Reversible myocardial dysfunction in patients with ischemic heart disease

The diagnosis of viable myocardium in patients with ischemic heart disease (IHD) with left ventricular (LV) dysfunction is essential for prediction of effectiveness and validity of myocardial revascularization as well as of prognosis in such patients. Great advances in intravascular reconstructive interventions on coronary arteries makes this diagnosis still more important. For diagnosis of reversible forms of LV myocardial dysfunction (stunned and hibernating myocardium) such highly informative methods as positron-emission tomography, single-photon emission computed tomography, nuclear magnetic resonance may be applied but they are not easily available because of high cost. Introduction of stress echo-CG into cardiological practice helps solve this problem as the method is available, relatively cheap, reproducible and sufficiently precise. It detects viable myocardium in IHD patients with high sensitivity and specificity. Echocardiographically, viable myocardium is marked by increased contractility in one or more segments with initial hypo- and akinesia.     

The role of interventricular septum in kinetics of left and right ventricular contraction in patients with ischemic heart disease and chronic cardiac failure

AIM: To study the role of interventricular septum (IVS) in kinetics of left ventricular (LV) and right ventricular (RV) contraction in IHD patients with chronic cardiac failure (CCF). MATERIAL AND METHODS: Standard equilibrium biventricular radioventriculography was used for the study of an inotropic function of LVand RV myocardium in 117 IHD patients with CCF of NYHA FC I-IV (mean age 58+/-4.1 years). Local myocardial contractility was studied with a unified 16-segment L V and RV model. RESULTS: Segments, local ejection fraction (EF) of which exceeded 50% were considered as normokinetic, 25-50%--hypokinetic, under 25%--akinetic. Total EF of both ventricles in all patients with FCI-II CCF was normal being 63.6+/-4.6% in the left and 53.4+/-5.2% in the right ventricle. Alterations of segmental contractility as zones of hypo- and akinesia of primarily anteroseptal region of the ventricles were revealed. Patients with CCF of FC III had zones of interventricular septum (IVS) akinesia and hypokinesia of its free wall in lowering of LV EF to 43.2+/-6.3%. RV EF also decreased to 38.4+/-4.8%, IVS diskinesia zones appeared due to pulmonary hypertension. Patients with CCF of FC IV had LV EF of 15.1+/-4.1%, RV EF was 25.9 +/-6.8% with more definite disorders of segmentary contractility in the form of increased percentage of dys- and akinetic segments in the septal region and a free wall of both ventricles. CONCLUSION: In IHD patients with initial CCF defects in local contractility occurred in IVS segments. With progression of CCF, lowering of total EF of both ventricles was associated with deterioration of local dysfunction in the form of increased proportion of hypo-, dys- and akinesia zones.     

多巴酚丁胺多普勒超声心动图评价心肌梗塞后左室收缩功能储备

应用脉冲多普勒超声心动图观察静注多巴酚丁胺（Ｄｏｂ）对心肌梗塞（ＭＩ）后左室收缩功能各项参数的影响。经Ｄｏｂ超声心动图检测，将２６例陈旧性心肌梗塞患者分为存活心肌（ＶＭ）组和无存活心肌（ＮＭ）组；分析比较用药前后多普勒之收缩功能参数的变化情况。结果：主动脉瓣口的峰值血流速度、峰值加速度、血流速度积分和心搏出量、心排出量及其变化率ＶＭ组明显大于ＮＭ组。上述指标对于评价ＭＩ后心肌收缩储备及左室整体功能是一种很有价值的方法     

