Quantitative Stress Echocardiography in Chronic Aortic and Mitral Regurgitation

It was the purpose of the present study to prove the feasibility and reliability of quantitative stress-echocardiography as an alternative method to radionuclide angiography (RNA) in chronic regurgitant valvular lesions. Echocardiography and RNA are most commonly used to obtain various left ventricular (LV) morphometric and functional parameters that have been postulated to predict long-term prognosis in patients with aortic and mitral valvular regurgitation. Supine bicycle ergometry with a workload ranging from 25-250 Watts was used to evaluate stress dependent LV volumes and ejection fractions (EFs) in patients with pure aortic (n = 18) and mitral regurgitation (n = 14). Most patients (23/32) underwent simultaneous right heart catheterization. Echocardiographic EFs were validated by RNA with good correlations (r = 0.81, P < 0.01). Patients with aortic regurgitation and functional class I/II (9), had a significant increase in EF during exercise (60%-67%, P < 0.001) and a reduction in end-systolic volume (71-52 mL, P < 0.01). In comparison, patients with class III symptoms (9), had a drop in EF (53%-49%, P < 0.01), had larger baseline end-systolic volume (104 mL, P = NS), which did not decrease during stress (104 vs 107 mL, P = NS). In patients with chronic mitral regurgitation baseline and exercise EF did not differ between class I/II (6) and class III (8), however, mildly symptomatic patients increased from 57%-67%, (P < 0.01) versus patients in class III (65% vs 69%, P = NS). Stroke volume index was not different at baseline (44 vs 33 mL/m(2), P = NS); however, there were significant differences during exercise (70 vs 41 mL/m(2), P = 0.05). Quantitative stress-echocardiography is a noninvasive and safe alternative method to RNA, which allows reliable calculation of stress dependent LV volumes and EF. Determination of end-systolic volumes may be of additional prognostic value. The combination of a high baseline EF and low stroke volume index with the inability to improve during exercise might reflect early stages of impaired LV function in patients with severe mitral regurgitation.     

Exercise training without ventricular remodeling in patients with moderate to severe left ventricular dysfunction early after acute myocardial infarction

BACKGROUND: The purpose of this study was to determine whether or not patients with moderate to severe left ventricular (LV) dysfunction benefit from exercise training starting early after acute myocardial infarction (AMI) without deteriorating LV remodeling. METHODS: We investigated changes in exercise capacity and LV end-diastolic dimension (LVDd by two-dimensional echocardiography) before and after exercise training in 126 patients after AMI. Patients were divided into three groups according to LV ejection fraction (EF) at the beginning of exercise training: 74 patients with LVEF>/=45% (Group H), 35 patients with 35%相似文献   

Intramyocardial injection of autologous bone marrow mononuclear cells in patients with chronic myocardial infarction and severe left ventricular dysfunction

The present study investigated the safety, feasibility, and potential efficacy of autologous bone marrow cell injection in patients with chronic myocardial infarction and severe left ventricular (LV) dysfunction. In 15 patients (63 +/- 9 years; 14 men) bone marrow was aspirated from the iliac crest. Using the NOGA system (Biosense-Webster, Waterloo, Belgium), 94 +/- 14 x 10(6) bone marrow-derived mononuclear cells were injected into the infarction border zone. Bone marrow cell injection was performed without periprocedural complications in all patients. At 2.5 months, 1 patient died from worsening heart failure. New York Heart Association class improved from 3.5 +/- 0.5 at baseline to 2.7 +/- 0.8 at 3 months (p <0.01) and 2.9 +/- 0.8 at 6 months (p <0.01 vs baseline). LV ejection fraction (technetium-99m tetrofosmin single-photon emission computed tomography) increased from 23 +/- 8% to 27 +/- 9% at 3 months (p = 0.02) and regional wall thickening improved from 12.8 +/- 5.9% to 15.3 +/- 7.2% at 3 months (p = 0.02). Injected myocardial segments displayed a significant improvement in regional wall thickening (6.6 +/- 6.3% vs 11.7 +/- 7.0% at 3 months, p <0.01) and perfusion score (3.5 +/- 0.7 vs 3.0 +/- 0.9 at 3 months, p = 0.02) and a trend toward an improved fluorine-18 fluorodeoxyglucose score (2.9 +/- 0.9 vs 2.6 +/- 1.0 at 3 months, p = 0.06). Regional wall thickening (16.5 +/- 8.9% vs 19.1 +/- 9.1% at 3 months, p = NS), perfusion score (1.8 +/- 0.4 vs 1.7 +/- 0.5 at 3 months, p = NS), and fluorodeoxyglucose score (1.7 +/- 0.4 vs 1.6 +/- 0.4 at 3 months, p = NS) did not improve in noninjected myocardial segments. In conclusion, bone marrow cell injection in patients with chronic myocardial infarction and severe LV dysfunction is safe and feasible and appears to be associated with a decrease in heart failure symptoms and an improved LV function.     

