室收缩功能降低。     

Reduced early diastolic inflow velocities in the antero-posterior transverse direction in the left ventricle of patients with dilated cardiomyopathy

In patients with dilated cardiomyopathy (DCM), the left ventricular (LV) inflow jet is narrow and has a high pressure gradient. A pulsed Doppler restrictive transmitral flow pattern is a characteristic feature of severe left ventricular disease. However, Doppler flow analysis is limited by the angle between the blood flow jet and the ultrasonic beam. In this study we used gated magnetic resonance imaging (MRI) to investigate the inflow velocity in the LV transverse directions during early diastole in patients with DCM. Methods: We studied 10 patients with DCM (mean age: 47 y). Ten age-matched healthy volunteers were also examined. Gradient echo images of the LV were obtained. Left ventricular short axis phase contrast images were obtained at the level of the mitral valve tip and 1 cm inside the LV. Long axis images were also obtained. Through-plane peak velocities at peak early diastolic filling were measured along the LV long axis, antero-posterior short axis, and right-left short axis. Blood velocity was measured in 50 ms blocks. Results: Early diastolic inflow velocity along the long axis, especially at the center of the LV, was well preserved in DCM. However, the inflow velocity in the antero-posterior transverse direction of the LV (i.e., in the direction of mitral valve excursion) was significantly reduced in DCM. Conclusions: Early diastolic inflow velocity in the antero-posterior transverse direction of the LV is reduced in patients with DCM indicating that the vector component of the forces acting in the antero-posterior transverse direction of the LV may be decreased in patients with DCM during early diastolic filling.     

中青年扩张型心肌病伴心力衰竭患者心功能的临床研究

目的探讨青年人扩张型心肌病伴或不伴心力衰竭与心脏功能关系及临床意义。方法对我院扩张型心肌病伴有心力衰竭患者65例（心力衰竭组）和不伴有心力衰竭患者58例（非心力衰竭组）给予超声心动图、心电图检查。比较两组心脏的大小、功能以及发生心律失常的情况。结果①心力衰竭组的左心室收缩末内径（LVESd）、左心室舒张末内径（LVEDd）、左心房内径（LAD）、左心室射血分数（LVEF）,左心室短轴缩短分数（LVFS）与非心力衰竭组比较,差异有统计学意义（P〈0.01）。②心力衰竭组在心电图上的QRS时限、肢导低电压、异常Q波、ST-T改变的比例略高于非心力衰竭组,差异无统计学意义（P〉0.05）。心力衰竭组的房性心律失常、室性心律失常和传导阻滞发生率与非心力衰竭组比较,差异有统计学意义（P〈0.01）。③心力衰竭组患者入院时心脏功能Ⅲ级、Ⅳ级分别占58.4%、21.5%。两组经住院治疗后,心脏功能较入院时明显改善（P〈0.05）。结论扩张型心肌病伴心力衰竭、心律失常时,LVEDd明显增大,LVEF显著降低,并与心脏功能有一定的相关性。早期诊断和治疗,除去心力衰竭诱发因素,能够改善心脏功能,提高患者的生活质量,改善预后。     

扩张型心肌病患者心外膜脂肪厚度与左心室重构的相关性

目的研究扩张型心肌病(DCM)患者心外膜脂肪厚度与左心室重构及左心室功能不全的关系。方法收集DCM患者120例(DCM组)和健康体检者76例(对照组),应用常规心脏超声测量左心室收缩末内径(LVESD)、左心室舒张末内径(LVEDD)、左心室收缩末容积(LVESV)、左心室舒张末容积(LVEDV)、左心室收缩末容积指数(LVESVI)、左心室舒张末容积指数(LVEDVI)、左心室收缩末球形指数(SIs)、左心室舒张末球形指数(SId)、LVEF、心外膜脂肪厚度等,比较2组各超声指标的关系。结果 DCM组LVESD[(53.0±9.6)mmvs(33.2±4.5)mm]、LVEDD[(68.5±9.3)mmvs(38.3±3.0)mm]、LVESV[(79.5±13.6)ml vs(42.0±10.5)ml]、LVEDV[(165.0±18.6)ml vs(98.2±14.0)ml]、LVESVI[(49.2±10.7)ml/m2 vs(30.6±9.6)ml/m2]、LVEDVI[(101.8±10.0)ml/m2 vs(61.4±9.0)ml/m2]较对照组明显增高,LVEF[(31.5±7.2)%vs(64.9±6.4)%]、SIs[(1.3±0.2)vs(2.0±0.3)]、SId[(1.3±0.2)vs(1.8±0.2)]和心外膜脂肪厚度[(4.9±1.1)mmvs(7.8±2.0)mm]较对照组明显降低(P<0.05)。DCM组心外膜脂肪厚度与LVESD、LVEDD、LVESV、LVEDV、LVEDVI、LVESVI、SIs、SId呈正相关(P<0.05)。结论 DCM患者的心外膜脂肪厚度与左心室重构明显相关,与左心室功能不全无相关性。     

Frequency, prognosis and predictors of improvement of systolic left ventricular function in patients with 'classical' clinical diagnosis of idiopathic dilated cardiomyopathy

In patients with dilated cardiomyopathy (DCM) of different aetiologies, a variable frequency of improvement in the left ventricular (LV) systolic function has been reported, while in patients with a 'classic' idiopathic DCM, the frequency of improvement is still under debate, and clinical and haemodynamic predictors of recovery of the LV function are needed. The aim of the present study was to determine the frequency of improvement in the LV systolic function in idiopathic DCM and to identify predictors of reversibility of the impaired LV contractility. A sample of 98 consecutive patients with idiopathic DCM was retrospectively evaluated. Echocardiographic and Doppler measurements were directly taken from the routine echo-report. LV systolic function was assessed semiquantitatively using a score index (SFSI). According to the improvement in the LV systolic function, the patients were divided into group 1 patients with improvement, and group 2 patients without improvement. During a follow-up of at least 12 months, 19 patients (19%) showed an improvement, with a significant increase in the mean SFSI; all these group 1 patients survived without heart transplant; in group 2, 18 patients (23%) died and 3 (4%) received a heart transplant. Patients in group 1 had a significantly shorter duration of symptoms (P=0.0045), a younger age (P=0.006), a shorter DtE (P=0.04), a lower SFSI (P<0.01), a worse NYHA class (P<0.001) and more frequently had a history of hypertension (P<0.0001). The same variables were significant predictors of improvement at the univariate analysis. At the multivariate logistic regression analysis, a shorter duration of symptoms (P=0.02), a history of hypertension (P=0.003), and a worse NYHA class (P=0.01) were independent predictors of improvement. A relatively large percentage of patients with an idiopathic DCM will have a marked improvement in the LV systolic function. This is more likely to happen in the presence of a short duration of symptoms and a history of hypertension. After an improvement, the prognosis is excellent.