The dismal outcome in patients with acute leukaemia who relapse after an autograft is improved if a second autograft or a matched allograft is performed. Acute Leukaemia Working Party of the European Group for Blood and Marrow Transplantation (EBMT)

All patients receiving autografts for acute leukaemia in remission between 1 January 1981 and 31 December 1996 and reported to the European Group for Blood and Marrow Transplantation and had a relapse, were included. The patients underwent an allograft (n = 90, group A), were treated with chemotherapy (n = 2584, group B) or received a second autograft (n = 74, group C). The 2-year survival after relapse was 32 +/- 5%, 11 +/- 1% and 42 +/- 6% in groups A, B and C, respectively. In group A, those with an HLA-A, -B and -DR compatible related or unrelated donor had a 2-year survival of 37 +/- 7% compared to 13 +/- 8% for those receiving a graft from an HLA mismatched donor (n = 20). The following factors were associated with better survival in multivariate analyses: an interval from first autograft to relapse >5 months (P < 0.00001), a first autograft performed later than 1991 (P < 0.00001), patient age below 26 years (median, P < 0.002), group B vs HLA mismatches from group A (P = 0.002), group C vs group B (P < 0.005), patients who were not treated with total body irradiation at first autograft (P < 0.02) and patients in first remission at first autograft (P = 0.02). To conclude, the poor outcome in these patients was improved if a second autograft was feasible (P < 0.005), or if an HLA-matched allograft was performed (NS). Bone Marrow Transplantation (2000).     

Deterioration of left ventricular function following atrio-ventricular node ablation and right ventricular apical pacing in patients with permanent atrial fibrillation.

AIMS: Transcatheter radiofrequency ablation of the atrio-ventricular (AV) node followed by ventricular pacing has been shown to improve symptoms and quality of life of patients with atrial fibrillation (AF). It is assumed that function improves, but this has been less well demonstrated. The aim of this study was to assess the long-term effect of AV node ablation and ventricular pacing on left ventricular ejection fraction (LVEF) in patients with permanent AF. METHODS AND RESULTS: All 12 patients studied had permanent AF for at least 12 months (mean age 70 years, range 41 to 78). LVEF was determined 6 days and 3 months after AV node ablation by radionuclide ventriculography, at a paced rate of 80 beats . min (-1). Cardiac dimensions were measured by means of transthoracic echocardiography. No major changes in pharmacological therapy were made during 3 months follow-up period. LVEF showed a significant deterioration after 3 months follow-up period for the group (47.5 +/- 14.4%; 6 days after ablation vs 43.2 +/- 13.7%; 3 months after ablation, P < 0.05). There were no significant differences in left ventricular cavity dimensions directly after AV node ablation and 3 months later (LVEDD 51.2 +/- 10.7 mm vs 52.6 +/- 8.6 mm, P = NS: LVESD: 36.1 +/- 14.2 mm vs 36.6 +/- 9.7 mm, P = NS). Left atrial size did not show reduction 3 months after AV node ablation (50.8 +/- 13.6 mm vs 51.0 +/- 14.1 mm, P = NS). CONCLUSION: The restoration of a regular ventricular rhythm following AV node ablation for patients in permanent AF does not result in improvement in left ventricular function.     

Long-term survival and functional results after aortic valve replacement in asymptomatic patients with chronic severe aortic regurgitation and left ventricular dysfunction

OBJECTIVES: We examined the influence of medical treatment on the results of surgery in terms of long-term survival and functional results in patients with chronic, severe aortic regurgitation (AR). BACKGROUND: Asymptomatic patients with AR and a reduced left ventricular ejection fraction (LVEF) are at high risk because of a higher-than-expected long-term mortality. The influence of preoperative medical therapy on the outcome after aortic valve replacement (AVR) is not well known. METHODS: Surgery was indicated for the appearance of a reduced LVEF (<50%). At the time of AVR, there were 134 patients treated with nifedipine (group A), and 132 received no medication (group B). RESULTS: Operative mortality was similar in the two groups (0.75% vs. 0.76%, p = NS). The LVEF normalized in all of group A, whereas it remained abnormal in 36 group B patients (28%). At 10-year follow-up, LVEF persisted higher in group A (62 +/- 5% vs. 48 +/- 4%, p < 0.001). Five-year survival was similar in the two groups (94 +/- 2% vs. 94 +/- 3%, p = NS). Group A showed a 10-year survival not different from expected and significantly higher than that in group B (85 +/- 4% vs. 78 +/- 5%, p < 0.001), which had a worse survival than expected. CONCLUSIONS: Unloading treatment with nifedipine in AR allows one to indicate AVR at the appearance of a reduced LVEF with a low operative mortality and an optimal long-term outcome. The concept of surgical correction of AR indicated for reduced LVEF may not be applied to all patients. Indeed, in a large amount of untreated patients, a reduced LVEF preoperatively is not reversed by prompt surgery, indicating irreversible myocardial damage, and 10-year survival is worse than expected.     

