Improved diagnosis and characterization of postinfarction left ventricular pseudoaneurysm by cardiac magnetic resonance imaging.

A patient with a ruptured left ventricular pseudoaneurysm complicating an acute posteroinferior myocardial infarction is described. Left ventricular pseudoaneurysms are a rare complication of acute myocardial infarction, usually occurring with inferior and/or posterior infarction. In contrast to true aneurysms, pseudoaneurysms are much more likely to rupture, regardless of size, causing hemopericardium and death. Therefore, once the diagnosis has been confirmed, prompt surgical resection is the current accepted treatment. The most accurate noninvasive diagnostic method has been echocardiography, with recent reports suggesting improved diagnosis with color flow Doppler echocardiography. Ventriculography confirms the diagnosis with more accurate anatomic detail, but is an invasive procedure. In our patient, two-dimensional and color Doppler echocardiography could not demonstrate the suspected pseudoaneurysm, which was demonstrated by ventriculography. However, magnetic resonance imaging (MRI) demonstrated the pseudoaneurysm, showing detailed anatomy not obvious on ventriculography. Before surgery could be performed, the patient died and was autopsied. Heart sections corresponding to MRI planes confirmed the MRI findings. A review of the literature has revealed no similar reports using MRI in the diagnosis of postinfarction pseudoaneurysms. Major advantages of MRI are generation of three-dimensional soft tissue images noninvasively, and generation of tissue contrast by rapid imaging sequences, obviating the need for contrast injection. Major disadvantages of MRI are the high cost of instrumentation, nonportability, and a requirement for patient immobility during the study. In cases of suspected pseudoaneurysm with equivocal echocardiography findings, MRI could provide early diagnosis, leading to early surgical intervention and increased patient survival.     

Three-dimensional echocardiographic acquisition and validity of left ventricular volumes and ejection fraction

Transthoracic (TTE) and transesophageal (TEE) three-dimensional echocardiography (3DE) is now used in daily clinical practice. Advancements in technology have improved image acquisition with higher frame rates and increased resolution. Different 3DE acquisition techniques can be used depending upon the structure of interest and if volumetric analysis is required. Measurements of left ventricular (LV) volumes are the most common use of 3DE clinically but are highly dependent upon image quality. Three-dimensional LV function analysis has been made easier with the development of automated software, which has been found to be highly reproducible. However, further research is needed to develop normal reference range values of LV function for both 3D TTE and TEE.     

Neurohumoral prediction of left-ventricular morphologic response to beta-blockade with metoprolol in chronic left-ventricular systolic heart failure

BACKGROUND: In order to tailor therapy in heart failure, a solution might be to develop sensitive and reliable markers that can predict response in individual patients or monitor effectiveness of therapy. AIMS: To evaluate neurohumoral factors as markers for left-ventricular (LV) antiremodelling from metoprolol treatment in patients with chronic LV systolic heart failure. METHODS: Forty-one subjects randomised to placebo or metoprolol were studied with magnetic resonance imaging and blood samples to measure LV dimensions and ejection fraction, epinephrine, norepinephrine, plasma renin activity, aldosterone, atrial (ANP) and brain natriuretic peptides, arginine-vasopressin and endothelin-1 at baseline, 5 weeks and 6 months after randomisation. RESULTS: Baseline ANP was identified as sole independent marker for changes in LV end-diastolic (deltaLVEDVI: r=-0.70, P=0.002), and end-systolic (deltaLVESVI: r=-0.53, P=0.03) volumes during metoprolol treatment. Change in ANP during the study was an independent marker for deltaLVEDVI: r=0.66, P=0.004, and deltaLVESVI: r=0.69, P=0.002 in the entire metoprolol group, but at the individual patient level, results were less clear. CONCLUSION: The pre-treatment plasma level of ANP may be a predictor of LV antiremodelling from treatment with metoprolol in patients with chronic heart failure. However, the potential for individual neurohumoral monitoring of the effects on LV dimensions during beta-blockade appears limited.     

Evaluation of left ventricular diastolic function from the pattern of left ventricular filling

The pattern of left ventricular (LV) filling can be determined by Doppler echocardiography. Normally most LV filling occurs early in diastole, with some additional filling occurring during atrial systole, late in diastole. In the absence of mitral stenosis, three patterns of LV filling indicate progressively greater diastolic dysfunction: (1) Reduced early diastolic filling with a compensatory increase in importance of atrial filling, termed a pattern of “impaired relaxation;” (2) “pseudo-normalization” with most filling early in diastole but with rapid deceleration of mitral flow; and (3) “restricted filling” with almost all filling of the LV occurring very early in diastole in association with very rapid deceleration of mitral flow. A large, prolonged atrial regurgitant flow in the pulmonary veins also indicates impaired diastolic performance. The time for early filling deceleration is predominantly determined by LV stiffness: the shorter the deceleration time, the stiffer the LV. Patients with short deceleration time have a poor prognosis.     

