心功能不全与缺氧

缺氧 (ｈｙｐｏｘｉａ)是指氧的供应不能满足机体代谢的需要或组织的氧的利用过程发生障碍 ,使机体的代谢、机能和形态结构发生变化 ,甚至危及生命的一系列病理变化过程。缺氧的原因诸多 ,按照发生机制可以将缺氧粗略地分为低氧血症性、循环性和组织性缺氧。心功能不全是循环性缺氧的常见原因之一。1　心功能不全导致缺氧的机制心功能不全 (ｃａｒｄｉａｃｉｎｓｕｆｆｉｃｉｅｎｃｙ)是指在静脉回流正常的情况下 ,由于原发的心脏损害引起心排出量减少 ,不能满足组织代谢需要的一种综合征。其导致缺氧的发病机制包括有 :1 1　供血不足　氧的…     

Cardiac insufficiency in infectious endocarditis

The aim of this study of 101 cases of infective endocarditis was to determine the factors predisposing to cardiac failure, the prognostic factors of this complication and the therapeutic implications. A significant (p less than 0.05) Chi square test was the statistical reference. Fifty-two per cent of patients developed cardiac failure which was biventricular in 48 p. 100 of cases and the presenting symptom in 64 p. 100. The mean age of the patients with cardiac failure was 56.6 years with a clear male predominance. In 48 p. 100 of cases, cardiac failure complicated a pre-existing cardiac lesion which was usually acquired (84 p. 100). The commonest condition was valvular insufficiency of the aortic and mitral valves (70 p. 100 of cases with cardiac failure). Severe cardiac failure was observed more frequently and earlier in aortic than in mitral regurgitation. The commonest infecting organism was the streptococcus (53 p. 100 of cases with cardiac failure) and the most frequent presumed portal of entry was dental (25 p. 100). Arrhythmias were observed in 51 p. 100 of patients in cardiac failure, the commonest being atrial fibrillation (34 p. 100) complicating mitral valve disease in 56 p. 100 of cases; 17 p. 100 of arrhythmias were ventricular. Conduction defects were observed in 26 p. 100 of cases with cardiac failure, 55 p. 100 of which had aortic valve disease. Valvular vegetations were demonstrated by echocardiography in 43 p. 100 of cases with cardiac failure. Valve replacement had to be performed for resistant cardiac failure in 13 p. 100 of cases.(ABSTRACT TRUNCATED AT 250 WORDS)     

Cardiac insufficiency and its morphological expression]

The paper sets forth materials reflecting the present-day views of morphologists concerning the problem of cardiac insufficiency. The current state of the problem relating to morphology of the myocardium in cardiac incompetence is characterized. It is suggested that cardiac incompetence cannot be approached as a unique issue, and in different affections the pathogenesis of the heart muscle debility may prove to be dissimilar. Ultrastructural changes in the left heart myocardium of the rabbit, at a distance from the ischemic area, in experimental myocardial infarction at the stage of compensatory hypertrophy and with developing acute cardiac incompetence are described. In the lastly named case the mitochondria of myocites were found to contain compact bodies, apparently made up of calcium phosphate. Their appearance comes as a proof of irreversibility of the supervened changes.     

Epidemiology of heart insufficiency

The epidemiology of congestive heart failure is not well known in France, despite its dramatic economic impact on the health care system. The number of patients with congestive heart failure is about 500,000 with 120,000 new cases per year. The incidence ranges from 4@1000 in men and 3@1000 in women 55-64 years old to 50@1000 in men and 85@1000 in women 85-94 years old. Mean age at onset is 73.5 years, and two thirds of the patients are older than 70 years of age. There are about 3,500,000 outpatient visits and 150,000 hospitalizations for congestive heart failure every year. It is responsible for more than 32,000 deaths every year. Costs of congestive heart failure represent more than 1% of the total medical costs. It represents a major and growing public health burden. This should encourage us to optimize its medical treatment and prevention.     