实时心肌声学造影与二维应变成像技术评价心肌梗死后患者心肌存活性

目的 探讨实时心肌声学造影与二维应变成像技术评价心肌梗死后患者存活心肌的价值.方法 20例准备进行血运重建术心肌梗死患者,于术前1周内行实时心肌造影检查,根据心肌灌注结果进行半定量评价:3分为充盈缺损,2分为回声稀疏不均匀及心内膜下充盈缺损,1分为回声均匀性增强;MCE定义心肌存活性为心肌灌注计分≤2分,而心肌充盈缺损表示无心肌存活性.血运重建术前及术后3个月分别获取心尖位四腔、两腔及左心长轴切面二维图象,进行室壁运动评分,根据术后的室壁运动有否改善分为存活心肌组和无存活心肌组,测定术前左室各节段心肌的收缩期纵向峰值应变.结果 (1) 血运重建术前,二维超声心动图发现共有90个室壁明显发生节段性运动异常,其中有70个室壁的节段性运动异常术后得到改善.(2)血运重建术前,实时心肌声学造影评价存活心肌为65节段,无存活心肌为25节段,敏感性、特异性及准确性分别为93.8%、64%和85.5%.(3) 存活心肌组术前心肌收缩期纵向峰值应变明显高于无存活心肌组[(-7.34±5.84)% vs (-2.11±1.66)%,P＜0.001].以术前心肌收缩期纵向峰值应变≤-5.0%作为截断值判断心肌梗死时存活心肌的敏感性为72%,特异性为85%.结论 实时心肌声学造影可以准确地预测梗死心肌的存活性;同时二维应变成像技术以术前心肌收缩期纵向峰值应变≤-5.0%作为截断值也可以预测梗死心肌的存活性,其敏感性和特异性与实时心肌声学造影相当.     

Effect of losartan, lisinopril and their combination on hemodynamics and morphofunctional parameters of the heart in patients with chronic cardiac failure

The aim of the study was to evaluate effects of losartan receptor I antagonist (AT) and/or angiotensin converting enzyme inhibitor (iACE) on clinical manifestations of the disease, hemodynamic characteristics, morphofunctional heart parameters in patients with chronic cardiac insufficiency (CHI) complicating coronary heart disease (CHD). A total of 60 patients aged 48-72 (mean 62 +/- 8.4) years with persistent symptoms of functional class II-IV CHI and left ventricular (LV) fraction = < 45% complicating CHD. They were divided into 3 groups of 20 patients each. Patients in group 1 were given losartan (50 mg daily), in group 2 lisinopril (10 mg daily), in group 3 combination of the two drugs for 24 weeks. Combined treatment produced more significant improvement of CHI symptoms than monotherapy with either drug. In all cases, the size of heart left chambers decreased while contractility of left ventricular myocardium increased but these effects were more pronounced after combined therapy.     

心肌肥厚性疾病患者左心室扭转与心肌纤维化的相关性研究

目的应用三维超声斑点追踪成像技术分析心肌肥厚性疾病患者左心室扭转与心肌纤维化程度的相关性。 方法收集2017年7月至2019年2月在哈尔滨医科大学附属第四医院行心脏超声及心脏磁共振（CMR）检查的心肌肥厚性疾病患者31例,根据CMR钆造影剂延迟强化阳性与否诊断患者是否存在心肌纤维化,并将患者分为心肌纤维化组20例,无心肌纤维化组11例。另选取健康体检者35例作为对照组。应用三维斑点追踪成像技术测量左心室基底段、中间段、心尖段旋转角度峰值,左心室整体扭力及左心室扭转角度峰值。比较心肌肥厚性疾病患者与健康对照组的常规二维超声参数,以及心肌肥厚性疾病心肌纤维化组、无心肌纤维化组与健康对照组的左心室旋转、扭转参数。分析左心室扭转角度峰值与钆造影剂延迟强化阳性心肌/左心室心肌质量比值的相关性。 结果与健康对照组比较,心肌肥厚性疾病无心肌纤维化组及心肌纤维化组的左心室基底段、中间段、心尖段旋转角度峰值及左心室扭转角度峰值均明显升高（无心肌纤维化组：t=4.45、7.51、-5.45、-6.79,心肌纤维化组：t=-5.53、-9.84、-5.82、-9.45;P均<0.01）;心肌肥厚性疾病心肌纤维化组左心室心尖段旋转角度峰值及左心室扭转角度峰值较无心肌纤维化组明显升高（t=-2.71、2.36,P均<0.05）。心肌肥厚性疾病患者左心室扭转角度峰值与钆造影剂延迟强化阳性心肌/左心室心肌质量比值呈正相关（r=0.58,P=0.001）。 结论三维斑点追踪技术可有效评估心肌肥厚性疾病患者左心室扭转及旋转,左心室整体扭转角度峰值与左心室心肌纤维化呈正相关,三维斑点追踪技术可为临床检测心肌肥厚患者心肌纤维化提供新的方法和选择。     