Diagnosis and treatment of heart failure with preserved left ventricular ejection fraction

Nearly six million people in United States have heart failure. Fifty percent of these people have normal left ventricular (LV) systolic heart function but abnormal diastolic function due to increased LV myocardial stiffness. Most commonly, these patients are elderly women with hypertension, ischemic heart disease, atrial fibrillation, obesity, diabetes mellitus, renal disease, or obstructive lung disease. The annual mortality rate of these patients is 8%-12% per year. The diagnosis is based on the history, physical examination, laboratory data, echocardiography, and, when necessary, by cardiac catheterization. Patients with obesity, hypertension, atrial fibrillation, and volume overload require weight reduction, an exercise program, aggressive control of blood pressure and heart rate, and diuretics. Miniature devices inserted into patients for pulmonary artery pressure monitoring provide early warning of increased pulmonary pressure and congestion. If significant coronary heart disease is present, coronary revascularization should be considered.     

AHFREF和AHFPEF患者远期预后情况观察

目的：观察射血分数降低的急性心力衰竭（Heart failure with reduced left ventricular ejection fraction, AHFREF）和射血分数保留的急性心力衰竭（Heart failure with preserved left ventricular ejection fraction, AHFPEF）远期预后,并分析影响预后的危险因素。方法 选取我院急诊科2013年3月至2014年3月收治的首次入院的急性心力衰竭患者280例,根据左室射血分数（left ventricular ejection fraction, LVEF）将患者分为两组：AHFREF组,LVEF<50%,n=152;AHFPEF组,LVEF≥50%,n=128例。记录所有患者性别、年龄、左心房扩大、左心室扩大、Killip分级为IV级和急性冠脉综合征（Acute coronary syndrome, ACS）等发病率,以及吸烟史、高血压和糖尿病等合并症、心房颤动等发生率,并记录血尿酸水平、超敏C反应蛋白（high-sensitivity C-reactive protein, hs-CRP）、脑钠肽前体（pro-brain natriuretic peptide, BNP）水平。所有患者均随访3年,记录随访期内心血管源性再住院率及病死率。采用非条件Logistic回归分析影响患者再住院的危险因素,并采用多因素Cox回归分析影响患者生存时间的预后因素。结果 AHFREF组患者左心室扩大、高血压、ACS、尿酸>30umol/l、BNP>220mg/l、hs-CRP>10mg/l发生率显著高于AHFPEF组（P<0.05）;AHFREF组患者因ACS再住院率及总再住院率均高于AHFPEF组（P<0.05）。非条件Logistic回归分析发现高血压、血尿酸、血BNP、血hs-CRP 是影响急性心力衰竭患者再住院的危险因素（P<0.05）。多因素Cox回归分析发现高血压、血尿酸、血BNP、血hs-CRP是影响患者生存期的影响因素（P<0.05）。结论 AHFREF患者3年内远期预后低于AHFPEF患者,高血压、高尿酸、高hs-CRP和高BNP水平是影响急性心力衰竭患者再住院和生存期的独立危险因素。     

Risk and predictors of dyssynchrony cardiomyopathy in left bundle branch block with preserved left ventricular ejection fraction

BackgroundLeft bundle branch block (LBBB) and left ventricular (LV) dyssynchrony likely contribute to progressive systolic dysfunction. The evaluation of newly recognized LBBB includes screening for structural heart abnormalities and coronary artery disease (CAD). In patients whose LV ejection fraction (EF) is preserved during initial testing, the incidence of subsequent cardiomyopathy is not firmly established.HypothesisThe risk of developing LV systolic dysfunction among LBBB patients with preserved LVEF is high enough to warrant serial imaging.MethodsWe screened records of 1000 consecutive patients with LBBB from our ECG database and identified subjects with an initially preserved LVEF (≥45%) without clinically relevant CAD or other cause for cardiomyopathy. Baseline imaging, clinical data, and follow‐up imaging were recorded to determine the risk of subsequent LV systolic dysfunction (LVEF ≤40%).Results(Data are mean + SD) 784 subjects were excluded, the majority for CAD or depressed LVEF upon initial imaging. Of the remaining 216, 37 (17%) developed a decline in LVEF(≤40%) over a mean follow‐up of 55 ± 31 months; 94% of these patients had a baseline LVEF≤60% and LV end systolic diameter (ESD) ≥ 2.9 cm indicating that these measures may be useful to define which patients warrant longitudinal follow‐up. The negative predictive value of a LVEF>60% and LVESD <2.9 cm was 98%.ConclusionsSeventeen percent of patients with LBBB and initial preserved LVEF develop dyssynchrony cardiomyopathy. We believe the risk of developing dyssynchrony cardiomyopathy is high enough to warrant serial assessment of LV systolic function in this high‐risk population.     

