Experience of appendicular thermal therapy applied to a patient with a left ventricular assist device awaiting heart transplantation

Thermal therapy for heart failure is recognized to improve clinical symptoms. We describe our experience with appendicular thermal therapy applied to a patient fitted with an extracorporeal left ventricular assist device (LVAD) who was wait-listed for a heart transplant. A 21-year-old male with end-stage heart failure due to dilated cardiomyopathy was fitted with a LVAD. His general condition stabilized after LVAD placement and the status of his heart failure has remained at NYHA class II for the past 13 months. However, his cardiac function did not sufficiently recover to discontinue LVAD support. We conducted appendicular thermal therapy using a steam foot bath and heated gloves for 2 weeks. Immediately after thermal therapy, his average sublingual temperature increased from 36.3 to 37.0 °C and the grade of mitral regurgitation, as well as LV ejection fraction and endothelial function improved. Furthermore, levels of oxidative and anti-oxidative stress markers decreased and increased, respectively, after 2 weeks of therapy. No complications developed. We conclude that appendicular thermal therapy was safe in this patient waiting for a heart transplant and who had an extracorporeal LVAD, and that the procedure might be beneficial for others with end-stage heart failure.     

Cellular evidence of reverse cardiac remodeling induced by cardiac resynchronization therapy

Left ventricular assist devices (LVADs) induce reverse cardiac remodeling by reducing myocyte size and collagen deposition. On the other hand, cardiac resynchronization therapy (CRT) induces reverse cardiac remodeling by improving electromechanical synchronization. The clinical and structural changes produced by CRT in failing myocardium are known, but whether these changes are accompanied by reverse cellular remodeling is unknown. A total of 12 patients with chronic heart failure (CHF) who underwent CRT and 15 patients who had LVAD therapy as clinically indicated and 8 healthy controls were compared. Demographics, echocardiographic data, and histologic samples from myocardial biopsies were analyzed and compared among groups. The authors found significant increases in myocyte size, myocardial fibrosis, and inflammation in both CHF groups who underwent CRT or LVAD, compared with healthy controls. After CRT or LVAD therapy, a significant decrease in myocyte size and tumor necrosis factor α (TNF-α) expression compared with healthy controls (P < .05) was found. In the CRT group, 6 of 8 patients demonstrated reduction in myocyte size and interstitial fibrosis. In addition, there was a decrease in myocyte size by 13%, total collagen by 27% and TNF-α by 49% in the CRT group vs 28%, 45%, and 45% in the LVAD group. CRT produces cellular reverse remodeling in failing human hearts that are comparable with those produced by LVAD therapy.     

Acute Hemodynamic Effects of Biventricular Pacing After Left Ventricular Assist Device

Background

Despite cardiac resynchronization therapy (CRT), some patients with heart failure progress and undergo left ventricular assist device (LVAD) implantation. Management of CRT after LVAD implantation has not been well studied. The purpose of this study was to determine whether RV pacing or biventricular pacing measurably affects acute hemodynamics in patients with an LVAD and a CRT device.

单中心心脏再同步治疗的长期病死率及原因分析

目的观察本中心心脏再同步治疗（CRT）的长期病死率,分析可能的相关因素。方法2001年3月至2010年4月135例患者行CRT治疗,男106例,平均年龄（59．95±11．14）岁。缺血性心肌病（ICM）44例,心功能Ⅲ～Ⅳ级（NYHA分级）,LVEF≤0．35。随访最长9年。结果全因死亡率为31．11％,其中心力衰竭占26．19％,猝死占38．1％。与存活患者比较,心力衰竭恶化死亡患者更年轻、CRT治疗前的临床指标差、肺动脉压高、左心室舒张末内径增大明显（P〈0．05）,而且PR间期明显延长（P〈0．05）,不理想的左心室电极导线位置（心中静脉和心大静脉）的比例增加（P〈0．01）。非心力衰竭死亡组CRT治疗后心功能的各项指标及活动耐量均改善,且随着时间延长改善更明显,而心力衰竭死亡组随着时间延长病情反复且加重。结论本中心CRT长期治疗的全因死亡率为31％,死亡原因中心脏性猝死发生率最高,心力衰竭恶化排第2位,经CRT后因心力衰竭和猝死导致的死亡率低于以前药物治疗（20％／4年和〉50％／5年）。对于心功能好转的患者预防猝死是重要的,心脏再同步治疗除颤器（CRT－D）应是首选治疗。     

