Usefulness of PCR Strategies For Early Diagnosis of Chagas'' Disease Reactivation and Treatment Follow-Up in Heart Transplantation

Heart transplantation (HTx) is a useful therapy for end‐stage Chaga? cardiomyopathy; however, Chagas reactivation remains a mayor complication. Parasitological methods offer poor diagnostic sensitivity, and use of more sensitive tools such as the Polymerase chain reaction (PCR) is usually necessary. In the present study, reactivation incidence and PCR usefulness for early reactivation diagnosis, as well as for treatment response evaluation during follow‐up, were analyzed using Strout parasite detection test, in 10 of 222 consecutive HTx patients suffering Chagas cardiomyopathy. PCR strategies targeted to minicircle sequences (kDNA, detection limit 1 parasite/ 10 mL blood) and miniexon genes (SL‐DNA, 200 parasite/10 mL) were performed to compare parasite burdens between samples. No patients received prophylactic antiprotozoal therapy (benznidazole). Five patients (50%) exhibited clinical reactivation within a mean period of 71.6 days; positive Strout results were observed in most cases presenting clinical manifestations. kDNA‐PCR was positive 38–85 days before reactivation, whereas SLDNA‐PCR became positive only 7–21 days later, revealing post‐HTx parasitic load enhancement present prior to clinical reactivation development. Reactivations were successfully treated with benznidazole and generated negative PCR results. Results observed in this study indicate the value of PCR testing for an early diagnosis of Chagas reactivation as well as for monitoring treatment efficacy.     

Surgery for ventricular tachycardia in patients undergoing surgical ventricular restoration: The Karolinska approach

This article presents a review on the efficacy of surgical ventricular restoration and direct surgery for ventricular tachycardia in patients with left ventricular aneurysm or dilated ischemic cardiomyopathy. The procedure includes a non-electrophysiologically guided subtotal endocardiectomy and cryoablation in addition to endoventricular patch plasty of the left ventricle. Coronary artery bypass surgery and mitral valve repair are performed concomitantly as needed. In our experience, this procedure yielded a 90% success rate in terms of freedom from spontaneous ventricular tachycardia, with an early mortality rate of 3.8%. A practical guide to the pre- and postoperative management of these patients is provided. Electronic supplementary material The online version of this article (doi: ) contains supplementary material, which is available to authorized users.     

Heart insufficiency in traumatic arteriovenous fistulas

Objective: To analyse the incidence, clinical presentation, and outcome of heart insufficiency in patients with chronic arteriovenous fistulas (AVF). Methodology: From 1991 to 2000 we treated 49 patients with traumatic AVF. The present study included 19 patients with AVF present for 6 months or longer, as it was presumed that these AVF will have an impact on cardiac overload. There were 16 male and three female patients with a mean age of 36 years (17–59). The time from injury to admission varied from 6 months to 33 years. Cardiological examination checked for dyspnoea and palpitation. ECG, chest X‐ray and ECHO‐cardiography were also performed. All AVF were deleted, magistral vessels reconstructed, non‐magistral obliterated, either surgically or by percutaneous embolization. Results: Mean follow up was 44.2 months (3–93). Serious heart insufficiency was seen in two patients only, with AVF in the subclavial vessels. Both suffered from serious heart disease prior to the therapeutic procedures that resulted in iatrogenic AVF, so it was difficult to connect heart insufficiency to the AVF alone. Despite surgical closure of AVF and intensive medical treatment, signs of heart insufficiency remained in both patients. Signs of cardiac overload were seen in six patients with long‐standing AVF in major vessels. Except for one patient who refused surgical closure of femoral AVF, the remaining five were symptom free for cardiac overload during the follow‐up period. Conclusion: In our series, heart insufficiency was an infrequent complication in long‐standing AVF, even when major vessels were involved.     

Evaluation of left ventricular mechanical dyssynchrony as determined by phase analysis of ECG-gated SPECT myocardial perfusion imaging in patients with left ventricular dysfunction and conduction disturbances

Background  Cardiac resynchronization therapy (CRT) is approved for the treatment of patients with advanced systolic heart failure and evidence of dyssynchrony on electrocardiograms. However, a significant percentage of patients do not demonstrate improvement with CRT. Echocardiographic techniques have been used for more accurate determination of dyssynchrony. Single photon emission computed tomography (SPECT) myocardial perfusion imaging has not previously been used to evaluate cardiac dyssynchrony. The objective of this study is to evaluate mechanical dyssynchrony as described by phase analysis of gated SPECT images in patients with left ventricular dysfunction, conduction delays, and ventricular paced rhythms. Methods and Results  A novel count-based method is used to extract regional systolic wall thickening amplitude and phase from gated SPECT images. Five indices describing the phase dispersion of the onset of mechanical contraction are determined: peak phase, phase SD, bandwidth, skewness, and kurtosis. These indices were determined in consecutive patients with left ventricular dysfunction (n=120), left bundle branch block (n=33), right bundle branch block (n=19), and ventricular paced rhythms (n=23) and were compared with normal control subjects (n=157). Phase SD, bandwidth, skewness, and kurtosis were significantly different between patients with left ventricular dysfunction, left bundle branch block, right bundle branch block, and ventricular paced rhythms and normal control subjects (all P<.001) Peak phase was significantly different between patients with right ventricular paced rhythms and normal control subjects (P=.001). Conclusions  A novel SPECT technique for describing left ventricular mechanical dyssyn-chrony has been developed and may prove useful in the evaluation of patients for CRT. This study was funded in part by a research grant from the Medtronic-Duke Strategic Alliance, of which Dr Borges-Neto is the primary investigator.     