自体外周血干细胞移植治疗急性心肌梗死对左心室功能的影响研究

目的探讨自体外周血干细胞(PBSCs)移植治疗急性心肌梗死(AMI)对左心室功能的影响。方法选择2003年11月至2005年9月辽宁省人民医院收治的69例AMI患者,分成干细胞移植组35例和对照组34例,两组均接受药物和冠状动脉内介入治疗,干细胞移植组在此基础上动员自体骨髓干细胞,进行外周血干细胞移植。两组均于治疗前、治疗后6个月进行超声心动图检查。结果6个月时干细胞移植组心脏收缩末容积(ESV)明显减小(P<0·05);舒张末容积(EDV)无显著性变化(P>0·05);左室射血分数(LVEF)显著增高(P<0·05);左室壁节段性运动积分指数(WMSI)明显减低(P<0·001);对照组于介入术前及术后6个月随访ESV、EDV、LVEF及WMSI差异均无显著性意义;术后6个月随访移植组与对照组比较ESV下降,LVEF升高,WMSI降低(P<0·05)。结论自体外周血干细胞治疗AMI可以在近期有效地缩小缺血梗死面积,减轻左室重构,改善心功能。     

Ventricular Mechanical Asynchrony in Patients with Different Degrees of Systolic Dysfunction: Results from AVE Registry by the Italian Society of Cardiovascular Echography (SIEC)

Objective: The aim of the study was to compare the prevalence of interventricular and intraventricular asynchrony in patients with different degrees of left ventricular (LV) dysfunction. Methods: We enrolled 182 patients (male 79%, mean age 64 ± 11 years) with LV ejection fraction (EF) < 50% and identified two groups: Group A (n = 79) with mild‐to‐moderate LV dysfunction (EF between 36% and 49%) and Group B (n = 103) with severe dysfunction (EF ≤ 35%). An echocardiogram was performed in all patients and a delay longer than 40 msec in the time difference between the aortic and pulmonary preejection intervals was considered as an index of interventricular asynchrony. The electromechanical delays were assessed by pulsed tissue Doppler technique. A time difference between the earliest and the latest segment greater than 40 msec was considered the cutoff for intraventricular asynchrony. The sum of asynchrony was calculated by adding to the LV intraventricular delay the delay between the lateral basal right ventricular segment and the most delayed LV basal segment. Results: The prevalence of interventricular asynchrony was lower among Group A patients (19.8% vs. 37.9%; P = 0.007) while the prevalence of intraventricular asynchrony did not differ between groups (32.9% vs. 44% in Group A and Group B respectively; P = 0.18). The sum of asynchrony (cutoff >102 msec) did not differ between groups either (29.9% vs. 35.9%; P = 0.39). Conclusions: The prevalence of intraventricular asynchrony is independent of the LV systolic dysfunction severity. This could indicate the potential role of cardiac resynchronization therapy in patients with mild‐moderate systolic dysfunction. (ECHOCARDIOGRAPHY 2010;27:110‐116)     

Median-term course of left ventricular effects in aortic insufficiency. Echocardiographic study of 90 patients

It is important to know the natural evolution of the changes in left ventricular dimensions and contractility in AR if one wishes to determine the critical echocardiographic values at which LV function starts to deteriorate. This was the aim of our echocardiographic study of 90 patients with chronic pure AR in whom we analysed the changes in LV dimensions, mass and contractility for 11 to 84 months (average 34.6 months). The patients were divided into 2 groups according to the degree of ventricular dilatation (delta DD): Group A: delta DD less than 30% (58 patients), Group B: delta DD greater than 30% (32 patients). The annual mean increase in diastolic and systolic LV dimensions and myocardial mass in each group was: 1.5 mm vs 3.2 mm (p less than 0.02); 0.9 mm vs 4.1 mm (p less than 0.003), 14 g vs 24 g (p = 0.07 NS) respectively. The parameters of the systolic function were normal in Group A (EF = 68 +/- 8% and % FS = 38 +/- 6%) and decreased in Group B (EF = 58 +/- 13%, % FS = 32 +/- 9%). A significant annual decrease of the mean values of these parameters was only observed in patients of Group B (EF = 1.8% per year; % FS = -1.2% per year). These results are on average of unequal individual variations: variations of DD or EF greater than the variability due to the reproducibility of the method were only observed in 43 patients. The number of patients in whom echocardiographic changes were observed was comparable in Groups A and B.(ABSTRACT TRUNCATED AT 250 WORDS)     

