Left atrial reverse remodeling and prevention of progression of atrial fibrillation with atrial resynchronization device therapy utilizing dual-site right atrial pacing in patients with atrial fibrillation refractory to antiarrhythmic drugs or catheter ablation

Introduction

Dual-site right atrial pacing (DAP) produces electrical atrial resynchronization but its long-term effect on the atrial mechanical function in patients with refractory atrial fibrillation (AF) has not been studied.

Methods

Drug-refractory paroxysmal (PAF) and persistent AF (PRAF) patients previously implanted with a dual-site right atrial pacemaker (DAP) with minimal ventricular pacing modes (AAIR or DDDR mode with long AV delay) were studied. Echocardiographic structural (left atrial diameter [LAD] and left ventricular [LV] end diastolic diameter [EDD], end systolic diameter [ESD]) and functional (ejection fraction [EF]) parameters were serially assessed prior to, after medium-term (n?=?39) and long-term (n?=?34) exposure to DAP.

Results

During medium-term follow-up (n?=?4.5 months), there was improvement in left atrial function. Mean peak A wave flow velocity increased with DAP as compared to baseline (75?±?19 vs. 63?±?23 cm/s, p?=?0.003). The long-term impact of DAP was studied with baseline findings being compared with last follow-up data with a mean interval of 37?±?25 (range 7–145) months. Mean LAD declined from 45?±?5 mm at baseline to 42?±?7 mm (p?=?0.003). Mean LVEF was unchanged from 52?±?9 % at baseline and 54?±?6 % at last follow-up (p?=?0.3). There was no significant change in LV dimensions with mean LVEDD being 51?±?6 mm at baseline and 53?±?5 mm at last follow-up (p?=?0.3). Mean LVESD also remained unchanged from 35?±?6 mm at baseline to 33?±?6 mm at last follow-up (p?=?0.47). During long-term follow-up, 30 patients (89 %) remained in sinus or atrial paced rhythm as assessed by device diagnostics at 3 years.

Conclusions

DAP can achieve long-term atrial reverse remodeling and preserve LV systolic function. DAP when added to antiarrhythmic drug (AAD) and/or catheter ablation (ABL) maintains long-term rhythm control and prevents AF progression in elderly refractory AF patients. Reverse remodeling with DAP may contribute to long-term rhythm control.     

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。     

Effects of cardiac resynchronization therapy on disease progression in patients with congestive heart failure.

BACKGROUND: Cardiac resynchronization therapy (CRT) represents a new therapeutic modality of proven efficacy for selected patients with heart failure and ventricular asynchrony. The aim of this study was to assess the effects of CRT on clinical variables and cardiac remodeling in patients with moderate-to-severe congestive heart failure and inter/intraventricular conduction delays. METHODS: Thirty-seven patients (32 males, 5 females, mean age 73 +/- 7 years), in NYHA functional class III-IV, with left ventricular ejection fraction (LVEF) < or = 35%, QRS > or = 150 ms, and left ventricular end-diastolic diameter (LVEDD) > or = 55 mm, underwent CRT by biventricular pacing (InSync, InSync III, InSync ICD; Medtronic Inc.). Fourteen (37.8%) had a previous pacemaker, and 11 (29.7%) were in permanent atrial fibrillation. The QRS width, NYHA functional class, LVEDD, left ventricular end-systolic diameter (LVESD), left ventricular end-diastolic volume (LVEDV), left ventricular endsystolic volume (LVESV), and LVEF were retrospectively evaluated in the period before CRT. For the purposes of the present study, the pre-CRT period was divided in two: T(-2) (from 6 to 3 years) and T(-1) (from 3 years to CRT). Moreover, these parameters were measured at the time of CRT (T0) and prospectively in the post-CRT follow-up (Tp). RESULTS: Before CRT, a progressive worsening of the parameters was observed. The QRS duration steadily increased from T(-2) to T(-1) and T0 (both p = 0.000). The NYHA functional class increased from T(-2) to T(-1) and T0 (both p = 0.000). LVEDD and LVESD also increased and were higher at T(-1) (p = 0.001 and p = 0.000, respectively) and at T0 (both p = 0.000) compared to T(-2). Similar results were observed for LVEDV and LVESV. Finally, LVEF was higher at T(-2) than T(-1) and T0 (both p = 0.000). After CRT, there was a reduction in the QRS duration and an improvement in the NYHA functional class compared to T0 (both p = 0.000). LVEDD and LVESD were also reduced (p = 0.005 and p = 0.016, respectively), LVEDV and LVESV decreased (both p = 0.000), and LVEF increased (p = 0.000) with respect to T0. A highly significant correlation was found between LVEDD and LVESD both in the pre- and post-CRT time intervals, with a non-significant difference between the two linear regression lines. Similar results were obtained for the correlations between LVEDV and LVESV. CONCLUSIONS: Congestive heart failure is associated with a progressive widening of the QRS complex and a worsening of the clinical status and results in anatomic remodeling with deterioration of the left ventricular function. CRT induces opposite changes in QRS duration, clinical status, and left ventricular remodelling.     