急性心肌梗死后螺内酯干预对左室重构的影响

目的　探讨急性心肌梗死(AMI)患者应用螺内酯干预对于左室重构(LVRM)的影响。方法　4家医院共入选AMI患者88例,采用多中心、随机、对照的方法,对46例AMI患者在常规治疗的基础上加用螺内酯40mg/d(螺内酯组),对照组(n=42)常规治疗。在6个月干预期内检测两组血清Ⅲ型前胶原氨基端肽(PⅢNP)、脑钠肽(BNP)及超声心动图,以评价左室纤维化、左室功能和左室容积。结果　88例中,急性前壁心肌梗死患者43例,螺内酯组23例、对照组20例;急性下壁心肌梗死患者45例,螺内酯组23例、对照组22例。急性前壁心肌梗死组在治疗3、6个月时螺内酯组与对照组相比,血清PⅢNP和BNP明显降低[PⅢNP分别为( 260 .2±59. 9 )ng/L比( 328 .0±70 .3 )ng/L, P=0 .001, ( 197 .1±46 .3 )ng/L比( 266. 7±52 .4 )ng/L, P<0. 001 ,BNP分别为( 347 .4±84 .0)ng/L比(430 .1±62 .9)ng/L, P<0 .001, (243 .7±79. 7)ng/L比(334. 6±62. 8)ng/L, P<0. 001]。治疗6个月时螺内酯组较对照组左室舒张末期内径、左室收缩末期内径明显降低[分别为(51. 0±5 .5)mm比(55. 6±4 .5)mm, P=0 .005, (35 .7±4 .6)mm比(39 .1±5 .6)mm, P=0 .046]。急性下壁心肌梗死组在治疗6个月时螺内酯组与对照组相比血清PⅢNP、BNP水平无统计学意义,(P>0 05),并且左     

慢性心力衰竭患者心脏β1受体自身抗体与心功能的相关性及临床意义

目的 通过对慢性心力衰竭（心衰）患者血清中β1肾上腺素能受体自身抗体水平的监测,预测心功能情况,并指导β受体阻滞剂卡维地洛的临床应用。方法 65例心衰患者采用酶联免疫法测定患者血清中β1受体自身抗体水平,据此分为β1受体自身抗体阳性组（β1阳性组）30例和β1受体自身抗体阴性组（β1阴性组）35例,在血管紧张素转换酶抑制剂、利尿剂和洋地黄制剂治疗基础上加用β受体阻滞剂卡维地洛。随访半年,治疗前后采用超声心动图测量左室舒张末径（LVEDD）,左室收缩末径（LVESD）和左室射血分数（LVEF）进行比较。结果 （1）β1阳性组卡维地洛靶剂量明显高于β1阴性组[（36．25±14．31）mg／d与（25．97±8．83）mg／d],P〈0．01。（2）治疗前,p1阳性组心率显著高于p1阴性组[（94．19±14．46）次／min与（86．56±15．88）次／min],P〈0．05。治疗后,两组心率、血压均较治疗前显著减低（P〈0．01）,β1阳性组心率与β阴性组差异无统计学意义（P〉0．05）。（3）治疗前,β1阳性组LVEDD显著大于β1阴性组[（66．01±5．47）mm与（63．07±5．64）min],P〈0．05;LVESD大于β1阴性组[（54．24±8．43）mm与（50．72±6．12）min],P=0．052;LVEF显著低于β1阴性组[（32．16±9．00）％与（36．64±8．20）％],P〈0．05。治疗后,两组LVEDD、LVESD均较治疗前显著减小（P〈0．01）,LVEF较治疗前提高（P〈0．01）。β1阳性组LVEDD、LVESD和LYEF与β1阴性组差异无统计学意义（P〉0．05）。（4）β1阳性组治疗后血清中抗心脏β1受体自身抗体滴度较治疗前显著降低（1：119．35与1：72．21）,P〈0．01。结论 β1受体自身抗体参与心衰的病理生理过程,通过对β1受体自身抗体的检测可以预测患者的临床过程,提示对β1受体抗体阳性患者尽早使用β受体阻滞剂对于抑制心肌重构、改善心功能受益更大。     

Noninvasive therapy of gallbladder calculi with a radiopaque rim.