多巴酚丁胺负荷磁共振成像检测存活心肌的临床研究

目的 评价小剂量多巴酚丁胺(10μg·kg-1·min-1)负荷磁共振成像(MRI)检测存活心肌的临床价值.方法 经彩色多普勒超声检查存在左心室壁节段运动障碍冠心病患者24例,进行MRI、小剂量多巴酚丁胺负荷MRI、冠状动脉造影(CAG)及经皮冠状动脉介入治疗(PCI),所有狭窄病变行完全血运重建.参照美国超声心动图学会16节段划分法,经MRI测得各运动异常节段小剂量多巴酚丁胺负荷前后舒张末期室壁厚度(EDWT),以应用小剂量多巴酚丁胺后室壁增厚为存活心肌标准;术后1、3、6个月时复查心脏超声,以冠状动脉血运重建后室壁节段收缩功能改善为判断存活心肌的金标准.结果 24例冠心病患者共获得符合条件的室壁运动异常节段170个,根据金标准判断其中115个为存活心肌,55个为非存活心肌;MRI检测存活心肌的敏感度、特异度、准确度分别是76.5%、90.9%、81.2%.结论 小剂量多巴酚丁胺负荷MRI检测存活心肌有较高的临床价值.     

心肌存活及灌注对急性心肌梗死冠状动脉介入治疗术后患者心功能的影响

目的探讨急性心肌梗死冠状动脉介入治疗(PCI)术后患者梗死区心肌存活性对左室重构及功能的影响。方法 2006年2月-2010年12月208例急性心肌梗死急诊PCI术后的患者接受静息状态下18氟-脱氧葡萄正电子断层显像进行心肌代谢显像检查,根据基线梗死区心肌有无存活分为两组,同时进行超声心动图检查,评价左室壁运动、左室射血分数,左室舒张末内径、左房内径及舒张期二尖瓣血流速度峰值的比值。血运重建术后12个月随访超声心动图,观察梗死区心肌存活状态对于左室重构以及心功能的影响。结果 PCI术后12个月,有存活心肌组左室射血分数(46.7±6.98)%高于无存活心肌组(45.1±7.12)%,两组差异有统计学意义(P<0.01),有存活心肌组左室舒张末期内径(53.17±3.89)mm小于无存活心肌组(55.46±4.75)mm,两组差异有统计学意义(P<0.05)。左房内径及舒张期二尖瓣血流速度峰值的比值两组随访时均无明显变化。结论急性心肌梗死行PCI治疗后的患者,在有存活心肌的情况下,心功能改善明显;而梗死区无心肌存活的患者,12个月后,心功能减低,左室重构更加明显。     

Comparative efficacy of conservative and surgical treatment of ischemic heart disease in long-term prospective follow-up studies]

The author presents comparative results of conservative and surgical (coronary artery bypass) treatment of 125 men (mean age 52.3 +/- 6.1 years) with ischemic heart disease (IHD). Though all the patients have indications for surgical treatment, 47 (37.6%) of them rejected surgery. They comprised a group of conservative treatment (CT) vs a group of surgical treatment (coronary artery bypass) consisting of 78 (62.4%) patients. The groups were matched by age, IHD severity, coronary affection and concomitant diseases. A 5-year follow-up revealed a marked difference between the groups: left ventricular function has improved significantly in the operated patients. In CT group 5-year survival reached 89.4%, in operated patients it was 94.9%. Thus, direct revascularization of the myocardium improves quality of life in more than in half of the operated patients who were able to resume their jobs.     