大剂量缬沙坦治疗急性心肌梗死后心室重构的临床效果

目的探讨大剂量缬沙坦治疗急性心肌梗死后心肌重构的临床效果。方法纳入急性心肌梗死患者73例,患者入院后采用随机数表法将患者分为对照组(给予常规剂量的缬沙坦,n=36,80 mg/日)和观察组(给予大剂量的缬沙坦,n=37,160 mg/日),比较两组左心室结构参数,包括左心室收缩末期内径(LVESD)、左心室舒张末期内径(LVEDD)、室间隔厚度(IVSD)和左室后壁厚度(LVPWD)以及左心室功能参数,包括左心室收缩末容量(LVESV)、左心室舒张末容量(LVEDV)、左心室射血分数(LVEF)、心输出量(CO)的差异。结果两组患者经治疗后左心室结构(LVESD、LVEDD、IVSD及LVPWD)、左心功能(LVESV、LVEDV、LVEF及CO)与治疗前比较均有显著改善(P均0.05);与对照组治疗后相比,观察组改善更为显著(P均0.05);观察组患者不良反应发生率为13.5%,与对照组8.1%相比差异无统计学意义(P0.05)。结论大剂量缬沙坦治疗急性心肌梗死可显著改善患者的梗死后心室重构。     

Catheter ablation for atrial fibrillation results in greater improvement in cardiac function in patients with low versus normal left ventricular ejection fraction

Purpose

It is still unknown whether left ventricular ejection fraction (LVEF) might affect the magnitude of improvement after atrial fibrillation (AF) ablation on cardiac function in persistent or longstanding persistent AF (CAF) patients.

Method

We performed echocardiography in 35 patients with CAF before and after catheter ablation (CA). Patients were stratified by LVEF into two groups prior to CA—normal LVEF (≥50 % LVEF, N group, n?=?24) and a low LVEF group (<50 % LVEF, L group, n?=?11). Patients were followed at 1 month, 3 months, 6 months, 1 year, and 2 years after ablation.

Results

After 15.8?±?7.4 months follow-up, the L group showed greater improvement in LVEF and left atrial ejection fraction (LAEF; N group vs L group: LVEF difference (%), 5?±8 vs 20±?13, p?<?0.01; LAEF difference (%), 11?±?12 vs 21?±?10, p?<?0.05). LA maximal volume and E/e′ showed the same tendency after ablation, although the extent of improvement was not statistically significant. Both groups showed almost the same time course of improvement up to 2 years, although the L group showed earlier recovery in LVEF.

Conclusion

The greater improvement in several cardiac functions was seen in patients with greater LV dysfunction, after the CA for CAF.     

Efficacy and safety of catheter ablation vs. rate control of atrial fibrillation in systolic left ventricular dysfunction

Purpose

It is unclear what constitutes the optimal strategy for management of atrial fibrillation (AF) in patients with systolic left ventricular (LV) dysfunction. We hypothesized that catheter ablation of AF had benefits compared with rate control in patients with systolic LV dysfunction.

Methods

PubMed, Embase, and the Cochrane Library were searched for randomized controlled trials and nonrandomized, observational studies. Weighted mean differences (WMD) and 95?% confidence intervals (CIs) were calculated to compare the improvement of left ventricular ejection fraction (LVEF), functional capacity, and quality of life between a catheter ablation group and a rate control group.