Independent effects of both right and left ventricular function on plasma brain natriuretic peptide

BACKGROUND: Brain natriuretic peptide (BNP) is increased in heart failure; however, the relative contribution of the right and left ventricles is largely unknown. AIM: To investigate if right ventricular function has an independent influence on plasma BNP concentration. METHODS: Right (RVEF), left ventricular ejection fraction (LVEF), and left ventricular end-diastolic volume index (LVEDVI) were determined in 105 consecutive patients by first-pass radionuclide ventriculography (FP-RNV) and multiple ECG-gated equilibrium radionuclide ventriculography (ERNV), respectively. BNP was analyzed by immunoassay. RESULTS: Mean LVEF was 0.51 (range 0.10-0.83) with 36% having a reduced LVEF (<0.50). Mean RVEF was 0.50 (range 0.26-0.78) with 43% having a reduced RVEF (<0.50). The mean LVEDVI was 92 ml/m2 with 22% above the upper normal limit (117 ml/m2). Mean BNP was 239 pg/ml range (0.63-2523). In univariate linear regression analysis LVEF, LVEDVI and RVEF all correlated significantly with log BNP (p<0.0001). In a multivariate analysis only RVEF and LVEF remained significant. The parameter estimates of the final adjusted model indicated that RVEF and LVEF influence on log BNP were of the same magnitude. CONCLUSION: BNP, which is a strong prognostic marker in heart failure, independently depends on both left and right ventricular systolic function. This might, at least in part, explain why BNP holds stronger prognostic value than LVEF alone.     

Approaches to determination of left ventricular volume and ejection fraction by real-time two-dimensional echocardiography.

Left ventricular volumes and ejection fraction were derived from real time two-dimensional echocardiographic images (2 DE) and single plane (RAO) left ventricular cineangiograms in a series of 50 patients. Prospective application of a series of 6 alternate algorithms showed that a modified Simpson's rule approach using mitral and papillary muscle cross sections and an apical four chamber view provided the best 2 DE - angiographic correlations: for end-diastolic volume r = 0.82, SEE = 39 ml; for end-systolic volume r = 0.90, SEE = 29 ml and for ejection fraction r = 0.80, SEE = 0.09. The large SEE for volume determination indicates that further refinements are necessary to predict left ventricular volumes adequately; however, ejection fraction can be derived with an accuracy which allows practical clinical decisions in patients with satisfactory 2 DE images.     

不同生物标志物在射血分数降低与射血分数保留的心力衰竭患者中的对比研究

目的探讨血清氮末端脑钠肽前体（NT-proBNP）、高敏C反应蛋白（hs-CRP）、胱抑素c（Cys-C）在射血分数降低的心力衰竭（HF-REF）与射血分数保留的心力衰竭（HF．PEF）中的表达水平及其之间的关系,探讨其临床价值。方法门诊收集106例心力衰竭（HF）患者,其中HF．REF患者58例（A组）,HF-PEF患者48例（B组）,测定两组患者血浆NT-proBNP、hs-CRP、Cys-C、肾功能、肝功能、血脂、左室射血分数等指标。横向比较NT-proBNP、Cys-C、高敏C反应蛋白等指标在两组中的浓度;分析两组中各HF指标的相关性。结果HF-REF患者与HF．PEF的患者体内NT-proBNP浓度和Cys-C浓度差异显著（P〈0．05）,但hs-CRP未见明显差异（P〉0．05）;HF．REF患者中,NT-proBNP与hs．CRP和Cys-C均具有相关性,hs-CRP与Cys-C不具有相关性（γ=0．338,P=0．079）;在HF-PEF患者中,NT-proBNP与Cys-C有显著相关性（γ=0．429,P=0．041）,与hs-CRP不具有相关性（γ=0．411,P：0．051）,hs．CRP与Cys-C具有显著相关性（γ=0．834,P=0．000）。结论两种类型HF患者中HF标志物浓度不同。NT-proBNP在HF．PEF患者中可能没有HF．REF患者有用。     

左室射血分数正常的心力衰竭患者诊治进展

左室射血分数正常的心力衰竭(HFPEF)老年女性更常见。基础病因多为糖尿病、高血压、缺血性心脏病。机制为左室松弛受损和舒张期僵硬度增加。诊断包括有心力衰竭的症状和体征,左室射血分数≥50%,超声检查无心瓣膜异常。治疗针对原发病为主。     

Heart rate turbulence and left ventricular ejection fraction in Chagas disease.