Myocardial viability during dobutamine echocardiography predicts survival in patients with coronary artery disease and severe left ventricular systolic dysfunction

Objectives. The purpose of this study was to assess whether the presence or absence of myocardial viability during dobutamine echocardiography (DE) predicts survival in patients with coronary artery disease (CAD) and severe left ventricular (LV) dysfunction.Background. In patients with CAD, the presence of myocardial viability during DE identifies viable myocardium and predicts recovery of LV systolic function after revascularization. However, there is little data on the relation between myocardial viability and clinical outcome in patients with CAD and severe LV dysfunction.Methods. We studied 318 patients with CAD and a LV ejection fraction (EF) ≤35% who underwent DE and were followed for 18 ± 10 months. Patients were classified into four groups. Group I (n = 85) consisted of patients who had evidence of myocardial viability and subsequently underwent revascularization. Group II (n = 119) consisted of patients with myocardial viability who did not undergo revascularization. Group III (n = 30) consisted of patients who did not have myocardial viability and underwent revascularization. Finally, group IV (n = 84) patients lacked myocardial viability and did not undergo revascularization.Results. The four groups had similar baseline characteristics and rest LVEF. During follow-up there were 51 deaths (16%). The mortality rate was 6% in group I, 20% in group II, 17% in group III and 20% in group IV (p = 0.01, group I vs. other groups).Conclusions. In patients with CAD and severe LV dysfunction who demonstrated myocardial viability during DE, revascularization improved survival compared with medical therapy.     

Functional recovery after coronary artery bypass grafting in patients with severe left ventricular dysfunction and preserved myocardial viability in the left anterior descending arterial territory as assessed by thallium-201 myocardial perfusion imaging.

To evaluate the functional recovery after coronary bypass surgery in patients with severe left ventricular (LV) dysfunction (ejection fraction (EF) < or = 35%), 100 consecutive patients with viable myocardium in the territory supplied by the left anterior descending artery (LAD) underwent coronary bypass grafting. In addition, cardiac catheterization and single-photon emission computed tomography (SPECT) perfusion imaging with thallium-201 were repeated 1-year postoperatively. Although 12 patients with severe LV dysfunction were preoperatively in a worse New York Heart Association functional class (3.1+/-0.7 vs 2.4+/-0.8; p<0.01), had a higher incidence of heart failure (10/12 vs 14/88; p<0.001) and had a worse LVEF (29+/-5 vs 61+/-14%; p<0.001) compared with 88 patients without severe LV dysfunction, the operative mortality was similar in the 2 groups (1/12 vs 2/88; p=NS). The postoperative NYHA functional class in the patients with severe LV dysfunction was similar to that in the patients without such dysfunction (1.6+/-0.7 vs 1.3+/-0.6; p=NS). In addition, the 1-year postoperative study revealed a significant improvement in the thallium defect score in both the LAD territory (1.7+/-1.2 to 0.7+/-1.0, p=0.01) and all the territories (5.2+/-2.2 to 3.2+/-1.9, p=0.002) in patients with severe LV dysfunction, whereas no improvement in defect score was found in either of these territories in those without severe LV dysfunction (LAD: 0.6+/-1.4 to 0.4+/-1.2, p=NS; All: 1.9+/-2.2 to 1.8+/-2.0, p=NS). Furthermore, a marked 1-year postoperative improvement (15-24%; 95% confidence interval) in LVEF (29+/-5 to 48+/-10%, p<0.001) was demonstrated in patients with severe LV dysfunction, but not in those without such dysfunction (60+/-13 to 61+/-11%, p=NS). These results indicate that myocardial viability in the LAD territory, as demonstrated by thallium-201 SPECT perfusion imaging, predicts a significant improvement in functional class and LVEF of at least 10% or more after coronary artery bypass grafting in patients with severe LV dysfunction.     

