冠状动脉血运重建术对左心室收缩功能严重减低患者左心室重构及收缩功能的作用

目的:评价冠状动脉血运重建术对陈旧性心肌梗死伴左心室收缩功能严重减低患者的左心室重构及整体和节段收缩功能的改善作用.方法:对陈旧性心肌梗死伴左心室收缩功能严重减低(左心室射血分数 0.39±0.05),并证明病变部位有存活心肌的患者26例,均完成冠状动脉血运重建术,其中冠状动脉旁路移植术12例,经皮冠状动脉腔内成形术 支架14例.于冠状动脉血运重建术前、后[平均(6.8±2.9)月]进行二维超声心动图检查,评价左心室容积及整体和节段收缩功能的变化,并完成术后临床随访.结果:26例患者冠状动脉血运重建术后与术前相比, 57.4%的运动异常节段(156/272)有收缩运动改善;术后平均左心室舒张末容积(LVEDV)和收缩末容积(LVESV)均显著缩小(P<0.05～0.01),而左心室射血分数和室壁节段运动评分指数均显著改善(P均<0.001);随访期间的临床症状和NYHA心功能分级亦均明显改善,无心脏事件发生.去除4例行室壁瘤切除者后,各指标的变化与上述相同.再以冠状动脉血运重建术后左心室射血分数增加≥0.05与否分为心功能改善者和心功能无改善者各11例,心功能改善者的LVEDV和LVESV均较术前显著缩小(P均<0.01),心功能无改善者两参数较术前均无明显扩大.此外,术后功能改善的节段数与术后左心室射血分数呈显著正相关(r=0.51,P<0.01);而术后功能无改善节段数在心功能无改善者显著高于心功能改善者(P<0.05).结论:对陈旧性心肌梗死伴左心室收缩功能严重减低并证明病变部位有存活心肌的患者,冠状动脉血运重建术能够阻抑进行性左心室重构,改善左心室整体、节段收缩功能和临床症状.术后功能改善节段数与整体心功能改善正相关,而无功能改善节段数可能与术后整体心功能不改善有关.     

心肌梗死择期经皮冠状动脉介入治疗对左心室重构和收缩功能的影响

目的:评价心肌梗死恢复期经皮冠状动脉介入治疗对左心室重构和收缩功能的影响。方法:将成功经皮冠状动脉介入治疗后又有造影复查的380例冠心病患者分为2组,①心肌梗死组224例,其中前壁梗死者106例,下壁梗死者102例,其它部位梗死者16例;介入治疗时梗死相关冠状动脉闭塞者118例,非闭塞者105例,梗死相关冠状动脉无法判断者1例。②非心肌梗死组156例。结果:380例中冠状动脉单支、双支和三支病变者占28％、37％和35％。①非心肌梗死组经皮冠状动脉介人治疗前、后左心室大小和收缩功能参数无显著变化,且在正常范围。②心肌梗死组经皮冠状动脉介入治疗前左心室舒张末容积(LVEDV)及指数(LVEDVI)、收缩末容积(LVESV)及指数(LVESVI)比非心肌梗死组均已显著增大(P均<0．001),左心室射血分数(LVEF)和左心室收缩末压(LVESP)均显著降低(P均<0．001);经皮冠状动脉介入治疗后LVESV、LVESVI均比治疗前显著降低(P均<0．001),每搏量(SV)及其指数(SVI)、LVEF、LVESP均显著提高(P<0．05-0．001);LVESVI降低和LVEF升高的程度比非心肌梗死组更显著(P<0．05～0．001);且在前壁和下壁心肌梗死患者间均无显著差异,疗效相当。③经皮冠状动脉介入治疗前梗死相关动脉闭塞和非闭塞患者,经皮冠状动脉介入治疗后LVEF均显著提高(P均<0．001),而LVESV、LVESVI仅在梗死相关动脉闭塞者显著降低(P均<0．05)。结论:急性心肌梗死患者恢复期已发生左心室重构伴收缩功能减低,择期经皮冠状动脉介入治疗可有效逆转左心室重构,提高左心室收缩功能。     

