Body mass index,cardiac surgery and clinical outcome. A single-center experience with 9125 patients

Background and AimThere is evidence for a J-shaped association between Body Mass Index (BMI) and all-cause mortality in general populations. In cardiac surgical patients, the effect of BMI on mortality and major adverse cardiac and cerebrovascular events (MACCE) is not completely clear.Methods and ResultsWe investigated the effect of BMI on MACCE (primary endpoint), as well as intensive care unit (ICU)-related outcomes and mid-term mortality in 9125 consecutive patients who were operated on at our institution between July 2009 and July 2012. Of the study cohort, 3.0% were underweight (BMI < 20 kg/m²), 28.0% had a normal BMI (20–24.99 kg/m²), 43.1% were overweight (BMI 25–29.99 kg/m²), 19.3% were obese (BMI 30–34.99 kg/m²), and 6.6% were severely obese (BMI ≥ 35 kg/m²). Compared with overweight patients (lowest incidence of MACCE), the multivariable-adjusted odds ratio of MACCE in severely obese patients was 1.39 (95% CI: 1.03–1.87). Underweight and severely obese patients had the longest risk-adjusted duration of mechanical ventilator support and ICU stay (P-values 0.004–0.001). The red blood cell concentrates requirement was highest in underweight patients (P < 0.001). Compared with normal and overweight patients, the multivariable-adjusted hazard ratio of 2-year mortality was higher in underweight patients (1.72 [95% CI: 1.26–2.36] and =2.07 [95% CI: 1.51–2.83], respectively), but did not differ significantly in severely obese patients.ConclusionData demonstrate that both severe obesity and underweight are independent risk factors for operative complications in cardiac surgical patients. With respect to mid-term survival, special attention should be paid to underweight patients scheduled for cardiac surgery.     

Coronary microvascular spasm triggers transient ischemic left ventricular diastolic abnormalities in patients with chest pain and angiographically normal coronary arteries

Aims

Impaired coronary microvascular dilatory function can lead to exercise induced myocardial ischemia and angina pectoris even in patients without significant (>50%) obstructive coronary atherosclerosis (APWOCA). Diffuse distal vessel epicardial spasm and microvascular spasm have been also proposed as a plausible explanation for angina at rest in these patients. However, objective systematic evidence for the latter i.e. echocardiographic wall motion abnormalities during angina, is lacking at present. Coronary epicardial and microvascular spasm can be triggered in susceptible patients by the administration of intracoronary acetylcholine (Ach). We sought to assess whether Ach induced diffuse distal epicardial coronary artery spasm (≥75% diameter reduction) and coronary microvascular spasm can cause transient ischemic left ventricular dysfunction, as assessed by echocardiography.

Methods

50 patients (19 men aged 60.5 ± 8.9 years) with stable APWOCA were assessed for coronary spasm and myocardial ischemia with intracoronary Ach infusion, 2D transthoracic echocardiography (before and during Ach testing), continuous 12-lead ECG monitoring, and ultrasensitive cardiac troponin (US-cTn) measurement before and within 4 h after Ach testing.

Results

14 patients (28%) had a “negative” Ach test, 14 (28%) developed coronary microvascular spasm and 17 (34%) had diffuse distal epicardial spasm. In 5 patients (10%) the test was inconclusive. Echocardiographic variables including deceleration time, EF slope and E/A, as well as ultrasensitive-cTn concentrations were abnormal during Ach induced ischemic ECG changes. Conclusions: We have, for the first time, demonstrated that Ach induced coronary microvascular spasm is associated with echocardiographic changes and ultrasensitive-cTn elevations, indicative of myocardial ischemia.     

心肌自噬在异丙肾上腺素诱导心肌肥厚中的作用

目的 探讨心肌自噬在异丙肾上腺素（ISO）诱导大鼠心肌肥厚中的作用。方法 将 29只大鼠随机分为 3组：皮下联合腹腔注射生理盐水（Con）组 9只、腹腔注射生理盐水联合皮下注射异丙肾上腺（ISO）组 10只、腹腔注射雷帕霉素（RAP）联合皮下注射 ISO（ISO+RAP）组 10 只。连续干预 14 d 后,将 Con 组和 ISO 组存活大鼠（Con,n=9;ISO,n=8）行心脏超声检查左室壁厚度及左室射血分数（LVEF）,再将各组大鼠腹腔注射过量的 10%水合氯醛处死,摘除心脏,计算心脏体质量指数（HWI）。心肌组织病理切片行 HE染色和 Masson染色,Western blot检测 p62表达和LC3Ⅱ/Ⅰ比值,透射电镜观察心肌组织自噬泡数量。结果 与 Con组比较,ISO组左室壁厚度和 LVEF明显增加（P＜0.01）。与 Con组比较,ISO组和 ISO+RAP组的 HWI增大（P＜0.01）,且 ISO+RAP组的 HWI小于 ISO组（P＜0.01）。与Con组比较,ISO组心肌病理切片显示心肌组织病理性肥厚改变明显;而与 ISO组比较,ISO+RAP组心肌组织病理性肥厚明显改善。与 Con 组比较,ISO 组心肌组织 LC3Ⅱ/Ⅰ比值下调,而 p62 表达上调,自噬泡数量明显减少（P＜0.05）;与 ISO组比较,ISO+RAP组心肌组织 LC3Ⅱ/Ⅰ比值上调,而 p62表达下调,自噬泡数量明显增多（P＜0.01）。结论 上调心肌自噬活性可以逆转 ISO诱导的病理性心肌肥厚。     

Prevalence of acute cardiac disorders in patients with suspected ST-segment elevation myocardial infarction and non-significant coronary artery disease

Background and purpose

We aimed to study the prevalence of acute cardiac disorders in patients with suspected ST-segment elevation myocardial infarction (STEMI) and non-significant coronary artery disease (CAD).