Results

Six trials with 324 patients were included in the analysis. Patients in the catheter ablation group had greater improvement of LVEF (WMD: 8.89; 95?% CI: 6.93–10.86; p?<?0.001), 6-min walk distance (WMD: 46.9; 95?% CI: 28.5–65.4; p?<?0.001), and lower Minnesota Living With Heart Failure Questionnaire (MLHFQ) scores (WMD: ??19.6; 95?% CI: ??23.6–??15.7; p?<?0.001) compared with patients in the rate control group. Overall, there were only ten procedure-related events and the procedure-related events rate was 4.9?% per procedure and 5.6?% per patient.

Conclusion

The present analysis suggests that catheter ablation of AF has benefits in terms of an improvement in LVEF, in functional capacity, and in quality of life compared with rate control in patients with systolic LV dysfunction, and the risk of complications related to procedures is acceptable.

     

Native QRS narrowing reflects electrical reversal and associates with anatomical reversal in cardiac resynchronization therapy

Purpose

Abbreviation of paced QRS duration has been taken as electrical resynchronization imposed by cardiac resynchronization therapy (CRT). However, little is known about alteration in native QRS duration and its correlation with therapeutic response as well as anatomical remodeling post-CRT.

Methods

Data of 74 consecutive patients with complete ECG records were reviewed. Response was defined as absolute improvement in LVEF by ≥10 % from baseline. Changes in native QRS duration (native ΔQRS) were analyzed to CRT response and to changes in echocardiography.

Results

Over median follow-up of 13 months, 47 patients had response to CRT and 30 subjects had abbreviation in native QRS duration. Native ΔQRS correlated positively with QRS duration pre- and post-CRT as well as with changes in echocardiography. Reversal of electrical remodeling as assessed by native QRS narrowing accompanied with greater improvements in LVEF (20 %?±?11 % vs 10%?±?10 %, p?=?0.000) and LVEDD (14?±?11 mm vs. 4?±?10 mm, p?=?0.000). Multivariate analysis indicated that native ΔQRS was the lone independent factor of ECG in association to response to CRT (OR1.049, 95%CI 1.015–1.085, p?=?0.004): 83.3 % of patients with native QRS reduction were responders. Among the non-responders, 18.5 % had native QRS narrowing at follow-ups.

Conclusions

Native QRS narrowing associated with beneficial response and greater improvements in echocardiography. Abbreviation in native QRS duration could reflect electrical reversal imposed by CRT.     

Evaluation of trimetazidine in angina pectoris by echocardiography and radionuclide angiography: a meta-analysis of randomized, controlled trials

Background:

The objective of this meta‐analysis was to evaluate the efficacy of the metabolic agent trimetazidine (TMZ) as monotherapy in the treatment of stable angina pectoris, from echocardiography and radionuclide angiography data.

Hypothesis:

Treatment with TMZ proved to be as effective as other first‐line antianginal agents for coronary patients, and it provided additional efficacy in combination with hemodynamic agents.

Methods:

A search of the literature published between 1965 and 2008 was performed on the MEDLINE and EMBASE databases. Only randomized, controlled trials were included in this meta‐analysis. Patients had to be treated for at least 2 weeks with data on the following 4 parameters at baseline and at the end of the treatment period: left ventricular ejection fraction (LVEF), LV end‐diastolic volume (LVEDV), LV end‐systolic volume (LVESV), and wall motion score index (WMSI). The quality of the trials was assessed by the Jadad score.

Results:

Eleven clinical studies meeting our criteria were analyzed. Results showed that TMZ significantly improved LVEF, with a mean increase of 6.88% (95% confidence interval [CI]: 5.50–8.25), and significantly reduced LVESV by 11.58 mL (95% CI: 5.79–17.37) and WMSI by 0.23 (95% CI: 0.07–0.38). Changes in LVEDV were variable. In both the long term and the short term, TMZ can improve LV function. The efficacy was unchanged in patients with diabetes mellitus.

Conclusions:

This meta‐analysis confirmed the efficacy of TMZ monotherapy in improving LV function compared with placebo. © 2011 Wiley Periodicals, Inc. The authors have no funding, financial relationships, or conflicts of interest to disclose.     