Surgery of heart insufficiency

Apart from heart transplantation for heart failure, the problem arises of which surgical approach should be adopted to treat this disorder. Ischemic heart disease can be surgically managed in three ways: via bypass, the Dor procedure, or by isolated or associated mitral plasty; however, cases of enlarged heart disease can only be surgically treated in two ways: i.e., by mitral plasty, or by the Batista procedure. In cases of ischemic heart disease, the following conditions must be present for coronary bypass: the patients should have an adequate contractile myocardial reserve, that is to say the left ventricle should not be greatly enlarged (< 80 mm in telediastole) or a cardiac output reserve, and there should not be any sign of over-high pulmonary hypertension (an index of > 1.6 or a pulmonary pressure of < 45); an assessment of myocardial viability should then be carried out, mainly based on a thallium fixation at rest and on echographically determined doubtamine-associated stress. In the present study, the mortality rate in a series of 260 patients was 6.3% for subjects aged under 70 years old, with an actuarial survival rate of 82% at one year post-surgery, and of 70% at five years. The Dor procedure can be used in the treatment of dyskinesia, which is now practically non-existent, but also in cases of acute akinesia with resulting left ventricular dysfunction. The aim of this technique is to alter the form of a cavity that has become ovoid to an elliptical form via the insertion of a circular endoventricular patch. The results reported for this technique show an improvement in functional class and ejection fraction. Finally, the technique for repairing mitral failure is more complicated than the two previous methods, as it requires a dynamic assessment of mitral failure, which is best carried out by an evaluation of echographically determined stress. Any mitral failure of ischemic origin of > grade 2 can be corrected during bypass surgery by ring insertion, thereby effecting a simple annuloplasty. On the other hand, the assessment of cases of enlarged heart disease is more complicated, and it is more difficult to carry out palliative surgery. The mitral plasty procedure proposed by Bolling is the technique of choice for patients with severe mitral failure, in general when the ventricle is not too enlarged. However, surgery involving the reduction in size of the left ventricle (the Batista procedure) always includes mitral plasty, and may be performed in patients with a very enlarged ventricle (> 70 mm), in general with moderate mitral failure. These two techniques have been critically assessed both as regards results and when they should be adopted, and their limitations have also been discussed. In conclusion, there are valid surgical alternatives to heart transplantation in cases of heart failure that does not respond to medical treatment, and they should probably be seriously considered before any decision is made to perform heart transplantation. These results appear encouraging, particularly in terms of functional class and left ventricular function, but there are conflicting results for hemodynamic improvement. As regards survival, it is not yet possible to propose prospective randomized trials to compare medical treatment with these surgical techniques. However, further development of these techniques is bound to occur, and an ever-widening gap will exist between the limited number of cases requiring transplantation and the more complex surgical approaches adopted in future, such as permanent circulatory backup or xenografts.     

Cardiac responses to β-adrenergic stimulation in anesthetized dogs with chronic congestive heart failure

Summary The cardiac responses to i. v. bolus injections of norepinephrine (NE, 5 and 10 g) and isoproterenol (ISO, 2 and 5 g) were compared in dogs with and without chronic congestive heart failure (CHF) induced by construction of a large infrarenal aortacaval fistula. Prior to establishing the shunt there was a significant increase in left ventricular pressure (LVSP), dp/dt_max cardiac output (CO) and stroke volume (SV) to both doses of NE. Pre-shunt there was a significant increase, in dp/dt_max, heart rate (HR), CO and SV to both doses of ISO. Following establishment of the shunt and CHF, there was a significantly depressed response of LVSP and dp/dt_max to both doses of NE compared to pre-shunt changes. Following the shunt and CHF, the response of LVSP was significantly greater at the 2 g dose of ISO while there was a depressed response of dp/dt_max at both, doses of ISO and a depressed chronotropic response of ISO at both doses. In eight dogs with ligated A-V fistulas and a return of hemodynamic variables as well as heart size to pre-shunt level, there was a reversal of inotropic and chronotropic response to ISO while the inotropic responses to NE were more variable and appeared to remain depressed. In a group of seven normal dogs which were volume expanded with isotonic, isooncotic dextran to similar levels of end diastolic pressures as the CHF dogs, the responses to ISO were not depressed. NE responses were not tested in this group. It is concluded that dogs with chronic volume overload heart failure have a reduced capacity to respond to exogenous catecholamines and that this phenomenon is not related to the volume expanded state of these animals.

---

Antwort auf -adrenerge Stimulation des Herzens bei narkotisierten Hunden mit chronischer Stauungsinsuffizienz