Methods

From January to October 2012 we consecutively included patients admitted with suspected STEMI and non-significant CAD (coronary artery stenosis diameter < 50%). Patients were diagnosed with acute cardiac disorder in the presence of elevated cardiac biomarkers (troponin T > 50 ng/l or creatine kinase MB > 4 μg/l) or dynamic ECG changes (ST-segment changes or T-wave inversion).

Results

Of the 871 patients admitted with suspected STEMI, 11% (n = 95) had non-significant CAD. Of these, 67% (n = 64) had elevated cardiac biomarkers or dynamic ECG changes and were accordingly diagnosed with acute cardiac disorders. In the remaining 33% (n = 31) of patients, cardiac biomarkers were normal and ECG changes remained stationary.

Conclusions

Acute cardiac disorders were diagnosed in two thirds of patients with suspected STEMI and non-significant CAD.     

Alpha‐Tocopherol during lactation and after weaning alters the programming effect of prenatal high salt intake on cardiac and renal functions of adult male offspring

Maternal salt overload programs cardiovascular and renal alterations in the offspring. However, beneficial and harmful effects of high dose vitamin E supplementation have been described in humans and animals. We investigated the hypothesis as to whether cardiac and renal alterations can be programmed by gestational salt overload, and can become further modified during lactation and after weaning. Male Wistar rats were used, being the offspring of mothers that drank either tap water or 0.3 mol/L NaCl for 20 days before and during pregnancy. α‐Tocopherol (0.35 g/kg) was administered to mothers daily during lactation or to their offspring for 3 weeks post‐weaning. Systolic blood pressure (tcSBP) was measured in juvenile rats aged 210 days. The response of mean arterial pressure (MAP) and heart rate (HR) to intravenous infusion of angiotensin II (Ang II) was also examined. Left ventricle plasma membrane (PMCA) and sarcoplasmic reticulum Ca²⁺‐ATPase (SERCA) activities, and certain parameters of renal function, were measured. Maternal saline programmed for increased body mass and kidney mass/body mass ratio, increased tcSBP, increased mean arterial pressure and heart rate with anomalous response to infused Ang II. In the heart, saline increased PMCA and α‐Tocopherol per se increased PMCA/SERCA. In the kidney, the most remarkable result was the silent saline programming of Cr_Cl, which was sensitized for a sharp decrease after α‐Tocopherol. In conclusion, the combination of maternal saline overload and high α‐Tocopherol immediately after birth leads to simultaneous cardiovascular and renal alterations in the young offspring, like those encountered in type V cardiorenal syndrome.     

热休克蛋白27心肌特异性高表达诱导小鼠产生心肌肥厚

目的探讨不同表达量的热休克蛋白27（Hsp27）在小鼠心脏中的作用。方法构建在心肌中特异性表达Hsp27的不同表达量的转基因鼠（TG）,对照组为野生型鼠（WT）。采用蛋白印记测定Hsp27蛋白表达水平;分别测量心脏质量与体质量的比值和心脏质量与胫骨长度的比值（HW／BW和HW／TL）;采用实时定量荧光PCR（real time PCR）技术测定心肌肥厚标记物心房利钠肽（ANP）、脑利钠肽（BNP）的表达;采用超声心动图观察心功能及心脏结构。通过长期饲养,观察存活率。结果不同TG系鼠,Hsp27心肌特异性表达水平不同。高表达TG10鼠与WT鼠相比,其HW／BW和HW／TL比值显著增加（P〈0．01）,并且ANP和BNP的mRNA水平也明显增加（P〈0．01）。TG10鼠的心功能与WT鼠比较显著下降（P〈0．01）,射血分数（EF）降低了24．64％,短轴缩短率（VS）降低了29．37％。TG10鼠的生存率明显降低（P〈0．01）。结论高表达的Hsp27在TG鼠心肌肥厚发展中起着重要作用,提示Hsp27可以作为心肌病患者治疗的潜在靶点。     

超声心动图新技术在慢性心力衰竭心脏同步化评估中的应用

许多研究表明了慢性心力衰竭患者再同步化治疗中超声心动图的重要性。目前越来越多的超声心动图新技术用于心脏再同步化治疗前评价房室之间、心室之间和心室内部的机械不同步情况,同时在指导最佳起搏电极安置和探讨心脏再同步化治疗有效性预测方面起到至关重要的作用,目的是进一步提高心脏再同步化治疗的临床疗效,但需要更多的研究进一步阐明。     

心脏核磁共振成像与心内电生理

透视介导的心脏内电生理术一个主要缺点为术中无法正确识别软组织及其与比邻结构关系,然而,心脏核磁共振成像介导的心内电生理术却弥补了这一缺陷.心脏核磁共振成像-心内电生理术不仅可精确地展示出心脏的三维空间形态结构,而且能直接识别心律失常病灶及观察射频消融的疗效,提高复杂心律失常手术成功率及减少并发症有重要作用.因而,心脏核磁共振成像被认为在心内电生理领域具有广泛运用前景.