Safety and efficacy of shock-wave lithotripsy and bile acid dissolution therapy of patients with gallbladder calculi with a radiopaque rim were evaluated. Eighty-six patients with symptomatic solitary stones were treated by this noninvasive therapy and were followed up to 18 months. Three different lithotripsy treatment modalities were used. Up to 1600 shock wave discharges were applied. Patients in group A (n = 20) were treated with an electrohydraulic water-bath lithotripter at a discharge voltage of 18 +/- 1 kV (mean +/- SD), group B patients (n = 25) were treated with an electrohydraulic water-cushion lithotripter at 19 +/- 2 kV, and group C patients were treated (n = 41) with the same lithotripter at 22 +/- 2 kV. Five to eight months after lithotripsy, 15% in group A were free of fragments compared with only 4% in group B (NS vs. group A), and 38% in group C had no stones (NS vs. group A; P = 0.007 vs. B). Thirteen to eighteen months after lithotripsy, the respective results were 59% in group A, 37% in group B (NS vs. group A), and 68% in group C (NS vs. group A; P = 0.05 vs. group B). Patients with fragments of less than or equal to 3 mm in diameter showed significantly better fragment clearance than those with larger fragments. The frequency of adverse effects was not significantly different between the three groups. Biliary colic occurred in 43% of the patients and mild biliary pancreatitis in 3 patients. Endoscopic sphincterotomy was required in 1 patient, and elective cholecystectomy was performed in 6 patients. Using a water-cushion lithotripter at high-power setting, selected patients with solitary gallbladder stones with a radiopaque rim may be treated safely and successfully by shock-wave lithotripsy combined with bile acid dissolution therapy.     

Effect of cough on heart rate and blood pressure in patients with "cough syncope".

BACKGROUND: "Cough syncope" is uncommon, and its mechanism remains controversial. OBJECTIVES: This study evaluated susceptibility to cough-triggered neural reflex hypotension-bradycardia among cough syncope patients. We hypothesized that individuals with cough syncope would manifest not only more profound cough-triggered hypotension than do other fainters but also an inappropriate chronotropic response accompanying cough-induced hypotension, thereby supporting the notion that a neural reflex hypotension-bradycardia contributes to the condition. METHODS/RESULTS: Three patient groups were studied. Group 1 patients (n = 9) had "cough syncope." The remaining patients had recurrent faints of other causes: group 2 (n = 13) had a positive head-up tilt test, and group 3 (n = 18) had a negative tilt test. With cough, group 1 patients exhibited a greater drop in systolic pressure (-51 +/- 19.3 mmHg) than did either group 2 (-23 +/- 11.1 mmHg, P < .04) or group 3 patients (-28 +/- 12.4 mmHg, P < .05). Recovery time to normalization of systolic pressure was greater in group 1 (25 +/- 9.1 seconds) than in group 2 or 3 (8 +/- 2.7 seconds and 9 +/- 6.1 seconds, respectively, both P < .01 vs group 1). The expected positive chronotropic response accompanying cough-induced hypotension was diminished in group 1 patients (0.16 +/- 0.21 bpm/mmHg) compared with that in either group 2 (0.74 +/- 0.60 bpm/mmHg, P < .05 vs group 1) or group 3 (0.33 +/- 0.15 bpm/mmHg, P = .06 vs group 1). CONCLUSION: Cough syncope patients not only exhibit more pronounced hypotension in response to cough than other fainters, but they also manifest an inappropriate cough-triggered blood pressure-heart rate relationship. These findings argue in favor of the importance of a neurally mediated reflex contribution to symptomatic hypotension in cough syncope.     

Reversibility of cardiac abnormalities in human immunodeficiency virus (HIV)-infected individuals: a serial echocardiographic study.

Seventy adults who tested positive for human immunodeficiency virus (HIV) were prospectively studied with serial echocardiography to better define the prevalence and progression of cardiac disease in such patients. Fifty outpatients (Group A), including 44 with acquired immunodeficiency syndrome (AIDS) and 6 with AIDS-related complex, and 20 additional patients (Group B) with asymptomatic HIV infection had baseline echocardiographic studies at a time when no patient had symptomatic heart disease. Follow-up studies were performed at 9 +/- 3 months in 52 patients (74%) and again at 15 +/- 3 months after baseline studies in 29 patients (41%). During the study, 22 patients (44%) in Group A and 1 patient (5%) in Group B died. Cardiac abnormalities were noted in 26 patients (52%) in Group A and 8 patients (40%) in Group B (p = NS) on initial or follow-up study. An abnormal left ventricular ejection fraction (less than 45%) or fractional shortening (less than 28%) was seen in seven patients in Group A; of these, three had normal left ventricular function on a later echocardiogram. One patient in Group B had persistent left ventricular dysfunction. All patients in Group A with left ventricular dysfunction on two serial studies died within 1 year after the initial echocardiogram. Ejection fraction did not change between baseline and two follow-up studies in either group (A: 52 +/- 9 vs. 56 +/- 9 vs. 55 +/- 5%, p = NS; B: 58 +/- 6 vs. 58 +/- 5 vs. 59 +/- 6%, p = NS). Right-sided cardiac enlargement resolved in 18 patients (44%), including 5 of 10 in Group A and 3 of 8 in Group B.(ABSTRACT TRUNCATED AT 250 WORDS)     

Impact of ethanol dosing on the long-term outcome of alcohol septal ablation for obstructive hypertrophic cardiomyopathy: a single-center prospective, and randomized study.