心室辅助装置在小儿原发性心肌病并发心力衰竭中的应用价值

目的:评价心室辅助装置在小儿原发性心肌病并发心力衰竭中的应用价值.方法:4例扩张型心肌病(DCM)患儿采用手术安装心室辅助装置代替并发心室行使泵功能.术后常规给予抗凝剂苯丙酸豆素和抗血小板药物阿司匹林以防止血栓事件的发生.术后每日采用毛细血管法测定INR,同时严密观察管道有无血栓形成.结果:1例6个月男婴安装左室辅助装置(LVAD);1例40个月男性患儿初安装LVAD,后因继发右心衰竭于9周后复手术安装双侧心室辅助装置(BIVD);1例13岁女性患儿和1例15岁男性患儿因全心力衰竭安装BIVD;4例目前心功能均恢复良好.其中6个月男婴已心脏移植,15岁男性患儿因心功能和心肌收缩力恢复良好,予撤机后痊愈出院.结论:对于原发性心肌病并发心力衰竭患儿,应用心室辅助装置如Berlin Heart系统进行治疗,效果良好.     

心脏再同步化治疗起搏参数优化对心脏同步性及心功能的影响

目的 应用组织多普勒研究心脏再同步化治疗(CRT)术后A-V、V-V间期优化对心脏同步性能及心功能的影响,探索A-V、V-V间期优化在增强CRT临床疗效中的作用.方法 32例慢性心力衰竭患者接受CRT治疗,于术后7天、3个月、6个月进行A-V、V-V间期优化,观察心脏同步性和心功能变化.采用彩色超声诊断仪进行图像采集及下线分析.结果 经观察,术后7天、3个月、6个月的A-V间期需行优化的例数分别为28例、10例、6例,V-V间期需行优化的例数分别为29例、6例、5例.与CRT术前相比:CRT治疗术后未优化时的左室12节段组织速度达峰时间标准差明显改善[(68.8±26.4)ms与(41.6±23.1)ms,P＜0.01],左室射血分数增加[(28±4)%与(31±3)%,P＜0.05],主动脉瓣前向血流速度时间积分增加[(13.6±3.1)cm与(15.5±4.3)cm,P＜0.05],舒张早期跨二尖瓣血流峰速和舒张早期心肌组织运动峰速的比值下降(13.1±5.3与9.3±4.3,P＜0.05),左室舒张充盈时间延长[(313.2±93.6)ms与(368.6±97.1)ms,P＜0.05].与术后未优化时相比:术后7天优化心脏同步性指标进一步改善(P＜0.05),心功能指标无明显改变;术后3个月、6个月优化与术后7天优化相比,心脏同步性指标无明显改变,P＞0.05;术后6个月优化的左室射血分数增加,左室舒张充盈时间延长,P＜0.01.结论 CRT术后7天,A-V、V-V间期优化治疗改善心脏同步指标;术后6个月优化进一步改善心功能.     

心脏再同步化治疗对心力衰竭患者血浆脑钠肽水平及心功能的影响

目的：观察心脏再同步化治疗（CRT）对心力衰竭患者血浆脑钠肽（BNP）水平及心功能的影响。方法：选择因顽固性心力衰竭行CRT术患者17人,分别于术前及术后6、12月测定血浆BNP水平,并行超声心动图检查,评估心脏功能。结果：CRT术后6、12个月的血浆BNP水平较术前明显降低（P〈0．05）,术后6、12个月患者的左室射血分数（LVEF）明显升高（P〈0．05）,左室舒张末期内径（LVEDD）减小（P〈0．05）。Pearson相关分析示,BNP与LVEF呈负相关（r=-0．653,P〈0．05）,BNP与LVEDD呈正相关（r=0．608,P〈0．05）。结论：对于心力衰竭患者,CRT能够明显降低患者的血浆BNP水平,改善其心功能;血浆BNP水平能够反应患者术后心功能情况。     