AIMS: Chagas disease patients often present premature ventricular complexes (PVCs), depression of left ventricular ejection fraction (LVEF) and autonomic dysfunction, which is generally evaluated by heart rate variability (HRV) analysis. As frequent PVCs may complicate HRV computation, we measured heart rate turbulence (HRT) and evaluated the correlation between ejection fraction and HRT or HRV in Chagas disease. METHODS: We studied 30 patients (47+/-11 years, 20 men) with Chagas cardiomyopathy and left ventricular dilatation who underwent clinical evaluation, ejection fraction (EF: 45+/-14%) determination and 24-h Holter monitoring (median PVC=1781). In all patients, the standard deviation of normal RR intervals (SDNN), the square root of the mean square differences of successive RR intervals (RMSSD) and values of turbulence onset (TO) and turbulence slope (TS) were calculated. RESULTS: HRT indices were independent of mean RR interval and presented high correlation with EF: TO (-0.11+/-0.01%, r=-0.60, P<0.001) and TS (5.8+/-3.7 ms/RR-interval, r=0.73, P<0.001). Of HRV parameters, only SDNN, corrected for mean RR interval, showed a weak but not significant correlation with EF (r=0.41). The comparison of HRT/EF and HRV/EF correlation coefficients, indicated the presence of a significant difference (P=0.017). CONCLUSIONS: HRT indices appear to correlate better with EF than SDNN in Chagas disease. Thus, an analysis based on heart rate transient adaptation seems to perform better than HRV in detecting the autonomic alterations that parallel left ventricular dysfunction in Chagas disease patients. The high number of PVCs observed in these patients further support the use of HRT methodology.     

大左室、低射血分值心脏瓣膜病的外科治疗

目的 :总结大左室、低射血分值心脏瓣膜病的外科治疗经验。方法 :72例大左室、低射血分值的心脏瓣膜患者行外科手术治疗 ,术前注意改善心肺功能 ,术中采用温血停搏液灌注 ,保留二尖瓣后瓣及瓣下结构 ,术后强心利尿扩血管治疗 ,积极防治术后并发症。结果 :本组术后早期发生心、肺、肝、肾等重要器官并发症 17例 ,围术期及术后早期住院期间死亡 7例 ,治愈出院 65例。结论 :大左室、低射血分值的心脏瓣膜患者行外科手术治疗危险性大 ,术后并发症多 ;选择合适手术时机 ,加强肺功能锻炼和围术期处理是提高大左室、低射血分值患者瓣膜置换术疗效的重要措施     

Tei指数评价左心室射血分数正常的尿毒症患者的左心室功能

目的利用Tei指数评价左心室射血分数（left ventricular ejection fraction, LVEF）正常的尿毒症患者的左心功能,以了解其临床应用价值。方法选取80例LVEF正常的尿毒症患者设为尿毒症组,50名健康人设为对照组,使用Vivid7pro对两组进行检测。检测左心房内径（LAD）、左心室舒张期末内径（LVDd）、左心室收缩期末末内径（LVDs）、室间隔（IVS）及左心室后壁厚度（LVPW）、LVEF、左心室短轴缩短率（LVFS）、二尖瓣血流频谱E峰及A峰、E／A比值、左心室等容收缩时间（ICT）及等容舒张时间（IRT）、主动脉射血时间（ET）,并计算左心室Tei指数。结果尿毒症组左心房内径、左心室舒张期末内径、左心室收缩期末内径、室间隔、左心室后壁厚度均较对照组增大,差异有统计学意义（P均〈O．01）。尿毒症组的二尖瓣血流频谱E峰及A峰较对照组明显增大（P均〈0．05）、左心室等容舒张时间比对照组延长（P〈0．01）、主动脉射血时间比对照组缩短（P〈0．01）、Tei指数比对照组明显延长（0．50±0．18眠0．33±0．12,P〈0．叭）,差异有统计学意义;尿毒症组E／A比值、左心室等容收缩时间、LVEF及左心室短轴缩短率与对照组比较,差异无统计学意义（P均〉0．05）。结论测量Tei指数能比单纯LVEF更好地评价尿毒症患者的左心功能,而且方便、快捷、有效。