BACKGROUND: The impact of ethanol dose on the long-term outcome of alcohol septal ablation (ASA) for obstructive hypertrophic cardiomyopathy was investigated. METHODS AND RESULTS: Fifty-four patients (age 24-82 years; 65% women) undergoing ASA were randomized into 2 groups according to the dose of injected ethanol: Group A 1-2 ml, Group B >2 ml. Clinical and echocardiographic data were obtained at baseline and during follow-up. The volume of ethanol injected was 1.50+/-0.4 and 2.60+/-0.6 ml (p<0.001) with a subsequent peak of creatine kinase-MB of 2.25+/-1.00 and 2.62+/-1.57 microkat/L (p=0.02) in Groups A and B, respectively. The median follow-up was 39 (range 6-72) months after ASA, during which 1 patient died and 1 repeat procedure was necessary in both groups of patients. Both groups had a significant and similar improvement in outflow pressure gradient, dyspnea (New York Heart Association functional class) and angina pectoris (Canadian Cardiovascular Society class) (p<0.001). There was a significant decrease in the left ventricular ejection fraction (LVEF) in Group B (81+/-7 vs 75+/-7%; p=0.002), but not in Group A (80+/-7 vs 79+/-7%; p=0.67). Thinning of the basal septum was more pronounced in Group B than in Group A (9.3+/-5.7 vs 6.6+/-3.4 mm; p=0.04). CONCLUSIONS: A lower dose of ethanol injected into the target septal branch reduces both the size of necrosis and subsequent thinning of the basal septum, and preserves LVEF during long-term follow-up. Moreover, the low dose (1-2 ml) is as safe and as hemodynamically efficacious as higher doses.     

冠状动脉内应用山莨菪碱对急性心肌梗死介入治疗后无再流及心室功能和收缩同步性的影响

目的探讨冠状动脉内应用山莨菪碱对急性心肌梗死介入治疗（AMI-PCI）后无再流患者的逆转作用并评价其对患者局部、整体心室功能和收缩同步性的影响。方法自2003年1月至2006年2月首发急性前壁心肌梗死并于12h内行急诊PCI的患者136例,根据心肌灌注分级方法（myocardial blush grade,MBG）确认无再流患者（MBG0-1级）47例（男36例,女11例）,平均年龄（63．23±11．24）岁,随机分为两组：A组（山莨菪碱组,24例）和B组（对照组23例）,A组于PCI后即刻由指引导管冠状动脉内注射山莨菪碱1000斗g／次,余治疗同B组。于PCI后即行左心室造影,测定心室容积、压力参数和室壁运动积分（wall motion score,WMS）;AMI后1周时行平衡法核素心室造影,测定左室整体和局部收缩功能、舒张功能和收缩同步性参数;AMI后6个月随访时重复行心室造影和核素心室造影检查测定上述参数,同时随访并记录术后6个月内主要不良心脏事件（MACE）的发生率。结果（I）A组患者在冠状动脉内应用山莨菪碱1000μg／次,平均（2．53±0．34）次后MBG由（0．74±0．32）级增加到用药后的（2．33±0．28）级。（2）AMI-PCI后6个月随访时,A组左室收缩末容积指数、左心室舒张末期容积指数、WMS和左室舒张末期压均较B组明显降低[（40．53±8．12）mL／m^2比（50．32±8．26）mL／m^2,（80．13±9．74）ml／m^2比（87．17±10．25）mL／m^2,（8．24±1．31）比（10．23±1．82）,（13．36±4．21）mmHg（1mmHg=0．133kPa）比（16．38±3．21）mmHg,P均〈0．05];核素心室造影参数比较,A组左室射血分数、峰射血率和峰充盈率等参数均较B组明显增加I（44．02±5．86）％比（38．52±5．18）％,（1．86±0．09）EDV／s比（1.61±0．09）EDV／s,（2．19±0．32）EDV／s比（1.78±0．17）EDV／s,P均〈0．05]。（3）A组AMI-PCI后6个月左室局部射血分数（LrEF）2-LrEF8均分别较B组增加13．96％、25．02％、30．36％、22．86％、27．67％、22．07％和18．71％（P均〈0．05）.（4）相位分析示A组左室收缩同步性参数相角程、半高宽和峰相位标准差亦均低于B组[（46．04±8．93）°比（53．19±16．62）°,P〈0．05;（23．02±6．27）°比（25．02±5．31）°,P〉0．05;（7．92±4．12）°比（11．76±4．11）°,P〈0．05]。（5）在6个月随访期内,A组MACE发生率明显低于B组。结论冠状动脉内注射山莨菪碱可明显逆转AMI-PCI后无再流现象,改善无再流患者的心室功能和收缩同步性,降低MACE发生率。     