The feasibility of left ventricular mechanical support as a bridge to cardiac recovery

OBJECTIVE: To study the achievability of device weaning in patients receiving left ventricular assist devices (LVADs) as a bridge to transplantation. METHODS: Eighteen consecutive patients receiving a LVAD between September 1997 and June 2002 were included in the study. During a four-month follow-up, patients were repeatedly evaluated with right heart catheterization and echocardiography and, if functional improvement was observed, studied with the device turned off. Cardiac recovery was defined as off-pump LVEF>or=40% together with a significant improvement in invasive haemodynamic measurements (CI>or=2.5 and PCWP相似文献   

心脏再同步化治疗对慢性心力衰竭的临床疗效

目的：观察心脏再同步化治疗（cardiac resynchronization therapy,CRT）对慢性心力衰竭（chronic heart failure,CHF）的临床疗效。方法选择2010年12月至2013年12月于我院成功植入C RT的慢性心力衰竭患者36例。在治疗前和治疗后6个月,分别对患者进行NYHA分级及6 min步行试验的评价,应用心脏超声评价患者左室射血分数（LVEF）、左室质量指数（LVMI）、左室舒张末期容量指数（LVEDVI）、左室收缩末期容量指数（LVESVI）等左室功能指数,对治疗前及治疗后6个月上述指标行t 检验,分析其差异性。结果治疗6个月时,患者 LVEF、LVMI、LVEDVI、LVESVI较治疗前有明显改善,且差异有统计学意义（P均＜0．05）;患者NYHA心脏功能分级及6 min步行试验较治疗前有明显改善,且差异有统计学意义（P均＜0．05）。结论 CRT-D明显改善慢性心衰的心功能,提高患者生活质量及运动耐量。     

Improvement in Cheyne-Stokes respiration following cardiac resynchronisation therapy.

The effect of standard cardiac resynchronisation therapy (CRT) on the severity of Cheyne-Stokes respiration (CSR) in patients with congestive heart failure was studied. It was hypothesised that CRT, through its known beneficial effects on cardiac function, would stabilise the control of breathing and reduce CSR. Twenty-eight patients who were eligible for CRT and receiving optimised medical treatment for congestive heart failure were referred for overnight polysomnography, including monitoring of thoracic and abdominal movements to identify CSR and obstructive sleep apnoea events. Patients underwent repeat polysomnography after 6 months of CRT to re-evaluate sleep quality and sleep-disordered breathing. Twelve of the 28 patients had significant CSR (43%); 10 patients had a successful implantation and underwent repeat polysomnography a mean+/-SD 27+/-7 weeks after continuous biventricular pacing. Six of the 10 patients experienced a significant decrease in CSR severity following CRT, associated with correction of congestive heart failure-related hyperventilation and hypocapnia. Circulation time, oxygen saturation, frequency of obstructive apnoeas and sleep quality did not change. In conclusion, cardiac resynchronisation therapy is associated with a reduction in Cheyne-Stokes respiration, which may contribute to improved clinical outcome in patients treated with cardiac resynchronisation therapy.     

Reduction in hospitalization rates following cardiac resynchronisation therapy in cardiac failure: experience from a single centre.