Zusammenfassung Bei Hunden mit und ohne chronische Stauungsinsuffizienz (CHF) als Folge einer großen aortokavalen Fistel wurde die Antwort des Herzens auf eine intravenöse einmalige Injektion von Noradrenalin (NE, 5 bzw. 10 g) und Isoproterenol (ISO, 2 bzw. 5 g) verglichen. Beide Dosen von Noradrenalin bewirkten vor Anlegen des Kurzschlusses einen signifikanten Anstieg des linksventrikulären Drucks (LVSP), des dP/dt_max, des Minutenvolumens (CO) und des Schlagvolumens (SV). Nach beiden Dosen von Isoproterenol ergab sich vor dem Kurzschluß ein signifikanter Anstieg von dP/dt_max, der Herzfrequenz (HR), des Minutenvolumens und Schlagvolumens. Nach Anlegen des Kurzschlusses und Eintritt einer Stauungsinsuffizienz war die Antwort des linksventrikulären Drucks und der maximalen Druckanstiegsgeschwindigkeit auf beide Dosen von Noradrenalin signifikant vermindert. Die Antwort des linksventrikulären Drucks auf 2 g Isoproterenol war nach Anlegen der Fistel und Eintritt der kongestiven Herzinsuffizienz signifikant gesteigert, während die Antwort von dP/dt_max und die chronotrope Antwort auf beide Dosen von Isoproterenol abnahm. Nach Unterbindung der AV-Fistel und Rückkehr der hämodynamischen Variablen und der Herzgrößen zum Ausgangszustand ergab sich bei 8 Hunden eine Umkehr der inotropen und chronotropen Antwort auf Isoproterenol, während die inotropen Antworten auf Noradrenalin größere Unterschiede zeigten und offensichtlich beeinträchtigt blieben. Bei einer Gruppe von 7 normalen Hunden wurde das Blutvolumen mit isotonischen, isoonkotischem Dextran gesteigert, so daß ein ähnlicher enddiastolischer Druck vorlag wie bei den Hunden mit Herzinsuffienz. Bei diesen Tieren wurde die Antwort auf Isoproterenol nicht vermindert. Die Antwort auf Noradrenalin wurde bei dieser Gruppe nicht untersucht. Es ergibt sich die Schlußfolgerung, daß Hunde mit Herzinsuffizienz auf der Grundlage chronischer Volumenüberbelastung eine herabgesetzte Ansprechbarkeit auf exogenes Katecholamin zeigen und daß dieses Phänomen nicht auf die Volumensteigerung als solche zu beziehen ist.

---

---

With 10 figures

---

Supported by National Institutes of Health Grant #HL13427 and by American Heart Association Grant #75-704.     

Amiodarone in heart insufficiency]

The purpose of this study was to analyse the effects of amiodarone on the treatment of cardiac failure. The effects of 200 mg/day of amiodarone were assessed in 18 patients with a history of cardiac failure. Functional class, heart rate, blood pressure, left ventricular ejection fraction, heart size, treadmill exercise tolerance and electrocardiogram were assessed before and eight weeks after the use of amiodarone, and the side effects were monitored. In 18 patients receiving amiodarone, the functional class and heart rate decreased significantly (p < 0.05) from 2.7 +/- 0.4 to 1.2 +/- 0.4 and 103 +/- 15 to 69 +/- 8.5 beats/min respectively. The ejection fraction and the exercise tolerance increased significantly (p < 0.05) from 29.2 +/- 5.5% to 41.5% and from 379.8 +/- 271 sec to 897.8 +/- 350.8 sec respectively. The incidence of atrial and ventricular arrhythmias decreased significantly and no side effects were observed. Amiodarone appears to produce benefits in patients with cardiac failure with atrial and ventricular arrhythmias.     

Therapeutic principles in pulmonary heart disease and right heart insufficiency

Until now the pathomechanism of pulmonary heart disease is insufficiently elucidated. Therefore, at present, rational therapeutical concepts are possible only in chronic obstructive lung diseases. Without any modification, the principle of comprehensive treatment of the basic pulmonary disease remains valid. In the symptomatic therapy of the pulmonary heart disease, in first place the long-term oxygen therapy becomes mandatory. Treatment with vasodilatory drugs remains in the long-term activity disappointing. Reasonable expectations are directed to clinical trials of angiotensin-converting-enzyme-inhibitors. Cardiac glycosides remain reserved for manifest cardiac failure. The stabilization of the acid-base-balance is of great importance for the efficacy of treatment. The decision on the use of additives depends upon a critical evaluation of the actual clinical state and upon the consideration of the risks from polymorbidity.     

充血性心力衰竭与慢性肾功能不全

心脏作为全身血液循环的中枢,在神经系统的控制下与肾脏共同调节机体血循环和稳定的血流动力学。不论是生理状态下还是病理状态下,心脏和肾脏是有着复杂联系的整体。充血性心力衰竭时肾脏是最易受累的器官,肾脏受累后又对心力衰竭的病程进展产生不利影响。充血性心力衰竭合并慢性肾功能不全的患病率远高出我们以往的认识。充血性心力衰竭和慢性肾功能不全从多方面相互影响,加重对方的功能障碍,加速对方病程的进展并对预后产生不利影响。