再灌注心律失常对急性心肌梗死患者心肌细胞凋亡和左室重构的影响

目的探讨急性心肌梗死（AMI）患者再灌注心律失常（RA）、心肌细胞凋亡和左室功能的关系。方法156例经急诊再灌注治疗的AMI患者,分为RA组58例（24小时内出现RA）,非再灌注心律失常（Non．RA）组98例。应用ELISA方法,分别检测再灌注治疗成功后即刻、7天和2—4周血清细胞凋亡信号分子Fas／APO-1水平,并在1周、6个月和1年做心脏彩超,检测左室射血分数（LVEF）和左室舒张末期内径（LVEDD）。结果（1）RA组血管开通时间较Non-RA组晚,且前降支病变较Non-RA组发生率高（P〈0．05）。（2）再灌注治疗成功后即刻,RA组血清Fas／APO-1浓度明显高于Non-RA组[（13．82±4．36）μg/L与（8．19±3．56）μg/L,P〈0．05]。（3）再灌注治疗成功后第7天,两组患者血清Fas／APO-1浓度达高峰,2—4周时明显下降,与第7天比较差异有统计学意义[RA组（10．91±3．65）μg/L与（14．26±4．98）μg/L,P〈0．05;Non-RA组（4．69±1．87）μg/L与（12．19±3．25）μg/L,P〈0．01],且2—4周时RA组Fas／APO-1浓度明显高于Non．RA组[（10．91±3．65）μg/L与（4．69±1．87）μg/L,P〈0．01]。（4）AMI再灌注治疗成功后1周,RA组与Non-RA组比较,LVEF和LVEDD差异无统计学意义[LVEF（47．7±9．6）％与（49．2±8．9）％,P〉0．05;LVEDD（59．7±10．3）mm与（57．4±12．4）mm,P〉0．05]。（5）AMI再灌注治疗成功1年后,Non-RA组LVEF明显高于自身急性期和RA组[分别为（59．5±9．2）％、（49．2±8．9）％和（49．9±10．1）％,P〈0．05],LVEDD虽然无显著性变化（P〉0．05）,但有增加趋势。结论心肌缺血严重患者易发生RA,且与心肌缺血所诱发心肌细胞凋亡有关,影响左室功能的恢复,促进心室重构。     

Angiocardiographic left ventricular volume determination in tricuspid atresia. Comparison of patients with and without palliative surgery.

Group A (n = 10) had reduced pulmonary blood flow and no previous surgery, group B (n = 9) had decreased pulmonary blood flow despite a systemic-to-pulmonary artery shunt and those in group C (n = 10) had increased pulmonary blood flow 9 of whom had no previous surgery and 1 a large Waterston anastomosis. Left ventricular end-diastolic volume (LVEDV) and left ventricular systolic output (LVSO) were higher than normal in all 3 groups with an order of descending magnitude of group C (278 +/- 20% and 264 +/- 32%), group B (264 +/- 19% and 243 +/- 37%) and group A (189 +/- 14% and 190 +/- 13%). For the entire group A, left ventricular ejection fraction (LVEF) was normal (0.66 +/- 0.06 or 97 +/- 8%) with low systemic arterial oxygen saturation (SAO2) averaging 58%, but the LVEF of those infants less than 6 months with a mean SAO2 of 49% was lowered to 0.58 +/- 0.08 or 87 +/- 13% of normal. The ejection fraction was reduced to the greatest extent (0.50 +/- 0.04 or 81 +/- 6%) in group B patients who averaged 12.8 years of age and had undergone shunt procedures 10 months to 13.6 years, median 7.8 years previously. These findings indicate that a moderate degree of arterial desaturation appears to be better tolerated than a chronic volume overload in patients with tricuspid atresia.     