Evaluation of the response to pharmacological stress in chronic aortic regurgitation

We evaluated the hemodynamic response of patients with chronic aortic regurgitation and decreased ejection fraction (EF), mean value +/- SD (37 +/- 9), to dobutamine stress echocardiography (DSE). Eleven patients were studied with DSE. Nine patients were in New York Heart Association (NYHA) Class II and two in NYHA Class III. Ten patients received medical treatment in the only other periodic evaluation. With DSE in nine patients, a significant decrease in left ventricular end-diastolic and end-systolic diameters (LVEDD and LVESD) as well as LV end-diastolic and end-systolic volumes (LVEDV and LVESV) was documented in comparison to resting values. EF and fractional shortening (FS) improved significantly with DSE. Systolic wall stress (SWS) and pulmonary arterial systolic pressure (PASP) did not change. Average follow-up was 6.7 months. Three patients underwent valve replacement with mechanical prostheses. Two of them are in NYHA Class I and the other died of LV failure 3 days after surgery. One patient deteriorated beyond surgical treatment and was in NYHA Class II. The other seven patients remain in NYHA Class II and await valve replacement. In patients with chronic aortic regurgitation and depressed EF, the variables relevant to myocardial reserve appear to be EF, FS, LVEDD, LVESD, LVEDV, and LVESV.     

Laparoscopic versus open total gastrectomy with D2 dissection for gastric cancer: a meta-analysis

Objective

To elucidate the feasibility and safety of laparoscopic total gastrectomy with D2 dissection (LTGD2) for gastric cancer in comparison with open total gastrectomy with D2 dissection (OTGD2).

Background

More surgeons have chosen laparoscopic total gastrectomy as an alternative to open total gastrectomy. But no meta-analysis has been performed to evaluate the value of LTGD2.

Methods

Original articles compared LTGD2 and OTGD2 for gastric cancer, which published in English from January 1990 to March 2013 were searched in PubMed, Embase, and Web of Knowledge by two reviewers independently. Operative time, blood loss, harvested lymph nodes, analgesic medication, first flatus day, postoperative hospital stay, postoperative complications, and hospital mortality were compared using STATA version 10.1.

Results

8 studies were selected in this analysis. A total of 1,498 patients were included (559 in LTG and 939 in OTG). LTGD2 showed longer operative time (WMD 39.29; 95 % CI 20.52, 58.06; P < 0.001), less blood loss (WMD ?157.94; 95 % CI ?245.25 ?70.62; P < 0.001), fewer analgesic requirements (WMD ?2.01; 95 % CI ?3.10, ?0.93; P < 0.001), earlier passage of flatus (WMD ?0.73; 95 % CI ?1.19, ?0.27; P = 0.002), earlier hospital discharge (WMD ?2.69; 95 % CI ?3.42, ?1.97; P < 0.001), and reduced postoperative morbidity (RR 0.70; 95 % CI 0.50, 0.98; P = 0.035). The number of harvested lymph nodes (WMD 0.27; 95 % CI ?1.43, 1.98; P = 0.752) and hospital mortality rate (RR 0.57; 95 % CI 0.11, 3.09; P = 0.513) were similar.

Conclusion

LTGD2 was associated with less blood loss, less postoperative pain, quicker bowel function recovery, shorter hospital stay, and reduced postoperative morbidity, at the expense of longer operative time. No statistical differences were observed in lymph node dissection, and hospital mortality, which indicated the similar ability of lymph nodes clearance and short-term outcomes with OTGD2. A positive trend was indicated toward LTGD2. So we encourage the experienced surgeons to achieve LTGD2 instead of OTGD2. Whereas, due to non-randomized control trails and lack of long-term outcomes, more studies are required.     

Dabigatran in the peri-procedural period for radiofrequency ablation of atrial fibrillation: efficacy, safety, and impact on duration of hospital stay

Purpose

Dabigatran is effective for both the prevention of stroke and bleeding in patients with atrial fibrillation (AF). However, the safety and efficacy of the use of dabigatran in the peri-procedural period for radiofrequency catheter ablation (RFCA) of AF is unknown. Therefore, the purpose of this study was to evaluate the safety and efficacy of dabigatran in the peri-procedural period for RFCA of AF and the duration of hospital stay.

Methods

Consecutive patients (n?=?227) who underwent RFCA for AF were prospectively analyzed. Peri-procedural anticoagulant therapy with dabigatran (n?=?101, D group) was compared with warfarin and heparin bridging (n?=?126, W group). Dabigatran was discontinued 12–24 h before and restarted 3 h after the procedure. Warfarin was stopped 3 days before the procedure and unfractionated heparin was administered.