AIMS: Frequent, lengthy hospital admissions for congestive cardiac failure (CCF) result in excessive health care costs. Cardiac resynchronisation therapy (CRT) is a novel treatment option for patients with CCF and associated cardiac conduction defects. We investigated whether CRT resulted in significant improvements in New York Heart Association (NYHA) symptom class, exercise tolerance, and hospitalization rates in such patients. METHODS: Twenty-seven patients who underwent CRT in a single centre were studied, with NYHA symptom class, exercise tolerance and hospitalization rates noted in the 12 months prior to and following CRT. RESULTS: Following 12 months of CRT, NYHA symptom class improved from 3.3 +/- 0.5 to 2.1 +/- 0.4 (P < 0.05). Exercise tolerance, assessed by 6 min hall walk test increased by 64% from 195 +/- 114 m to 320 +/- 85 m (P = 0.007). Days in hospital for stabilisation of cardiac failure decreased by 98% from 472 to 9 days (P < 0.001). Significant hospitalization cost savings of 201,684 euros were calculated, with an overall saving of 12,420 euros. CONCLUSIONS: These data demonstrate that CRT results in significant improvement in clinical parameters, and considerable reductions in hospital admissions, and costs in patients with CCF.     

The R-on-T phenomenon in patients with implantable cardioverter-defibrillators

Cardiac resynchronization therapy (CRT) can improve cardiac function in patients with heart failure and left bundle branch block. To test a new synchrony index derived from mitral annular velocity by color tissue Doppler, 19 subjects were studied: 9 patients with heart failure and left bundle branch block at baseline and at 1, 3 and 6 months after CRT and 10 normal controls. The synchrony index in patients with heart failure was less than that in controls at baseline (r = 0.60 +/- 0.13 vs 0.94 +/- 0.02; p <0.01), but improved at 6 months after CRT (r = 0.77 +/- 0.09; p <0.05 vs baseline).     

Cardiac resynchronization therapy setting personalization utilizing noninvasive hemodynamics

BackgroundCardiac resynchronization therapy (CRT) has been an important adjunct to goal directed medical therapy in heart failure patients who qualify for this device. Too often, when heart failure patients complain about severe fatigue, beta-blockers are immediately reduced. Personalization of settings, verified by noninvasive hemodynamics, can allow for maximizing medical therapy.CaseA newly diagnosed 40 year-old male presented to the heart failure clinic post hospital discharge with a severely dilated, non-ischemic cardiomyopathy. Even with an ejection fraction (EF) of 15-20%, he reports “feeling great”. Increasing medications resulted in excessive fatigue. Non-invasive studies showed an average cardiac index (CI) of 1.5l/min/m². It was decided to personalize his settings. Changes made increased his CI to 3.9l/min/m².ConclusionCombining current available technology with noninvasive studies significantly improved his CI and no reduction in beta-blocker therapy was necessary. CRT personalization can be of significant value for the heart failure patient.     

Symptomatic relief: left ventricular assist devices versus resynchronization therapy

In patients who have end-stage heart failure, medical therapy is of limited use, and heart transplantation is frequently not an option because of the shortage of donor hearts. Two new treatment options, left ventricular assist devices (LVADs) and implantable cardiac resynchronization therapy (CRT) devices, can improve survival and quality of life in patients who have heart failure. Both types of devices are easy to implant. However, LVADs carry the risk of infection and mechanical failure, and CRT is ineffective in a substantial proportion of patients who have heart failure. Therefore, methods must be devised to identify patients who have heart failure who are likely to benefit from these devices. Data suggest that early LVAD implantation, before end-stage heart failure develops, is critical to slowing or reversing disease progression. Similarly, in indicated patients who have less advanced disease, CRT may be particularly beneficial.     

心脏再同步化治疗慢性心力衰竭伴持续性心房颤动的疗效观察

目的评价心脏再同步化治疗(CRT)慢性心力衰竭(心衰)合并持续性心房颤动(房颤)患者的临床疗效。方法选择慢性心衰患者23例,其中13例窦性心律患者及4例房颤患者(房颤CRT患者)接受双心室起搏治疗,另6例房颤患者(药物治疗患者)继续服用抗心衰药物治疗。术后3个月进行随访,观察患者的心功能分级(NYHA),6 min步行距离,超声心动图测定各房室腔内径大小、LVEF、二尖瓣反流以及速度向量成像超声评价同步性参数的变化。结果 17例患者三腔起搏器置入术均取得成功。术后3个月随访,房颤CRT患者心功能分级[(3.00±0.00)级vs(2.25±0.50)级]、左心房内径[(52.75±3.50)mm vs (45.25±3.50)mm,P<0.05]、LVEF[(36.25±4.79)% vs (42.00±5.16)%]及二尖瓣反流(3.25±0.50 vs 1.50±0.58,P<0.01)较术前均有明显改善,速度向量成像超声结果显示,室内不同步较术前有明显改善。与药物治疗患者比较,房颤CRT患者LVEF、左心房内径、二尖瓣反流明显改善。结论对于慢性心衰合并持续性房颤患者,在有效控制心室率的基础上行CRT明显优于药物保守治疗,与窦性心律患者一样可以改善心功能。     