AMI患者PCI后心肌灌注水平对心功能及左室重构的影响

目的:探讨急性心肌梗死（AMI）患者经皮冠脉介入术（PCI）后TIMI血流III级时的心肌灌注水平及其对心功能与左室重构的影响。方法: 对36例AMI患者PCI后行经静脉心肌声学造影（MCE）和心脏二维超声检查。①利用心肌声学造影评分（MCS）及室壁运动评分(WMS)分析PCI后心肌灌注情况与室壁运动情况的关系;②根据声学造影积分指数（CSI）将患者分为A、B两组,比较两组的左室射血分数（LVEF）,评估心肌灌注水平对心功能的影响;③根据心脏二维超声结果,比较两组患者术后6个月时左室舒张末直径（LVEDD）及LVEF的变化,进一步评估心肌灌注水平对左室重构的影响。结果: PCI后梗死相关血管TIMI血流均达III级。共152节段与梗死相关血管的再灌注有关。①MCS为0分的18节段中,2个（11.1%）WMS为1~2分;MCS为0.5分的30节段中16个（53.3 %）WMS为1~2分;MCS为1分的104节段中,82个（78.8%）WMS为1~2分;统计学分析显示,PCI后心肌灌注水平与室壁运动呈正相关（P<0.05）。②心肌灌注好的A组LVEF显著大于B组［(52.1±3.4)%,(47.2±2.9)%,P<0.05］。③术后6个月A组的LVEF及LVEDD均无明显变化,B组的LVEF较前有所下降［(47.2±2.9)%,(43.8±4.4)%,P<0.05］,LVEDD较前有所增加［(50.2±2.9) mm,(56.3±3.1) mm,P<0.05］。结论: AMI患者PCI后心肌灌注水平与心功能及左室重构有一定相关性,良好的心肌灌注在一定程度上可以抑制左室重构。     

Increased arterial wave reflection may predispose syncopal attacks

BACKGROUND: The incidence of syncope increases with age, while aging is also associated with increased arterial wave reflection. HYPOTHESIS: The study was undertaken to determine whether increased arterial wave reflection is a predisposing factor of syncope. METHODS: We recruited 38 patients (28 men and 10 women, mean age 57.2 +/- 20.3 years, range 17-87 years) with a history of syncope within 6 months of entry. The etiology of syncope was documented for each patient by a complete assessment of vasomotor function and cerebral flow. All patients received a comprehensive echocardiographic evaluation of cardiac structure and function. Carotid augmentation index (AI) was estimated noninvasively with the tonometry technique. The results were compared with those from 54 age- and gender-matched controls. RESULTS: The most frequent diagnoses of syncope were postural hypotension (13 patients) and cerebrovascular dysautoregulation (10 patients), and the cause could not be determined in 9 patients. Compared with the control group, the syncope group had a greater AI (20 +/- 21 vs. 10 +/- 15%, p = 0.013). Subgroup analysis of 20 patients aged > 50 years and with the aforementioned diagnoses showed even more striking results: AI, 29 +/- 10 vs. 11 +/- 15%, p < 0.001. The enhanced augmentation in the patients remained when age, systolic blood pressure, height, and heart rate were accounted for. Analysis of the carotid pulse wave suggested that both the timing and intensity of wave reflection were enhanced in patients with a history of syncope compared with controls. CONCLUSIONS: Our results support the hypothesis that enhanced arterial wave reflection is associated with the occurrence of syncope, especially in the elderly.     

Syncope of unknown origin after electrophysiologic study: is the treatment with pacemaker useful?

The usefulness of pacemaker treatment appears doubtful in patients suffering from syncope of unknown origin after a complete diagnostic evaluation, which includes electrophysiological study. To better assess the effectiveness of this therapy, 24 patients with syncope of unknown origin and negative electrophysiological study were prospectively and alternatively assigned to treatment with pacemaker (group A) vs treatment without pacemaker (group B). Group A included 12 patients (7 males, 5 females) with a mean age of 64 +/- 10 years. No heart disease was present in 7 cases (58%); 3 cases had chronic ischaemic heart disease (25%) and 2 had hypertensive heart disease (17%). The standard ECG was normal in 7 patients, while various conduction abnormalities were observed in the other 5. The mean number of syncopal episodes was 4.8 +/- 3.9 per patient, and the mean between the onset of symptoms and the beginning of this study was 32 +/- 42 months. In these 12 cases a VVI-M pacemaker was implanted, at a programmed rate of 50 or 60 bpm; in three subjects, the pacemaker was of the diagnostic type ("bradycardia event counter"). Group B included 12 patients (8 females, 4 males) with a mean age of 56 +/- 11 years. Organic heart disease was absent in 7 cases (58%); 4 patients showed hypertensive heart disease (33%) and 1 had mitral prolapse (9%). The ECG was normal in 9 subjects. The mean number of syncopes was 3.2 +/- 1.5 per patient; the mean interval since the onset of symptoms was 18 +/- 19 months.(ABSTRACT TRUNCATED AT 250 WORDS)     