Results

Ischemic stroke occurred in one patient of the D group (0.8 %). There was no significant difference between the two groups in the incidence of major bleeding (three cases of cardiac tamponade in each group and one case of intracranial bleeding in the W group, p?=?0.93) or minor bleeding (five cases in the D group vs. five in the W group, p?=?0.54). The duration of hospital stay was significantly shorter in the D group than in the W group (7.2 vs. 10.3 days, p?=?0.0001).

Conclusions

Peri-procedural anticoagulation therapy with dabigatran for RFCA of AF was equally safe and effective compared with warfarin and heparin bridging. The use of dabigatran for RFCA of AF shortened the duration of hospital stay.     

Heart involvement in systemic lupus erythematosus: a systemic review and meta-analysis

Cardiovascular diseases are one of the most important causes of the disability and mortality in patients with systemic lupus erythematosus (SLE). The present study examined the cardiac abnormalities in patients with SLE by echocardiography. Case-control studies were obtained by searching PubMed MEDLINE, Embase, and MD Consult. Systemic review and meta-analysis were performed to assess the cardiac abnormalities based on the changes in the echocardiography in patients with SLE. Twenty-two studies including 1117 SLE patients and 901 healthy controls were enrolled into this study. We found that patients with SLE developed the pericardial effusion (odds ratio (OR) (95 % confidence interval (CI)) 30.52 (9.70–96.02); p < 0.00001) and the combined valvular alterations (OR (95 %CI) 11.08 (6.98–17.59); p < 0.00001). In addition, SLE patients also exhibited an increase in the left atrial diameter (LAD) (WMD—weighted mean difference (95 %CI) 0.18 (0.06–0.29); p = 0.002), the left ventricular internal diameter in diastole (LVDd) (WMD (95 %CI) 0.07 (0.02–0.12); p = 0.01), and the left ventricular mass index (LVMI) (WMD (95 %CI) 5.69 (2.69–8.69); p = 0.0002). In contrast, the left ventricular systolic function (WMD (95 %CI) ?1.22 (?1.69 to ?0.75); p < 0.00001) and diastolic function including E/A ratio and E/E’ ratio (WMD (95  % CI) ?0.13 (?0.24 to ?0.01); p = 0.04; WMD (95  % CI) 1.71 (0.43 to 2.99); p = 0.009) were decreased in SLE patients. Patients with SLE are associated with significant alterations in cardiac structure and function as demonstrated by echocardiography. Data from this study suggest that echocardiographic assessment should be considered as a part of routine examinations for SLE patients clinically.     

Immediate and medium-term outcomes of cryoballoon-based pulmonary vein isolation in patients with paroxysmal and persistent atrial fibrillation: single-centre experience

Background

Pulmonary vein (PV) isolation with cryoballoon is a recently developed technique for the treatment of atrial fibrillation (AF) with acceptable mid-term results in terms of the success and safety. The purpose of our study is to identify the periprocedural complications, mid-term success rates and predictors of recurrence after AF ablation with cryoballoon.

Method

A total of 236 patients (54 % male, mean age 54.6?±?10.45 years and 79.6 % paroxysmal AF) with symptomatic AF underwent PV isolation with cryoballoon due to failure with ≥1 antiarrhythmic drug previously. Procedural success, complications and follow-up data were defined according to recent guidelines.

Results

Acute procedural success rate was 99.5 %. Mean procedural and fluoroscopy times were 72.5?±?5.3 and 14?±?3.5 min. At a median of 18 (6–27)?months follow-up, 80.8 % of paroxysmal AF patients and 50.0 % of persistent AF patients were free from AF recurrence. In multivariate regression analysis, body mass index (BMI) (hazard ratio (HR), 1.35; 95 % confidence interval (CI), 1.18–2.93, p?=?0.001), smoking (HR, 2.12; 95 % CI, 1.36–6.67, p?<?0.001), non-paroxysmal AF (HR, 1.26; 95 % CI, 1.12–2.56, p?=?0.024), duration of AF (HR, 1.42; 95 % CI, 1.18–2.61, p?=?0.015), left atrium (LA) diameter (HR, 2.42; 95 % CI, 1.64–5.88, p?<?0.001) and early AF recurrence (HR, 4.88; 95 % CI, 2.86–35.6, p?<?0.001) were independent predictors of AF recurrence following cryoablation.