背向散射积分、组织多普勒与核素扫描对心肌缺血和存活的相关性临床研究

目的:进一步探讨组织多普勒和组织定征技术临床应用的可行性。方法:12例超声发现节段性室壁运动失常患者分别进行多巴酚丁胺负荷超声心动图、超声组织多普勒、背向散射积分及核素扫描检查。结果:有收缩储备节段背向散射积分曲线形态评分较无收缩储备节段明显降低,背向散射积分周期变异幅度(CVIB)、T波顶点时心内膜运动速度(Vendo)、心肌中部心动周期中最大运动速度(TVC)、收缩期心肌运动速度峰值跨壁梯度(MVGm+)及放射性核素摄取率均较无收缩储备节段显著增高,有收缩储备节段背向散射积分平均值(AII)与无收缩储备节段的差别无显著性。心肌收缩期运动指标与CVIB正相关,与AII负相关。放射性核素摄取率与TVC、Vendo、MVGm+正相关,与AII负相关,与CVIB相关呈临界状态。结论:背向散射积分和组织多普勒指标在判断心肌缺血与存活的临床应用方面有很大潜力。     

Effect of renitek--an ACE inhibitor--versus cozaar--an angiotensin I receptors antagonists--on morphofunctional state of left ventricular myocardium in patients with symptomatic cardiac insufficiency

128 patients treated by renitek or cozaar for ischemic heart disease of NYHA class II-III effort angina and circulation insufficiency were subjected to echocardiographic monitoring for 12 weeks. Both drugs have proved their effectiveness in relation to prevention and inhibition of progression of pathological remodelling of the myocardium. Renitek is superior to cozaar in improving total contractility and morphofunctional state of the left ventricular myocardium. Cozaar is more effective than renitek in improvement of left ventricular local contraction and relaxation.     

多普勒超声心动图评价多巴酚丁胺对心肌梗塞患者左室舒张功能的影响

目的：评价多巴酚丁胺对心肌梗塞患者左室舒张功能有何影响。方法：在静注多巴酚丁胺的同时应用二维和多普勒超声心动图观察３３例陈旧性心肌梗塞患者的心室壁运动及心内血流。结果：在多巴酚丁胺峰值剂量时，左室等容舒张时间（ＩＶＲＴ）和心率校正后的ＩＶＲＴ（ＩＶＲＴｃ）存活心肌（ＶＭ）组比无存活心肌（ＮＭ）组明显缩短，ＶＭ组的二尖瓣口血流Ａ峰用药后比用药前明显增高。结论：本研究提示，在多巴酚丁胺注射时ＩＶＲＴ和ＩＶＲＴｃ的变化对于检测存活心肌是一项敏感的参考指标     

伊贝沙坦对急性心肌梗死后左室重塑影响

目的　观察伊贝沙坦对急性心肌梗死 (AMI)后左室重塑的阻抑作用。方法　将 72例 AMI患者随机分为常规治疗组 36例、伊贝沙坦治疗组 36例 ,并于 AMI后 2、2 4周分别进行超声心动图和平衡法核素心室造影 ,测定左室心肌重量、左室收缩功能和舒张功能 ,了解伊贝坦对 AMI后左室重塑的阻抑作用。结果　 AMI后 2 4周时伊贝沙坦与常规治疗组比较室间隔厚度、左室后壁厚度、左室舒张末内径和左室心肌重量指数均明显降低 (P<0 .0 5 ,或 P<0 .0 0 1)。AMI后 2 4周时 ,伊贝沙坦治疗组与对照组比较左室射血分数明显增加 (P <0 .0 5 ) ,左室峰射血率和左室峰射血率时间均显著下降 (P<0 .0 5 ) ,同时左室高峰充盈率明显升高 (P<0 .0 5 ) ,左室高峰充盈率时间显著下降 (P<0 .0 0 1)。结论　伊贝沙坦能明显减轻心肌梗死后心肌肥厚和左室重塑 ,改善左室功能。     

静息下脉冲多普勒组织成像技术定量分析存活心肌舒缩功能

目的：采用脉冲多普勒组织成像技术（PW－DTI）在静息状态下定量分析民肌梗死后局部存活心肌舒缩功能。方法：20例陈旧性心肌梗死患者分别行静息下PW－DTI及小剂量多巴酚丁胺（LDDSE）检查。采用PW－DTI分析各节段收缩期峰值运动速度（Vs）、舒张早期、晚期峰值运动速度（VE、VA），并计算VE／VA比值；LDDSE检查判别存活心肌与非存活心肌节段。结果：160观察节段中室壁运动异常92节段（57．5％），LDDSE此92节段中56节段（60．9％）判为存活心肌，36节段（39．1％）判为非存活心肌。与正常节段比较，存活心肌组与非存活心肌组Vs、VE均显著降低（P＜0．01）；存活心肌与非存活心肌比较，两组间Vs并无显著性差异，而前者VE显著高于后者（P＜0．01），且VE／VA节段所占比率亦显著高于后者（P＜0．01）。结论：与非存活心肌相比，存活心肌收缩功能同样受损而舒张功能受损较轻；PW－DTI可在静息状态下区分存活心肌与非存活心肌。     