介入治疗对高龄急性心肌梗死患者临床预后的影响

目的　观察直接经皮冠状动脉内介入 (PCI)对高龄ST段抬高的急性心肌梗死 (STEMI)患者临床预后的影响。方法　STEMI连续行直接PCI的患者 1 56例 ,对IRA行直接PCI。随访 1～ 1 2个月患者主要心血管事件 (MACE)的发生率。结果　≥ 75岁组较 <75岁组中脑卒中比例较高 (P <0 0 5) ,患者发病至再灌注时间延长 (P <0 0 5) ,左室射血分数 (LVEF)降低 (P <0 0 5)。共随访 1 4 5例患者 ,两组住院期发生非致命性再次心肌梗死差异无显著性 ,但≥ 75岁组心脏性死亡增高 (9 4%比1 8% ,P <0 0 5) ;随访平均 (7 3± 3 2 )个月 ,≥ 75岁组患者总心脏性病死率明显高于 <75岁组(1 2 5 %比 1 8% ,P <0 0 5)。多变量logistic回归分析提示年龄≥ 75岁与LVEF值降低分别与STEMI患者行直接PCI后心脏性死亡增加密切相关 ,是心脏性死亡事件危险增高的独立预测变量。结论　年龄≥ 75岁因素可能是STEMI患者行直接PCI后心脏性死亡增加的独立预测因子     

Usefulness of left ventricular mass in predicting recovery of left ventricular systolic function in patients with symptomatic idiopathic dilated cardiomyopathy

Prognosis of idiopathic dilated cardiomyopathy (IDC) is variable. We determined the prognostic value of left ventricular (LV) mass and systolic and diastolic function in patients with IDC of <12 months duration. Clinical and echocardiographic assessment was performed at baseline and at 8+/-6 months follow-up in 25 patients (47+/-13 years) with IDC and an LV ejection fraction (LVEF1) of <40% (22+/-7%). Based on a follow-up LVEF (LVEF2) of < or >40%, patients were divided into unimproved (n = 13, LVEF2 = 21+/-9%) and improved groups (n = 12, LVEF2 = 51+/-11%). There was no difference in the LVEF1 (22+/-8% vs. 22+/-6%), LV end-systolic (5.7+/-0.8 vs. 5.8+/-0.9 cm) or end-diastolic (6.5+/-0.6 vs. 6.6+/-0.9 cm) dimension, wall stress (102+/-26 vs 99+/-28 g/cm2), end-systolic (1.7+/-0.3 vs. 1.8+/-0.2) or end-diastolic (1.7+/-0.3 vs. 1.6+/-0.1) sphericity, dp/dt (582+/-163 vs. 678+/-222 mm Hg/s), or right ventricular fractional shortening (20+/-9% vs. 27+/-7%, p = 0.06) in unimproved and improved groups. LV mass was lower (1.00+/-0.21 vs. 1.38+/-0.27 g/ml, p = 0007) and mitral inflow E-wave deceleration time shorter (97+/-42 vs. 164+/-58 ms, p = 0007) in the unimproved versus the improved group. On Pearson correlation analysis, LV mass (r = 0.62, p = 0.001), deceleration time (r = 0.68, p = 0.0002), wall motion score index (r = -0.47, p = 02), and dp/dt (r = 0.52, p = 03) were the significant predictors of LVEF2. There was correlation between LV mass (grams per milliliter) and deceleration time (r = 0.61, p = 0.001). During follow-up, death occurred in 1, and readmission for worsening heart failure in 4 patients in the unimproved group versus no hospitalization in the improved group. Thus, in patients with recent onset IDC, LV mass and diastolic function determine late outcome.     

Effect of preoperative transcatheter arterial chemoembolization on proliferation of hepatocellular carcinoma cells