超声心动图评价冠状动脉血运重建术对改善陈旧性心肌梗死区域室壁运动的意义

应用二维超声心动图观察陈旧性心肌梗死（ＯＭＩ）患者室壁运动异常（ＷＭＡ）节段在冠状动脉血运重建手术前后收缩功能改善与否，并和未行血运重建术的患者比较。旨在：①比较血运重建术与否对ＷＭＡ节段收缩功能改善的影响：②分析血运重建术后ＷＭＡ节段收缩功能改善的可能相关因素。结果发现：①血运重建组术后７４６％的ＷＭＡ收缩功能改善，而非血运重建组＞４个月随访仅１５％功能改善，即对ＭＩ相关冠脉的血运重建术可以使ＯＭＩ区域ＷＭＡ节段的收缩功能改善，即使是病程较长的ＯＭＩ。②ＷＭＡ节段血运重建术后收缩功能能否改善主要与其术前的收缩功能障碍程度有关：收缩运动减弱的节段约９０％左右可望在血运重建术后改善其功能，而无运动或矛盾运动的节段仍有３０％左右手术后改善功能。     

心肌梗死患者激光心肌血运重建术后左心室功能变化

目的　评价心肌梗死患者激光心肌血运重建术 (TML R)前后不同时期左心室功能的变化。方法　 2 4例心肌梗死患者接受 TML R治疗 ,采用二维、多普勒超声分别测定 TML R前、TML R后 3个月、6个月和 12个月的左心室功能 ,并进行比较。结果　 2 4例 TML R均获成功 ,术后 1天死亡 1例 ,余 2 3例恢复良好 ;术后 3个月、6个月和 12个月的左心室射血分数、心脏指数与术前比较明显改善。结论　 TML R对心肌梗死患者有疗效 ,能改善患者的左心室收缩功能。     

血运重建对冠心病合并心功能不全患者心肌收缩功能和心室重构的影响

目的探讨血运重建对冠心病合并左心功能不全患者心肌收缩功能和心室重构的影响。方法86例冠心病合并心功能不全患者术前应用超声心动图进行心功能、左心室(左室)几何形态和心肌活性评定,分为有存活心肌组和无存活心肌组,两组分别行血运重建或药物治疗。随访(13±5)个月后重新评价上述指标。结果57例有存活心肌的患者中行血运重建者较药物治疗者左室射血分数(LVEF)、存活节段数、左室球状指数(LVSI)明显提高;左室舒张末容积(LVEDV)、左室收缩末容积(LVESV)、左室重量(LVM)明显降低(P值均<0.01)。29例无存活心肌的患者中上述指标两种治疗间无显著性差异(P值均>0.05)。结论血运重建能改善冠心病合并左心功能不全但有存活心肌患者的心肌收缩功能和几何形态。     

经皮冠状动脉介入术对冠状动脉慢性闭塞病变患者心功能的影响

目的评价经皮冠状动脉介入术(PCI)对冠状动脉慢性闭塞病变患者心功能的影响。方法经冠状动脉造影证实的冠状动脉慢性闭塞病变患者24例均行PCI,其中手术成功20例,手术前后均行临床及超声心动图检查,评价PCI术对左心室收缩功能的改善作用。结果手术成功患者心功能改善显效14例,有效5例,无效1例,总有效率95.0%。术后左心室收缩末容量(LVESV)、舒张末容量(LVEDV)、左室射血分数(LVEF)分别为(85±17)mL、(53.5±8.2)mL和(62.5%±11.2%),术前分别为(101±16)mL、(59.6±8.3)mL和(50.2%±5.8%),手术前后比较,P均<0.05。结论 PCI能够改善冠状动脉慢性闭塞病变患者左心室收缩功能。     

室壁中层缩短率在2型糖尿病患者左心室收缩功能中的评估价值

目的研究室壁中层缩短率(MFS)在2型糖尿病患者左心室收缩功能中的评估价值。方法选择48例2型糖尿病患者为观察组,另选同期体检的正常群体48例作为对照组,对比两组血糖血压等相关指标、左心室超声检查相关指标,分析MFS与左心室质量指数(LVMI)及糖化血红蛋白(Hb A1c)的相关性。结果观察组血糖(Glu)、Hb A1c、体质量指数(BMI)及体表面积(BSA)水平均显著高于对照组(均P0.05)。观察组左心室质量(LVM)与LVMI水平均显著高于对照组,但MFS与应力相关MFS(S-c MFS)水平均显著低于对照组(均P0.05)。根据Spearman法分析相关性发现,MFS与LVMI及Hb A1c均呈负相关(r=-0.653,-0.582,P0.05)。结论糖尿病型心脏病进展缓慢,临床诊断时,MFS可敏感检测出患者早期心肌收缩力降低,有较高的评估价值,值得推荐。     