Conclusion

Our results showed that AF ablation with cryoballoon is effective and safe. Non-paroxysmal AF, duration of AF, smoking, BMI, LA diameter and early recurrence were found to be the most powerful predictors and could be helpful to select patients for appropriate therapeutic strategy.     

Single-incision laparoscopic colectomy versus conventional multiport laparoscopic colectomy: a meta-analysis of comparative studies

Objective

This study aimed to compare single-incision laparoscopic colectomy (SILC) to conventional multiport laparoscopic colectomy (MLC).

Background

Single-incision laparoscopic surgery (SILS) is a minimally invasive technique being recently applied to colorectal surgery. A number of studies comparing SILC to conventional MLC have recently been published.

Methods

A literature search of PubMed and MEDLINE databases for studies comparing SILC to conventional MLC was conducted. The primary outcome measures for meta-analysis were postoperative complications, length of stay, and operative time. Secondary outcome measures were incision length, estimated blood loss, and number of lymph nodes harvested.

Results

Fifteen studies comparing 467 patients undergoing SILC to 539 patients undergoing conventional MLC were reviewed and the data pooled for analysis. Patients undergoing SILC had a shorter length of stay (pooled weighted mean difference (WMD)?=??0.68; 95 % CI?=??1.20 to ?0.16; p?=?0.0099), shorter incision length (pooled WMD?=??1.37; 95 % CI?=??2.74 to 0.000199; p?=?0.05), less estimated blood loss (pooled WMD?=??20.25; 95 % CI?=??39.25 to ?1.24; p?=?0.037), and more lymph nodes harvested (pooled WMD?=?1.75; 95 % CI?=?0.12 to 3.38; p?=?0.035), while there was no significant difference in the number of postoperative complications (pooled odds ratio?=?0.83; 95 % CI?=?0.57 to 1.20; p?=?0.33) or operative time (pooled WMD?=?5.06; 95 % CI?=??2.91 to 13.03; p?=?0.21).

Conclusion

SILC appears to have comparable results to conventional MLC in the hands of experienced surgeons. Prospective randomized trials are necessary to define the relative benefits of one procedure over the other.     

超声三维斑点追踪技术检查肝硬化患者左心室收缩功能初步研究

目的 探讨三维斑点追踪成像技术（3D-STI）在肝硬化患者左心室收缩功能检查中的应用价值。 方法 选取68例肝炎肝硬化患者和30例健康体检者,进行超声检查,常规测量左室舒张末期内径（LVEDD）、左室收缩末期内径（LVESD）、左室舒张末期容积（LVEDV）、左室收缩末期容积（LVESV）、射血分数（LVEF）,并采用3D-STI测定心肌不同部位的收缩期峰值应变。采用ROC预测模型评估基底段、中间段、心尖段、心尖帽的收缩期峰值应变对患者预后的预测价值。 结果 肝硬化患者LVEDV和LVESV [（122.7±16.3） ml和（46.2±6.2） ml]均显著高于健康人[（102.6±12.2） ml和（35.3±5.2） ml,P<0.001],两组LVEDD、LVESD、LVEF差异无统计学意义（P>0.05）;肝硬化患者基底段、中间段、心尖段、心尖帽的收缩期峰值应变[（18.8±4.3）、（19.2±4.2）、（18.6±3.5）、（19.2±4.1）]均显著低于健康人[（21.3±5.2）、（23.8±3.9）、（22.4±4.1）、（23.9±4.3）,P<0.001];随访期间,失访3例,死亡21例。ROC曲线分析显示,基底段、中间段、心尖段、心尖帽的收缩期峰值应变对肝硬化患者死亡预测模型的曲线下面积分别为0.857、0.893、0.869、0.866,应变值分别为18.85、20.05、16.25、18.05,其敏感度分别为78.6%、69.0%、85.7%、74.7%,特异度分别为82.0%、91.0%、66.7%、84.5%。 结论 肝硬化患者多伴随左心室局部收缩功能减退,3D-STI检测有利于发现肝硬化患者左心室收缩障碍,且对患者预后有一定的预测作用。     

Common genetic variants in selected Ca2+ signaling genes and the risk of appropriate ICD interventions in patients with heart failure

Purpose

Defective Ca²⁺ handling in failing cardiomyocites predisposes patients with heart failure (HF) to ventricular arrhythmia. We investigated whether gene variants of Ca²⁺ handling proteins are associated with the occurrence of ventricular tachycardia/fibrillation (VT/VF) in HF patients implanted with a primary prevention implantable cardioverter-defibrillator (ICD).