Dobutamine stress-redisstribution-reinjection versus rest-redistribution thallium-201 spect in the assessment of myocardial viability

The aim of this study was to evaluate the value of thallium-201 chloride (²⁰¹Tl) reinjection imaging following dobutamine stress (DRi) to identify viable myocardium in comparison with a rest-redistribution ²⁰¹Tl protocol (RR). The identification of viable myocardium bears important consequences for adequate selection of patients with poor left ventricular function, often unable to exercise, who are considered for revascularization. Twenty-six patients with chronic coronary artery disease and depressed left ventricular function (ejection fraction 36±10%) were studied by both DRi and RR single photon emission computed tomography (SPECT). Semi-quantitative analysis of regional ²⁰¹Tl activity (5-point score) and wall motion by echocardiography using a 16-segment model was performed. Regions were classified as viable (normal/reversible/fixed moderate defects) or non-viable (fixed severe defects) and related to regional wall motion. Target heart rate was reached in 25 patients. Myocardial viability was demonstrated in 353/416 (85%) by DRi SPECT and in 346/416 (83%) by RR SPECT. The agreement between the 2 protocols was 98% with a K-value of 0.94; similar results were obtained when the analysis was limited to dyscontractile segments. In conclusion, this study demonstrates the feasibility and diagnostic value of DRi SPECT to identify viable myocardium.     

Clinical demonstration of vibration-induced depression of left ventricular function

In experimental studies, minute sinusoidal vibration has been reported to induce functional depression of the left ventricle and to be an index for evaluation of myocardial crossbridge kinetics. Therefore, to examine whether or not this vibration-induced functional depression could also be observed in the human ventricle, motion of the left ventricular (LV) wall or LV pressure was measured by echocardiography (n = 16) or by left heart catheterization (n = 4), in which 100 Hz, 2.07 mm-amplitude sinusoidal vibration was applied to the subject's precordium. In the echocardiographic study, left ventricular wall shortening did not change by vibration in nine healthy volunteers, but was depressed in two patients with aortic regurgitation (AR) and in one patient with ischemic heart disease (IHD). In measurement of LV pressure, the decrease in LV systolic pressure caused by vibration was obviously observed in two patients (AR and IHD) but was not observed in two patients with hypertrophic cardiomyopathy. These results suggest that we might be able to extend previously proposed experimental idea on early detection of the abnormality in myocardial crossbridge kinetics to the clinical setting.     

Polymorphism of the ACE gene,structural-functional state of the left ventricle in patients with post-infarction cardiac failure and effects of the ACE-inhibitor Perindopril

AIM: To evaluate relationships between structural-functional state of the left ventricle (LV) and genotype of angiotensin converting enzyme (ACE) gene in patients with postinfarction chronic cardiac failure (CCF) and effects of ACE inhibitor perindopril on hemodynamics depending on ACE gene polymorphism. MATERIAL AND METHODS: In 52 patients with CCF (functional class III-IV by NYHA criteria) who had survived macrofocal myocardial infarction we studied ACE gene using thermostable DNA-polymerase Taq. Isolation of genome DNA from human venous blood was made by phenolchloroform extraction with the use of chelate polymer Chelex-100. Polymerase chain reaction was conducted on amplificator PHC-2 or PolyChain II. LV contractile function was studied on echocardiograph "Toshiba SSH-160A (Japan). Echocardiography was performed before intake of perindopril, in the end of titration phase, on therapy month 6 and 12. RESULTS: Genotype II of ACE gene was detected in 11(21.1%) patients, ID genotype--in 20(38.5%), DD genotype--in 21(40.4%). Patients with ACE gene genotype II and ID have no differences by parameters of central hemodynamics. They were divided into two groups: group 1--patients with genotypes II and ID of ACE gene, group 2--patients with genotype DD. End diastolic volume (EDV), end systolic volume (ESV), index of LV myocardial mass were significantly less in group 1 than in group 2 (by 45.7, 81.6 and 31.2%, respectively). In group 1 ejection fraction (EF) and %delta S were higher by 35.3 and 35.7%, respectively. The hemodynamic effect of perindopril was higher in group 2. A month therapy resulted in a 8.7 and 14.8% reduction in group 2 EDV and ESV, respectively (p < 0.05). This entailed an increase in EF and %delta S by 18.3% (p < 0.05) and 19.8% (p < 0.05). Later, perindopril retained influence on central hemodynamics. Diastolic function to the end of therapy in both groups differed insignificantly. CONCLUSION: In CCF patients functional class III-IV with the history of myocardial infarction, structural-functional LV parameters depend on genotype of ACE gene. Perindopril is most effective in DD-genotype of ACE gene.     