左心室壁中层缩短率评价2型糖尿病患者早期左心室收缩功能变化

目的:运用左心室壁中层缩短率评价2型糖尿病患者早期左心室收缩功能改变.方法:51例2型糖尿病者(糖尿病组)及30例体验正常者(对照组),行常规及组织多普勒超声心动图检查,测量左心室壁中层缩短率(mFS),计算左心室经线及圆周收缩末期应力,对两组间左心室结构和收缩功能指标即mFS、左心室射血分数、左心室短轴缩短率(LVFS)和二尖瓣环收缩期峰值运动速度(Sm)进行比较,并对mFS与左心室结构参数、空腹血糖水平行相关分析.结果:糖尿病组与对照组比较,左心室舒张末径、左心室收缩末径、左心室质量、左心室心肌质量指数均增加(P<0.01),mFS减低[(21.9±3.4)% vs (24.2±2.6)%,P<0.01].两组间舒张期室间隔厚度、舒张期左心室后壁厚度及相对室壁厚度比较,差异无统计学意义.mFS与左心室收缩末径、左心室质量、左心室心肌质量指数负相关(r 值分别为-0.586、-0.332和-0.239,P<0.05),与空腹血糖水平亦呈负相关 (r =-0.315,P=0.011),这种负相关在校正了年龄、性别、收缩压和体重指数的影响后仍然存在.结论:2型糖尿病患者存在亚临床的左心室收缩功能变化,室壁中层缩短率是检测糖尿病患者早期心肌收缩力下降的敏感指标.     

左心室功能下降冠心病患者的血运重建治疗

冠心病是充血性心力衰竭的最常见病因。无瓣膜性病变的冠心病患者中,心力衰竭最常见由左心室收缩功能下降（左心室射血分数下降）导致,伴有左心室射血分数下降的冠心病患者预后不良。目前认为血运重建可以改善左心室射血分数下降的冠心病患者的预后,同时左心室射血分数下降患者血运重建风险高。现对左心室功能障碍的冠心病患者的血运重建治疗作一综述。     

经皮冠状动脉介入治疗与左心室舒张功能减退的相关性研究

目的:探究经皮冠状动脉介入治疗(PCI)对冠心病患者左心室舒张功能的影响及相关危险因素分析.方法:本研究共纳入2017年10月至2019年10月首次行PCI,且术后1年来院复查冠状动脉造影的不稳定性心绞痛患者302例.根据支架置入数目分Ⅰ组:1枚支架(123例),Ⅱ组:2枚支架(108例),Ⅲ组:≥3枚支架(71例)....     

Surgical coronary revascularization in severe left ventricular dysfunction

Surgical revascularization in patients with coronary artery disease and severe left ventricular dysfunction is a common practice and poses a surgical challenge. From September 2002 to May 2004, 50 patients (47 men and 3 women; mean age, 59 +/- 9 years) with a mean preoperative ejection fraction of 19.7% +/- 3.2% underwent surgical revascularization. The mean EuroSCORE was 7.2 +/- 3.4. Indications for surgery were congestive heart failure in 8 patients (16%), angina in 20 (40%), ventricular arrhythmias in 4 (8%), and critical left main stem disease in 12 (24%). Twenty-two patients (44%) had emergency surgery for critical anatomy and unstable symptoms. The number of grafts per patient was 3.7 +/- 0.8. Seventeen patients (34%) required intra-aortic balloon pump support, 16 (32%) needed pacing, and 48 (96%) had inotropic support postoperatively. Morbidity included re-operation for bleeding (2%), acute renal failure (10%), hemodialysis (4%), and fatal multiorgan failure (4%). Postoperative (4.9 +/- 3.7 months) 2-dimentional echocardiography was available in 18 patients of whom 11 (61%) showed improved left ventricular function (range, 5% to 45%). Thirty-day hospital mortality was 8%. These data indicate that surgical revascularization can be performed safely with acceptable hospital mortality in high-risk patients with severe left ventricular dysfunction.     

Effect of revascularization on left ventricular remodeling in patients with heart failure from severe chronic ischemic left ventricular dysfunction

Few data exist regarding the effect of revascularization on left ventricular (LV) geometry in patients with severe LV systolic dysfunction and viable myocardium. We hypothesized that patients with chronic ischemic LV dysfunction but viable myocardium will have improved LV geometry after revascularization, which in turn will improve long-term outcome. Accordingly, 70 patients with severe ischemic LV dysfunction (LV ejection fraction <0.35) were studied at rest. They then either underwent revascularization (n = 36) or were treated medically (n = 34). Fifty-four patients had viable myocardium, and 16 did not. They were evaluated for change in LV function and geometry (size and shape) a mean of 21 months later. Further follow-up was performed for a mean of 3.5 years to determine outcome. Patients with viable myocardium had improvement not only in regional and global function, but also in LV geometry (shape and size), which was independent of and incremental to the improvement in function. On long-term follow-up, change in LV end-systolic volume was the only multivariate discriminator between 15 patients who died and 55 who did not, irrespective of whether they had undergone revascularization. Thus, measurement of the effect of revascularization of viable myocardium in chronic ischemic heart disease should not only include improvement in resting regional and global LV function, but also LV geometry. Improvement in LV geometry contributes to better LV systolic function, which in turn is the best predictor of survival after revascularization.     