Methods

One hundred thirty-six patients with HF were followed from ICD implantation to the time of first appropriate ICD intervention for VT?>?170 bpm. The following polymorphisms were genotyped: ATP2A2 rs1860561 and rs56243033; RYR2 rs4142933; CASQ2 rs4074536; SLC8A1 g.-23449C?>?A; PLN rs12198461; FKBP1B rs7568163. Hazard ratios (HR) were derived from Cox proportional-hazards regression analysis.

Results

After a mean follow-up of 879 days (IQ range, 327 to 1,459), 34 patients (25 %) had appropriate ICD intervention. Non-sustained VT (HR, 2.12; 95 %CI, 0.87–5.19; p?=?0.09) and atrial fibrillation (AF) at ICD implantation (HR, 2.33; 95 %CI, 0.89–6.10; p?=?0.08) predicted appropriate ICD interventions with borderline statistical significance. Prevalence of ATP2A2 rs1860561 variant was 17 % in patients without VT/VF and 4 % in those with ventricular arrhythmia (p?=?0.009). After adjustment for AF and NSVT, the rs1860561 A mutant allele independently predicted lower incidence of VT/VF (HR, 0.29; 95 %CI, 0.09–0.98; p?=?0.04).

Conclusions

The observation that ATP2A2 rs1860561 gene variant associated with lower risk of life-threatening arrhythmia in HF patients suggests that selected calcium gene variants may modify the risk of SD even within the complex and polygenic pathological condition of HF. Combining traditional risk factors and genetic profiling could reveal helpful to identify HF patients who will benefit most from ICD implantation.     

Effect of continuous positive airway pressure on homocysteine levels in patients with obstructive sleep apnea: a meta-analysis

Purpose

Continuous positive airway pressure (CPAP) is an effective treatment for obstructive sleep apnea hypopnea syndrome (OSAHS), but previous studies assessing the effect of CPAP on homocysteine (HCY) in patients with OSAHS yielded conflicting results. In this study, we conducted a meta-analysis to determine whether CPAP therapy could reduce plasma HCY levels.

Methods

Searches of PUBMED, SCI, and Elsevier databases were completed. Studies of adult patients with OSAHS who reported HCY levels pre- and post-CPAP treatment were collected by two independent reviewers. RevMan (version 5.2) and STATA (version 12.0) were used to perform data synthesis.

Results

A total of 6 studies involving 206 participants were included. Meta-analysis showed that the total weighted mean difference (WMD) for HCY levels was ?0.62 units (95 % confidence interval (CI) ?1.21 to ?0.04, P?P?>?0.05), but it was significantly reduced after 3 months therapy (WMD, ?1.22, 95 % CI ?2.07 to ?0.38,P?Conclusions This meta-analysis suggests that HCY levels were significantly reduced by CPAP therapy in patients with OSAHS and the HCY levels may be clinically recognized as a valuable indicator for OSAHS treatment, but the clinical significance of this finding as it relates to cardiovascular risk reduction in OSAHS patients warrants further study.     

Comparison of left atrial electrophysiologic abnormalities during sinus rhythm in patients with different type of atrial fibrillation

Objective

The purpose of this study is to explore the left atrium (LA) electrophysiologic abnormalities in atrial fibrillation (AF) patients detected during sinus rhythm and to determine the relationship between the type of AF and the electrophysiologic substrate in the LA.

Methods

Eighty patients with AF (30 paroxysmal AF, 22 persistent AF, and 28 long-standing AF) and 20 age- and sex-matched patients with left-sided accessory pathway were prospectively studied. High-density three-dimensional electroanatomic mapping was performed during sinus rhythm in LA, which was divided into six segments for regional analysis. Mean bipolar voltage, low voltage zone (LVZ) distribution, LA activation time, and electrogram complexity were assessed.