Autologous myoblast transplantation for chronic ischemic mitral regurgitation.

OBJECTIVES: This study was designed to assess whether post-myocardial infarction (MI) in-scar transplantation of skeletal myoblasts (SM) could reduce chronic ischemic mitral regurgitation (MR) by decreasing left ventricular (LV) remodeling. BACKGROUND: Extensive work has confirmed the relationship between ischemic MR and post-myocardial infarction (MI) remodeling of the LV. METHODS: An infero-posterior MI was created in 13 sheep, thereby resulting in increasing MR. Two months post-MI, the animals were randomized and in-scar injected with expanded autologous SM (n = 6, mean: 251 x 10(6) cells) or culture medium only (n = 7). Three-dimensional echocardiography was performed at baseline, before transplantation, and for two months thereafter (sacrifice), with measurements of LV end-diastolic and end-systolic volumes (ESV), ejection fraction (EF), MR stroke volume, and leaflet tethering distance; wall motion score index (WMSi) was assessed by two-dimensional echo. RESULTS: Measurements were similar between groups at baseline and before transplantation. At sacrifice, transplantation was found to have reduced MR progression (regurgitant volume change: -1.83 +/- 0.32 ml vs. 5.9 +/- 0.7 ml in control group, p < 0.0001) and tethering distance (-0.41 +/- 0.09 cm vs. 0.44 +/- 0.12 cm in control group, p < 0.001), with significant improvement of EF (2.01 +/- 0.94% vs. -4.86 +/- 2.23%, p = 0.02), WMSi (-0.25 +/- 0.11 vs. 0.13 +/- 0.03 in controls, p < 0.01) and a trend to a lesser increase in ESV (23.3 +/- 3.5 ml vs. 35.4 +/- 4.2 ml in control group, p = 0.055). CONCLUSIONS: Autologous skeletal myoblast transplantation attenuates mild-to-moderate chronic ischemic MR, which otherwise is progressive, by decreasing tethering distance and improving EF and wall motion score, thereby enhancing valve coaptation. These data shed additional light on the mechanism by which skeletal myoblast transplantation may be cardioprotective.     

Location of myocardial necrosis as an independent determinant of left ventricular performance: Analysis of 96 patients

This study determines whether the location of myocardial scarring has an effect independent of its size on left ventricular (LV) ejection fraction (EF) in patients with coronary artery disease. Two groups of patients were studied: Group I (n = 44) had resting thallium-201 perfusion defects involving the anterior wall or septum or both, and Group II (n = 52) had perfusion defects involving the inferior wall or posterior wall or both. The thallium images were divided into 5 segments in each of 3 projections, and the thallium score was determined from the number of abnormal segments and the degree of reduction of thallium uptake; the higher the score, the more severe the perfusion deficit.If the thallium score was <- 10, EF was 45 ± 14% (mean ± standard deviation) in Group I and 47 ±11% in Group II (p = not significant [NS]). If the thallium score was > 10, EF was 30 ± 12% in Group I and 32 ± 11% in Group II (NS). Similarly, EF was not significantly different between the 2 groups when the perfusion defects were assessed by the number of abnormal segments. In each group EF was significantly lower as the number of abnormal segments increased or as the thallium score was higher (p < 0.01). The results were unchanged when patients with resting ischemic defects or women were excluded.Thus, the location of myocardial scar itself is not important in determining LV function. However, the size of the scar is important in determining LVEF. Therefore, the fact that LVEF is lower in patients with anterior infarction than in those with inferior infarction must be related to the extent of muscle necrosis rather than to an anatomic factor.     

The effects of mesenchymal stem cells transduced with Akt in a porcine myocardial infarction model