Comparative trial of efficacy of trimethasidine MB and 3-(2,2,2-trimethylhydrasine) propionate dihydrate in chronic heart failure

AIM: To study efficacy of the myocardial cytoprotector trimethasidine MB and metabolic drug 3-(2,2,2-trimethylhydrasine) propionate dihydrate (3-TMHP) in the treatment of chronic cardiac failure (CCF). MATERIAL AND METHODS: Sixty-five patients with CCF after myocardial infarction (> 6 months) with left ventricular ejection fraction (LV EF) <40% were randomized into 3 groups: group 1 (n=28) received basic therapy plus trimethasidine in a daily dose 70 mg; group 2 (n=25)--basic therapy plus 3-TMHP in a daily dose 1000 mg; control group (n=12) received basic therapy with ACE inhibitors, beta-blockers and diuretics. Before and after 6-month treatment all the patients have undergone stress echocardiography with dobutamine. Perfusion and myocardial metabolism were determined in 34 patients with single photon emission computed tomography of the myocardium (SPECT) with 99m-Tc-technetril and positron-emission tomography of the myocardium (PET) with F-18-fluorodesoxyglucose. RESULTS: Groups 1 and 2 significantly reduced functional class of CCF and prolonged the distance of a 6-min walk. Significant improvement of life quality was observed only in the treatment with trimethasidine. According to PET, treatment with trimethasidine MB and 3-TMHP has an anti-ischemic action manifesting with a significant attenuation of glucose hypermetabolism in the ischemic segment to normal values. However, significant improvement of systolic thickening in hybernated segments by SPECT as well as a significant rise of LV EF were recorded only in the treatment with trimethasidine MB. Stress echocardiography with dobutamine had high specificity (85.7%) but low sensitivity (50.4%) in detection of hybernated myocardium. CONCLUSION: Trimethasidine MB (preductal MB) has advantages over 3-TMHP, so it is preferable in ischemic CHF.     

The role of an overall coronary bed affection in heart remodeling in patients with stenocardia and arterial hypertension

AIM: To study a possible role of coronary circulation condition in remodeling heart in ischemic heart disease (IHD) patients with hypertension or without it. MATERIAL AND METHODS: The examination (veloergometry, echo-CG and Doppler echocardiography, selective coronaroangiography and left ventriculography) covered 45 hypertensive men with angina of effort functional class III and 69 normotensive patients. Mean age of the patients was 51.8 +/- 1.2 years, duration of the angina 3 to 10 years. RESULTS: Correlation analysis of the data on hypertensive examinees discovered a direct correlation between proportional overall lesion of the coronary arteries, myocardial mass index and left ventricular (LV) index of systolic sphericity, between the sphericity index and myocardial mass index. An inverse correlation--with LV ejection fraction. CONCLUSION: In anginal patients, coronary circulation is an independent factor influencing LV remodeling. With progression of coronary failure remodeling intensifies. In patients with angina arterial hypertension contributes to the same degree to an increase in the personage of overall affection of the coronary bed, LV systolic sphericity index and index of its myocardial mass, forms an integral, global risk of heart remodelling and, later, heart failure.