Results

The LA mean voltage was 3.67?±?0.68 mV in no AF group, 2.16?±?0.63 mV in the paroxysmal, 1.81?±?0.36 mV in the persistent, and 1.48?±?0.34 mV in the long-standing AF patients (P?<?0.001). The total LA activation time was 75.3?±?5.4 ms in no AF, 89.7?±?12.3 ms in paroxysmal AF, 104.9?±?6.1 ms in persistent AF, and 115.6?±?12.1 ms in the long-standing AF patients, respectively (P?<?0.001). With the progression of AF, there was a higher incidence of LVZ detection and increased prevalence of complex electrograms with 95 % of complex electrograms in areas with the bipolar voltage ≤?1.3 mV in persistent and long-standing AF patients.

Conclusion

Patients with AF have abnormal electrophysiologic substrate in sinus rhythm characterized by lower mean bipolar voltage, more prevalent complex electrograms, and longer LA activation time. This substrate progresses parallel to progression of AF type.     

Impact of cardiac resynchronization therapy using hemodynamically optimized pacing on left ventricular remodeling in patients with congestive heart failure and ventricular conduction disturbances

OBJECTIVES: We sought to investigate the impact of six months of cardiac resynchronization therapy (CRT) on echocardiographic variables of left ventricular (LV) function. BACKGROUND: Cardiac resynchronization therapy has recently been introduced as a new therapeutic modality in patients with advanced heart failure (HF) and conduction abnormalities. However, most studies have only investigated the early hemodynamic effects of CRT. METHODS: Twenty-five patients (12 women and 13 men; 59.8 +/- 5.1 years old) with advanced HF caused by ischemic (n = 7) or idiopathic dilated cardiomyopathy (n = 18) and a prolonged QRS complex were analyzed. All patients underwent early hemodynamic testing with a randomized testing protocol; echocardiographic measurements were compared before implantation and after six months of CRT. RESULTS: Left ventricular end-diastolic and end-systolic diameters (LVEDD and LVESD, respectively) were significantly reduced after six months (LVEDD from 71 +/- 10 to 68 +/- 11 mm, p = 0.027; LVESD from 63 +/- 11 to 58 +/- 11 mm, p = 0.007), as were LV end-diastolic and end-systolic volumes (LVEDV from 253 +/- 83 to 227 +/- 112 ml, p = 0.017; LVESV from 202 +/- 79 to 174 +/- 101 ml, p = 0.009). Ejection fraction was significantly increased (from 22 +/- 7% to 26 +/- 9%, p = 0.03). "Nonresponders," with regard to LV volume reduction, had significantly higher baseline LVEDV, compared with "responders" (351 +/- 52 vs. 234 +/- 74 ml, p = 0.018). Overall, there was only mild mitral regurgitation at baseline, with a minor reduction by semiquantitative analysis. The results of early hemodynamic testing did not predict the volume response. CONCLUSIONS: Cardiac resynchronization therapy may lead to a reduction in LV volumes in patients with advanced HF and conduction disturbances. Volume nonresponders have significantly higher baseline LVEDV.     

Determination of left ventricular volumes and ejection fraction by nuclear magnetic resonance imaging

To determine the ability of nuclear magnetic resonance (NMR) imaging to assess left ventricular (LV) volumes and ejection fraction (EF), we studied 24 patients within 48 hours of single-plane LV angiography. In all patients, a transverse, single-plane NMR acquisition technique was employed with LV end-diastolic (ED) and end-systolic (ES) volumes (V) calculated by a modified area-length algorithm. In nine patients, a multislice acquisition technique was employed with LVEDV and LVESV calculated by a Simpson's rule algorithm. NMR-determined LVV and EF correlated reasonably well with angiographic values (LVEDV: r = 0.75; LVESV: r = 0.90; and LVEF: r = 0.76). The single-plane NMR technique significantly underestimated LVEDV (p less than 0.01), whereas no significant difference was demonstrated for LVESV. As a result, angiographic LVEF was significantly underestimated (p less than 0.05). This underestimation is likely related to off-axis imaging and to the geometric constraints of a single-plane algorithm. In comparing multislice NMR to angiographic data, no significant difference was demonstrated for LVEDV, LVESV, or LVEF. Thus, quantitation of LVV and EF with NMR is feasible, and comparison to angiographic volumes is similar to results reported from other noninvasive imaging modalities. Improvement in current acquisition techniques and software should result in further quantitative potential.