OBJECTIVE: This study was designed to examine whether mesenchymal stem cells (MSCs) transduced with Akt enhance cardiac repair after transplantation into the ischemic porcine heart. METHODS: MSCs isolated from porcine bone marrow and transduced with myr-Akt were transplanted into porcine hearts after experimental myocardial infarction (MI) using intracoronary injection [Group I, vehicle; Group II, MSCs; Group III, Akt-MSCs]. Myocardial single photon emission tomography (M-SPECT) was performed to assess myocardial function and the infarcted area. Pigs were also sacrificed for immunohistochemical characterization and histologic analysis. In addition, in vitro assays were performed to examine the resistance of Akt-MSCs to H(2)O(2) stimulation. RESULTS: Transplantation of MSCs into the ischemic porcine myocardium (Group II) increased the left ventricular ejection fraction (DeltaLV EF; -6.3 +/- 15.1% versus 0.5 +/- 6.4%, P < 0.001) and decreased the Deltaarea of MI (6.8+/-5.6% versus -5.0+/-5.3%, P < 0.001) compared with the vehicle control (Group I). Transplantation of MSCs transduced with myr-Akt (Group III) resulted in further improvement in DeltaLV EF (-6.3 +/- 15.1% versus 5.8 +/- 11.3%, P < 0.001) and in Deltaarea of MI (6.8 +/- 5.6% versus -17.0 +/- 7.6%, P < 0.001). Akt-MSCs were more resistant to apoptosis, and the levels of extracellular signal-regulated protein kinase (ERK) activation and vascular endothelial growth factor (VEGF) were higher in H(2)O(2)-stimulated Akt-MSCs. CONCLUSION: Cellular transplantation of Akt-MSCs further enhances the repair of injured myocardium compared to MSC transplantation alone by increasing the number of viable MSCs after cellular transplantation.     

Left ventricular remodelling in patients with moderate systolic dysfunction after myocardial infarction: favourable effects of exercise training and predictive role of N-terminal pro-brain natriuretic peptide.

AIMS: To investigate the effects of exercise training (ET) on left ventricular (LV) volumes, cardiopulmonary functional capacity and N-terminal pro-brain natriuretic peptide (NT-proBNP) levels in postinfarction patients with moderate LV dysfunction. METHODS: Sixty-one postinfarction patients were randomized into two groups: group T [n=30, LV ejection fraction (EF) 41.6+/-11.3%, mean+/-SD] entered a 6-month ET programme, whereas group C (n=31, EF 42.0+/-7.6%, P=NS) did not. NT-proBNP assay, Doppler-echocardiography and cardiopulmonary exercise test were performed upon enrolment and at sixth months. RESULTS: At sixth months, trained patients showed an improvement in workload (+26%, P<0.001), Vo2peak (+31%, P<0.001), LV end-diastolic volume index (LVEDVI; -9%, P<0.001), a reduction in NT-proBNP (-71%, P<0.001) and a significant correlation between changes in NT-proBNP and in LVEDVI (r=0.858, P<0.001). Baseline NT-proBNP correlated with changes in LVEDVI in both trained (r=0.673, P<0.001) and untrained (r=0.623, P<0.001) patients. Group C showed unfavourable LVEDVI dilation (+8%, P<0.001; T vs. C group, P<0.001) and a smaller reduction in NT-proBNP (-40%, P<0.001; T vs. C group, P<0.001). CONCLUSIONS: Six month ET induced a favourable LV remodelling and a marked fall in NT-proBNP that could predict LV remodelling in postinfarction patients with moderate LV dysfunction.     

Myocardial positive pre-ejection velocity accurately detects presence of viable myocardium, predicts recovery of left ventricular function and bears a prognostic value after surgical revascularization.

AIMS: To assess the accuracy of tissue Doppler imaging-derived myocardial positive pre-ejection velocity (+Vic) in detecting myocardial viability defined by dobutamine stress echocardiography (DSE), fluorine-18 fluorodeoxyglucose positron emission tomography (PET), and contrast-enhanced magnetic resonance imaging (MRI), and in predicting recovery of left ventricular (LV) function after coronary artery bypass grafting (CABG) in patients with chronic ischaemic LV dysfunction. METHODS AND RESULTS: +Vic in dysfunctional segments was recorded in 54 patients treated medically and 65 patients undergoing CABG [age 67 +/- 9 year; LV ejection fraction (EF) 30 +/- 6%]. A good agreement was observed between +Vic and detection of viable myocardium at DSE, PET, and MRI (kappa = 0.76). The presence of +Vic in greater than or equal to five dysfunctional segments had the highest sensitivity (93%) and specificity (60%) to identify patients (n = 28) with > or =10% increase in LV EF between baseline and 6-month echocardiogram. During follow-up (median 333 days, interquartile range 209-490 days), 13 cardiac events (6 deaths, 7 hospitalizations) occurred in 24 patients with small extent of viable myocardium (< 5 + Vic), whereas only four hospitalizations in 39 patients with > or =5 + Vic (54% vs. 10%; P < 0.001). CONCLUSION: The extent of +Vic in dysfunctional segments accurately predicts extent of viable myocardium and bears a clinical prognostic value in patients with ischaemic LV dysfunction considered for CABG.     