Incidence of recovery of contractile function following revascularization in patients with ischemic left ventricular dysfunction

Contractile function in patients with ischemic left ventricular (LV) dysfunction may improve after myocardial revascularization. Currently, the incidence of contractile function recovery after revascularization in these patients is unclear. The aim of this study was to assess the incidence of function improvement after myocardial revascularization in patients with ischemic LV dysfunction. A total of 258 consecutive patients (aged 59 +/- 12 years) with severely depressed LV ejection fractions (EFs) due to chronic coronary artery disease and heart failure symptoms were studied. All patients underwent radionuclide ventriculography and 2-dimensional echocardiography at rest before and 3 to 6 months after revascularization. At baseline, 1,330 segments (32%) were normal and 2,775 segments (68%) were dysfunctional. Improvement after revascularization occurred in 736 of the 2,775 dysfunctional segments (27%). Overall, LVEF improved from 29 +/- 7 to 32 +/- 9 (p <0.0001). A clinically significant improvement of LVEF (>/=5% postrevascularization) was present in 101 patients (39%). Improvement of LVEF after revascularization was frequently observed in patients with a more severely impaired baseline LVEF. At least 3 segments with improvement of function were needed for an improvement of LVEF of >/=5%.     

Selection of angina-free patients with severe left ventricular dysfunction for myocardial revascularization

Stress thallium-201 myocardial imaging was used in two angina-free patients with severe congestive heart failure to identify clinically silent areas of ischemic myocardium and to distinguish between scar and reversibly ischemic myocardium as a cause for akinesia of left ventricular wall segments. Subsequent myocardial revascularization in these patients led to considerable improvement in their clinical state and findings in postoperative nuclear scans. Thus, stress myocardial imaging may be useful in selecting patients with severe left ventricular failure but no angina pectoris for myocardial revascularization.     

Relationship between coronary flow reserve and recovery of regional left ventricular function in patients with tako-tsubo-like transient left ventricular dysfunction

OBJECTIVES: This study assessed the relationship between coronary flow reserve and functional recovery of left ventricular wall motion in patients with tako-tsubo-like transient left ventricular dysfunction. METHODS: Coronary flow reserve was measured using the Doppler guide wire technique in the left descending coronary artery in nine consecutive patients (three men, six women, mean age 71 +/- 11 years) with tako-tsubo-like transient left ventricular dysfunction. Regional wall motion was analyzed to estimate anterior wall motion score index (anterior WMSI) by transthoracic echocardiography on admission and 3 weeks after the onset of symptoms. RESULTS: Anterior WMSI was 2.2 +/- 0.4 on admission and improved to 1.4 +/- 0.5 at 3 weeks later (p < 0.001). Coronary flow reserve on admission was not correlated to the anterior WMSI on admission (r = 0.19, p = 0.63). However, coronary flow reserve on admission was correlated to the improvement in anterior WMSI (r = 0.74, p = 0.02). CONCLUSIONS: Coronary microcirculation is damaged in acute phase of tako-tsubo-like transient left ventricular dysfunction. The severity of coronary microvascular dysfunction influences the degree of left ventricular wall motion recovery.     

Percutaneous transluminal coronary angioplasty in patients with severe left ventricular dysfunction

Although bypass surgery can be utilized in the patient with impaired left ventricular function, the acute outcome (regarding morbidity and mortality) and long-term survival have significant associated problems. Percutaneous transluminal coronary angioplasty (PTCA) was implemented effectively as an accessory or alternative to coronary bypass surgery to treat obliterative coronary lesions in patients with severe ventricular dysfunction. The authors present data which indicate that PTCA should be considered in patients with left ventricular dysfunction as a primary therapeutic modality.     

Revascularization for patients with severe coronary artery disease and left ventricular dysfunction

Heart failure is becoming increasingly prevalent, and currently coronary artery disease (CAD) is the primary cause of left ventricular (LV) systolic dysfunction. A potential therapeutic option for patients with severe CAD and LV dysfunction is a strategy of revascularization. In this review, we summarize the available literature regarding revascularization for these patients. The literature suggests that patients with severe CAD and LV dysfunction may benefit from revascularization and those patients with viable myocardium may derive the most benefit.