内镜下鼻胆管引流治疗急性梗阻性化脓性胆管炎(附25例报告)

目的探讨急性梗阻性化脓性胆管炎伴多器官衰竭的治疗方法。方法对25例急性梗阻性化脓性胆管炎伴多器官衰竭的患者采取以内镜下鼻胆管引流术、经鼻胆管冲洗及灌注抗生素为主的非手术综合治疗,观察患者治疗前后的血清总胆红素水平、B超下胆总管内径变化,并对患者临床资料进行回顾性分析。结果本组25例患者除2例需转外科急诊手术治疗外,其余23例内镜下胰胆管造影、内镜下鼻胆管引流术成功,胆汁引流通畅,多器官衰竭得以纠正,急性梗阻性化脓性胆管炎伴多器官衰竭治愈率为92.0%。结论对急性梗阻性化脓性胆管炎伴多器官衰竭患者采取内镜下鼻胆管引流术、静脉应用和经鼻胆管冲洗及灌注抗生素为主的综合治疗是有效、安全的。     

缬沙坦加参麦注射液治疗充血性心力衰竭的临床观察

目的观察缬沙坦（Valsartan）加参麦注射液（Shenmai Injection,SI）对充血性心力衰竭（CHF）心肌损害的疗效。方法采用随机分组的方法,分别用常规治疗（31例）和缬沙坦、SI加常规治疗（31例）,并对CHF的各项实验室指标[血浆肌钙蛋白T（cTnT）、心肌酶谱]进行观察。结果在CHF进程中,cTnT浓度随着心功能恶化呈进行性增高。应用缬沙坦加SI治疗2周后,患者左室收缩功能得到明显改善,未发现严重不良反应。结论血浆cTnT可作为CHF患者预后判断的一项重要生化指标。缬沙坦加SI是治疗CHF安全有效的药物。     

Characteristics of the Nonselective Cation Current （NSCCs） in Rabbit Left Ventricular Epicardial, Midmyocardial and Endocardial Myocytes

Objectives Recent studies have described regional differences in the electrophysiology and pharmacology of ventricular myocardium in canine, feline, rat, guinea pig, and human hearts. This has been shown to be due to a smaller IKs and a lager sodium-calcium exchange current (INa-Ca) and late INa in M region (deep subepicardial to midmyocardial). Studies from our laboratory have found a new repolarization current-nonselective cation current (NSCCs) existing in rabbit right ventricular myocytes. Methods We examined the characteristics of NSCCs in epicardial, M region, and endocardial cells isolated from the rabbit left ventricle with standard microelectrode and whole-cell patch-clamp techniques. The permeability to Na , K , Li , Cs but not to Cl- indicating that it was a nonselective cation current. Gd3 (0.1 mmol/l) and La3 (0.1 mmol/l) can block the current markedly. Results Further characterization of NSCCs was significantly smaller in M cells than in epicardial and endocardial cells. NSCCs current density was significantly smaller in M cells than in epicardial and endocardial cells. With repolarization to -80 mV, INs current density was (-0.44±0.05) PA/PF in endocardial cells, (-0.12±0.05) PA/PF in M cells and (-0.28±0.07) PA/PF in epicardial cells; and with repolarization to 30 mV, INs current density was (1.09±0.29) PA/PF in endocardial cells, (0.38±0.09) PA/PF in M cells and (0.91±0.32) PA/PF in epicardial cells. Conclusions Transmural dispersion of repolarization was due to the heterogeneity of NSCCs in rabbit left ventricle epicardial, endocardial myocytes and M cells. These findings may advance our understanding of the ionic basis for our understanding of factors contributing to the development of cardiac arrhythmias.     

非右房肥大的P波高电压(附39例临床分析)

本文报告39例临床上除外右房肥大的P波高电压,此种P波高电压主要见于冠心病及急性颅脑疾患,二者之和占76.9%。其形态64%与肺性P波相同。产生的机制可能与结间束传导阻滞、中枢调节机能受累、交感神经兴奋性增高等有关。