Diastolic left ventricular function after renal transplantation in patients with normal and hypertrophied myocardium

While diastolic left ventricular (LV) dysfunction is frequent and associated with cardiovascular complications in end-stage renal disease treated with dialysis, controversial information exists on diastolic LV function after renal transplantation. Therefore, Doppler echocardiographic parameters of LV diastolic filling were analyzed in 17 transplanted patients with normal LV mass (< 150 g/m2; mean: 128 +/- 17 g/m2) and 24 transplanted patients with LV hypertrophy (> 150 g/m2; mean: 197 +/- 36 g/m2) and compared with 28 normal controls without and 11 controls with LV hypertrophy. Mean age (normal vs. increased LV mass: 46 +/- 13 vs. 48 +/- 11 years; p = NS) and transplantation duration (60 +/- 35 vs. 50 +/- 37 months; p = NS) were comparable between renal patients, while systolic blood pressure (136 +/- 12 vs. 149 +/- 14 mmHg; p < 0.02) and serum creatinine (1.55 +/- 0.45 vs. 1.98 +/- 0.76 mg/dl; p < 0.05) were higher in patients with than without LV hypertrophy. In transplanted patients with LV hypertrophy, peak early/atrial filling velocity ratios were decreased (1.17 +/- 0.34 vs. 0.94 +/- 0.34; p < 0.05), mean atrial filling fractions were increased (37 +/- 7% vs. 42 +/- 7%; p < 0.05), and isovolumic relaxation periods were prolonged (86 +/- 23 vs. 106 +/- 26 ms; p < 0.02) compared with transplanted patients with normal LV mass. The frequency of pathologic peak early/atrial filling velocity ratios (12 vs. 42%; p < 0.05), atrial filling fractions (12 vs. 25%; p = NS) and isovolumic relaxation periods (6 vs. 29%; p = NS) was higher in transplanted patients with than without LV hypertrophy. Individual ratios of peak early/atrial filling velocity were inversely correlated with age in transplanted patients with normal LV mass (p < 0.002), and atrial filling fractions were correlated with LV mass index in transplanted patients with LV hypertrophy (p < 0.01). Diastolic LV function was comparable in both groups of transplanted patients with their corresponding non-renal controls. It is concluded that, in transplanted patients, diastolic LV filling is comparable to nonrenal controls; it is age-dependent in patients with normal LV mass and mass-dependent in those with LV hypertrophy.     

Improved survival with drug-eluting stent implantation in comparison with bare metal stent in patients with severe left ventricular dysfunction.

OBJECTIVE: We examined the efficacy of drug-eluting stent (DES) implantation (Sirolimus or Paclitaxel) in patients with ischemic cardiomyopathy and severe left ventricular (LV) dysfunction and compared the outcome with a similar group of patients undergoing bare metal stent (BMS) implantation. BACKGROUND: Patients with severe LV dysfunction are a high risk group. DES may improve the long term outcomes compared with BMS. METHODS: One hundred and ninety one patients (23% women) with severe LV dysfunction (LV ejection fraction < or =35%) underwent coronary stent implantation between May 2002 and May 2005 and were available for follow-up. One hundred and twenty eight patients received DES (Sirolimus in 72 and Paclitaxel in 54) and 63 patients had BMS. Patients with acute S-T elevation myocardial infarction (STEMI) were excluded. The primary endpoint was cardiovascular mortality. A composite endpoint of major adverse cardiac events (MACE) including cardiovascular mortality, myocardial infarction (MI), and target vessel revascularization (TVR) was the secondary endpoint. RESULTS: Mean follow-up was 420 +/- 271 days. No differences were noted in age (69 +/- 10 years vs. 70 +/- 10 years, P = NS), number of vessel disease (2.3 +/- 0.7 vs. 2.2 +/- 0.8, P = NS), history of congestive heart failure (47% vs. 46%, P = NS), MI (60% vs. 61%, P = NS), or number of treated vessels (1.3 +/- 0.5 vs. 1.3 +/- 0.6, P = NS) for the DES and BMS group, respectively. Diabetes was more common among DES patients (45% vs. 25%, P = 0.01). The left ventricular ejection fraction (LVEF) was similar between the two groups (28% +/- 6% vs. 26% +/- 8%, P = NS for the DES and BMS, respectively). During the follow-up, there were a total of 25 deaths of which two were cancer related (2 in DES group). There were 23 cardiac deaths, 8/126 (6%) which occurred in the DES group and 15/63 (24%) in the BMS group (P = 0.05 by log-rank test). MACE rate was 10% for the DES group and 41% for the BMS group (P = 0.003). NYHA class improved in both groups (from 2.5 +/- 0.8 to 1.7 +/- 0.8 in DES and from 2 +/- 0.8 to 1.4 +/- 0.7 in the BMS, P = NS). CONCLUSION: Compared with bare-metal stents, DES implantation reduces mortality and MACE in high risk patients with severe left ventricular dysfunction.     