AIM To evaluate the effect of preoperative transcatheter arterial chemoembolization (TACE) on proliferation of hepatocellular carcinoma (HCC) cells.METHODS A total of 136 patients with HCC underwent liver resection. Of 136 patients, 79 patients received 1 to 5 courses of TACE prior to liver resection (TACE group),who were further subdivided into four groups Group A (n = 11) who received 1 to 4 courses of chemotherapy alone; Group B (n = 33) who received 1 to 5 courses of chemotherapy combined with iodized oil; Group C (n = 23) who received 1 to 3 courses of chemotherapy combined with iodized oil and gelatin sponge; and Group D (n = 12) who received 1 to 3 courses of chemotherapy combined with iodized oil, ethanol and gelatin sponge.The other 57 patients only received liver resection (nonTACE group). The expressions of Ki-67 and proliferating cell nuclear antigen (PCNA) protein were detected in the liver cancer tissues by immunohistochemical method.RESULTS The Ki-67 protein expression was significantly lower in Groups C and D as compared with non-TACE group (31.35% ± 10.85% vs 44.43% ± 20.70%,30.93% ± 18.10% vs 44.43% ± 20.70%, respectively, P ＜ 0.05). The PCNA protein expression was significantly lower in Groups C and D as compared with non-TACE group (49.61% ± 15.11% vs 62.92% ± 17.21%, 41.16% ± 11.83% vs 62.92% ± 17.21%, respectively, P ＜ 0.05).The Ki-67 protein expression was significantly higher in Group A as compared with non-TACE group (55.44% ± 13.72% vs 44.43% ± 20.70%, P ＜ 0.05). The PCNA protein expression was significantly higher in Groups A and B as compared with non-TACE group (72.22% ± 8.71% vs 62.92% ± 17.21%, 69.91% ± 13.38% vs 62.92% ± 17.21%, respectively, P ＜0.05).CONCLUSION Preoperative multi-material TACE suppresses the proliferation of HCC cells, while a single material embolization and chemotherapy alone enhance the proliferation of HCC cells.     

Early and long-term results of coronary artery bypass grafting with severely depressed left ventricular performance

The effects of coronary artery bypass grafting (CABG) on ventricular performance and long-term clinical status were studied in 18 consecutive patients with disabling angina pectoris and severely depressed left ventricular (LV) performance (ejection fraction [EF] 27 +/- 9%). All patients survived CABG, although 1 patient had a perioperative myocardial infarction. There was no change in LVEF at rest, 29 +/- 12%, in the other 17 patients. However, LVEF during peak exercise increased from 22 +/- 7% to 27 +/- 14% (p less than 0.05). The 17 patients were separated into 2 groups: those who increased their peak exercise LVEF by at least 10% (group A, 8 patients) and those who increased it by less than 10% (group B, 9 patients). Preoperatively, patients in group A had a higher LVEF at rest (p less than 0.001) and smaller end-systolic and end-diastolic volumes at rest (p less than 0.001) and during exercise (p less than 0.005). Preoperatively, the LVEF in group A decreased with exercise, from 36 +/- 4% to 27 +/- 5% (p less than 0.01), but was unchanged in group B (19 +/- 3% vs 17 +/- 4%, difference not significant). After CABG, patients in group A had a smaller increase in end-systolic volume with exercise than those in group B (13 +/- 7 vs 34 +/- 22 ml/m2, p less than 0.05), but the changes in end-diastolic volume with exercise were not significantly different. At 27 +/- 5 months after CABG, 5 of 8 patients in group A were asymptomatic.(ABSTRACT TRUNCATED AT 250 WORDS)     

Implantable Cardioverter Defibrillator Utilization Among Device Recipients Presenting Exclusively with Syncope or Near-Syncope

ICD Use in Syncope. Introduction : Implantable cardioverter defibrillators (ICDs) are occasionally used in presumed high-risk patients with electrocardiographically undocumented syncope, although the incidence of ventricular tachyarrhythmias in this population is not well defined.
Methods and Results : We studied 33 consecutive patients receiving; an ICD (67% nonthoracotomy and 70% tiered therapy) after electrophysiologic testing for unmonitored "syncope" (n = 29) or "near-syncope" (n = 4). Atherosclerotic heart disease was present in 24 (73%); mean left ventricular ejection fraction (LVEF) was 0.39 ± 0.15; and sustained monomorphic ventricular tacycardia (SMVT) was inducible in 18 (55%). Over a median follow-up of 17 months (range 4 to 61), 12 patients (36%) received ≥ 1 appropriate ICD discharge triggered by SMVT (cycle length 230 lo 375 msec) in 10 and ventricular Mutter or fibrillation in 2—without concomitant antiarrhythmic medication in 8 of 12 cases, Inducible SMVT and LAEF ≤ 0.35 were statistically significant, independent predictors of an appropriate ICD discharge (P < 0.02 and P < 0.03, respectively). Estimated 1-year cumulative survival free of appropriate discharge was 34% versus 87%, respectively, in patients with versus without inducible SMVT (P < 0.02), and 18% versus 56%, respectively, in patients with LVEF ≤ 0.35 versus LVEF > 0.35 (P < 0.03).
Conclusion : In this highly select, multicenter population of ICD recipients with electrocardiographically undocumented syncope, a substantial incidence of appropriate device discharges was observed, particularly in patients with inducible SMVT and LVEF ≤ 0.35. These findings support the notion that, in patients with LV dysfunction and inducible SMVT, ventricular tachyarrhythmias are likely to account for episodes of syncope or near-syncope.