Changes in sarcolemmal Ca entry and sarcoplasmic reticulum Ca content in ventricular myocytes from patients with end-stage heart failure following myocardial recovery after combined pharmacological and ventricular assist device therapy.

AIMS: Support with left ventricular assist devices (LVAD) improves cardiac performance in patients with end-stage heart failure. In some cases this strategy, combined with pharmacological treatment, has led to a clinical improvement which remained after LVAD explant. This study defines changes in Ca handling at the cellular level in failing left ventricular tissue taken at LVAD implant (LVAD core) and LVAD removal (post-LVAD). METHODS AND RESULTS: We studied cell size and Ca regulation in enzymatically dissociated cardiac myocytes. We used confocal microscopy and electrophysiological techniques to investigate the SR Ca content and major Ca movements across the sarcolemma during the action potential. We firstly recorded a significant reduction in cell capacitance and cell volume consistent with regression of cellular hypertrophy in post-LVAD myocytes compared with LVAD core myocytes. Ca entry via sarcolemmal Ca channels during the action potential using action potential voltage-clamping was significantly increased in post-LVAD myocytes compared with LVAD cores myocytes. Finally, SR Ca content (assessed by integrating the caffeine-induced Na/Ca exchanger transient inward current) in post-LVAD myocytes was also significantly increased compared with LVAD cores myocytes. CONCLUSIONS: These results show that in myocytes from patients after LVAD support there is more Ca entry to trigger Ca release and more SR Ca content, leading to improved contractile function.     

Molecular Changes Occurring During Reverse Remodelling Following Left Ventricular Assist Device Support

Remodelling is the central feature that occurs in the progression of heart failure. However, unloading of the heart with a left ventricular assist device (LVAD) can lead to reversal of many of the remodelling changes even in patients with advanced heart failure. LVAD unloading can also lead to improved myocardial function and this improvement can be sufficient to allow removal of the device leaving the patient to lead a normal life. We review the molecular changes that have been demonstrated with LVAD unloading in patients bridged to transplantation and also those that have occurred in the myocardium of patients that have recovered their myocardial function enough to have the device removed. Changes in both the myocyte and the matrix are reviewed.     

心力衰竭伴不同宽度左束支传导阻滞患者对心脏再同步治疗反应的分析

目的:分析左束支传导阻滞(left bundle branch block,LBBB)心力衰竭患者对心脏再同步(cardiac resynchronization therapy,CRT)治疗的疗效反应情况。方法:回顾性分析在本院成功置入CRT伴LBBB的心力衰竭患者。所有患者术前、术后1w及最终随访均行12导联心电图、超声心动图、组织多普勒。均对比术前、术后左心室大小、射血分数及生存现状。结果:共44例完成随访,随访6~61个月,平均27.12个月,4例再同步治疗后仍反复出现心力衰竭并因此再入院治疗,无死亡病例。共有38例(86.4%)患者对CRT治疗有反应,真性LBBB亚组中29例(93.5%)有反应,非真性LBBB亚组中9例(69.2%)有反应。真性LBBB亚组左心室射血分数绝对值、左心室舒张末径(left ventricular end diastolic diameter,LVEDD)及左心室射血分数的改善程度更显著,差异有统计学意义。结论:CRT治疗可使大部分患者获益,真性LBBB患者心功能改善更为显著,但终末期心脏失代偿严重者难于从中获益。