Gender-specific differences of cardiac remodeling in subjects with left ventricular dysfunction: a population-based study

BACKGROUND: Recent studies suggest that female gender is associated with a lower prevalence and a more benign prognosis of heart failure. In the current population-based study, it was our objective to evaluate the implications of gender on the association between impaired left ventricular (LV) function and mass as well as neurohumoral activation. METHODS AND RESULTS: A total of 1883 subjects (992 female, 891 male) of two MONICA surveys in Augsburg, Germany, were analyzed. Participants of one of these surveys were additionally characterized with respect to neurohormonal activation. As compared to men, women were characterized by a slightly higher LV ejection fraction (EF, Teichholz-Method, 65.4 +/- 0.3% vs. 63.4 +/- 0.3, P<0.01) and a markedly lower LV mass index (LVMI 81 +/- 1 g/m(2) vs. 96 +/- 1, P<0.01). As compared to men with normal LV function, those with LV dysfunction (EF below mean minus two standard deviations, S.D.) were characterized by significantly increased LV mass (LVMI +48%, P<0.01), plasma BNP (+373%, P<0.01) and ANP (+57%, P<0.01), while no significant changes were observed in women (LVMI +3%, BNP +48%, ANP +27%, all P=n.s). Only a small subgroup of women with severe LVD (EF below mean - 3 S.D.) was characterized by significantly increased LV mass (LVMI +23%, P<0.05 vs. control and LVD), however, this increase was less pronounced as compared to men with severe LVD (LVMI +46%, P<0.01 vs. control). Gender-specific differences between LV function and structure were also confirmed by multivariate analysis. While LVMI was independently and significantly correlated with EF in male subjects in addition to systolic blood pressure, age, and body mass index (all P<0.01), these parameters displaced EF as a predictor of LVMI in female subjects. CONCLUSIONS: Men with moderate or severe LV dysfunction are characterized by an increase in both LV mass and cardiac natriuretic peptide plasma concentrations. In contrast, LV mass and natriuretic peptide concentrations increase to a lesser extent and only with severe LV dysfunction in women. These observational data suggest gender-specific control of myocardial adaptations to hemodynamic overload and a more rapid induction of LV hypertrophy during myocardial dysfunction in male subjects.     

Recurrent mitral regurgitation late after annuloplasty for ischemic mitral regurgitation

In 106 patients who had mitral annuloplasty for ischemic mitral regurgitation (MR), 71 patients (67%) had satisfactory outcomes with <2+ MR (grade 0-4) throughout the follow-up period (44 ± 31 months), while 35 patients (33%) had significant recurrent MR (≥2+) late after annuloplasty (≥6 months) during the follow-up period (45 ± 30 months). Compared to those with recurrent MR, the success group had a significantly higher proportion of patients whose left ventricular (LV) ejection fraction (EF) stayed stable or increased over the follow-up period postoperatively (47/70 = 67% vs. 14/35 = 40%, P < 0.01). The success group had a higher proportion of patients whose LV end-systolic volume stayed stable or decreased (37/63 = 59% vs. 6/35 = 17%, P < 0.01) and lower LV sphericity in systole (0.46 ± 0.096 vs. 0.60 ± 0.10, P < 0.01). In conclusion, recurrent ischemic MR after annuloplasty is associated with increasing LV size, decreasing LVEF, and increasing sphericity of the LV.     

Differences in left ventricular ejection fraction and volumes measured at rest and poststress by gated sestamibi SPECT.

BACKGROUND: Some studies suggested that the poststress left ventricle ejection fraction (LV EF) is lower than rest LV EF in patients with stress-induced ischemia. METHODS AND RESULTS: By using a 2-day protocol and 30 mCi Tc-99m sestamibi, LV EF, end-systolic volume (ESV), and end-diastolic volume (EDV) were measured with gated SPECT. Of 99 eligible patients, 91 had technically adequate studies. Poststress LV EF minus rest LV EF was defined as DeltaLV EF. DeltaEDV and DeltaESV were similarly defined. Rest and poststress LV EF (r = 0.89), EDV (r = 0.78), and ESV (r = 0.93) were highly correlated (P <.001). Rest LV EF, EDV, and ESV were not significantly different between patients with and without stress-induced ischemia. DeltaLV EF was significantly lower in patients with stress-induced ischemia (-3.5% +/- 4.5% vs -1.1% +/- 4.7%, P = .02). Mean LV EF poststress in ischemic patients was 55.0% +/- 10.5% vs 61.2% +/- 10.0% in nonischemic patients (P = .008). However, only 1 patient (3%) with ischemia had DeltaLV EF that exceeded the 95% confidence limit of DeltaLV EF for normal patients. Ischemia was significantly associated with increased DeltaEDV and DeltaESV (P < .01). CONCLUSIONS: Stress-induced ischemia is associated with poststress reduction in LV EF and increased poststress EDV and ESV. However, the effect of ischemia on the difference between poststress and rest EF measurements is modest and rarely exceeds the confidence limits in normal patients undergoing 2-day protocols. In most patients, poststress LV EF is an accurate reflection of rest LV EF.     

Left ventricular function in patients with coronary heart disease in the presence or absence of angina pectoris during exercise radionuclide ventriculography

This study compares left ventricular (LV) performance during exercise in patients with angiographically documented coronary artery disease (CAD) based on the presence or absence of angina pectoris during the index exercise tests. The patients were divided into 2 groups: Group I included 31 patients who had angina pectoris during the test and Group II included 43 who did not. Multivessel CAD was present in 21 patients (68%) in Group I and 26 patients (60%) in Group II (difference not significant [NS]). There were no significant differences between the 2 groups in age, sex, history of diabetes mellitus, history of myocardial infarction and in the exercise duration, work load, heart rate and systolic blood pressure. Exercise-induced ST-segment depression was present in 48% of the patients in Group I and in 40% in Group II (NS). The mean LV ejection fraction at rest was 52 ± 12% in Group I and 50 ± 17% in Group II (NS). There were significant differences in the 2 groups in the change from rest to exercise in ejection fraction (?4.5 ± 7.6% in Group I vs 1 ± 9.4% in Group II, p < 0.01), end-systolic volume (29 ± 38 ml in Group I vs 9 ± 23 ml in Group II, p < 0.005), the change in systolic blood pressure-to-end-systolic volume ratio (?0.1 ± 0.5 mm Hg/ml in Group I vs 0.3 ± 1.1 mm Hg/ml in Group II, p < 0.05), and wall motion score (?0.4 ± 0.6 in Group I vs 0.09 ± 0.7 in Group II, p < 0.05).Thus, asymptomatic myocardial ischemia may occur in patients with extensive CAD and be associated with abnormal exercise LV function; however, patients with symptomatic CAD have worse exercise LV function than those with asymptomatic CAD.     

急性心肌梗死患者介入治疗前后心肌血流灌注及心功能变化的临床研究

目的通过门控单光子发射计算机显像（GSPECT）检查,探讨急性心肌梗死（AMI）患者介入治疗前、后心肌血流灌注及心功能的变化。方法选择AMI并行介入治疗的患者40例,根据介入术前GSPECT测定的左室射血分数（EF）分为A、B两组（各20例）。在介入治疗前及治疗后4周行GSPECT检查,测定左室功能并评价心肌局部血流灌注。结果介入治疗前、后比较,各项心功能指标均有明显改善,心输出量分别为（4．52±0．44）L／min和（4．89±0．87）L／min（P〈0．01）,左室EF分别为（49．23±3．89）％和（55．37±5．57）％（P〈0．01）。A组与B组比较,介入治疗后心肌血流灌注改善率明显较高（38．1％比13．7％,P〈0．01）。结论AMI患者介入治疗后GSPECT检测的心功能各项指标均有不同程度的改善,左室功能正常组介入治疗后GSPECT心肌血流灌注改善更明显。