Protocol driven palliative care consultation: Outcomes of the ENABLE CHF-PC pilot study

Background

Little has been reported about protocol-driven outpatient palliative care consultation (OPCC) for advanced heart failure (HF).

慢性心力衰竭大鼠心肌细胞凋亡与心功能的关系及福辛普利和氯沙坦的干预作用

目的:探讨心力衰竭大鼠心肌细胞凋亡与心功能的关系及福辛普利和氯沙坦的干预作用。方法:雌性SD大鼠行左前降支结扎术致急性心肌梗死,术后4周行多普勒超声心动图检测,成功制作慢性心力衰竭(左心室射血分数≤0．45)大鼠36只,随机分成:福辛普利组(50 mg／kg·d,n=12);氯沙坦组(30 mg／kg·d,n=12);生理盐水组(1 mL／d,n=12)。另设假手术组(n=8)不结扎冠状动脉。治疗8周后,再次行超声心动图检测。原位末端标记法(TUNEL)和脱氧核糖核酸(DNA)梯形谱(DNA ladder)检测心肌细胞凋亡。结果:3组心力衰竭大鼠DNA电泳均显示凋亡特征性DNA ladder。与假手术组比较,生理盐水组各项心功能指标显著下降,凋亡指数显著升高(P<0．05)。与生理盐水组比较,福辛普利组和氯沙坦组各项心功能指标显著改善,福辛普利组(P<0．05)和氯沙坦组(P<0．05)凋亡指数显著降低。左心室射血分数与临近梗塞区心肌凋亡细胞数量之间呈负相关关系(r=-0．754,P<0．001)。结论:心肌细胞凋亡与心力衰竭时心功能不断恶化相关。福辛普利和氯沙坦能抑制心肌细胞凋亡并改善左心室收缩功能。     

心衰患者窦性心率震荡检测及多因素影响分析

目的　观察心力衰竭患者窦性心率震荡 (HRT)现象的特征并探讨其临床意义。方法　 2 0 0 4 - 0 1～ 0 4哈尔滨医科大学第一临床医学院门诊 30例心衰患者及 30名健康对照者均接受 2 4hHolter检查 ,分别计算HRT的初始值 (TO)、HRT的斜率 (TS) ,并进行TO、TS与年龄、左室射血分数 (LVEF)、左室舒张末期内径 (LVED)、室早数目、室早前心率、联律间期、代偿间期的相关分析及不同起源室早TO、TS的组间比较。结果　心衰者与健康者HRT间存在明显差别 :心衰者TO明显高于对照者 (0 5 7± 4 71%与 - 1 5 6± 2 6 0 % ,P <0 0 2 5 ) ;心衰者TS明显低于对照者 (3 17± 2 0 3%与 9 6 4± 6 4 7,P <0 0 0 1)。TO、TS与年龄、LVEF、LVED、室早数目相关 ,与室早前心率、联律间期、代偿间期不相关 ,起源不同室早的TO、TS间无明显差异。结论　慢性心衰患者中窦性心率震荡现象明显减弱 ,由于TO、TS与LVEF、LVED相关 ,可凭借TO、TS对心衰患者进行危险分层 ,但它对预后的预测价值有待于大样本长期随访来证实。     

经导管同期治疗复合型先天性心脏病的疗效观察

目的研究经导管同期治疗复合型先天性心脏病的策略并评价其疗效。方法34例患者,男12例,女22例。复合类型为:房间隔缺损(ASD)合并肺动脉瓣狭窄(PS)、室间隔缺损(VSD)、动脉导管未闭(PDA)分别是16例、7例、3例,合并二尖瓣狭窄(Lutembacher综合征)2例;VSD合并PDA3例、Taussig-Bing畸形合并PDA1例;2例并发3种畸形(并发ASD、VSD和PDA1例,并发ASD、PS和PDA1例)。经导管介入治疗的原则:先行瓣膜球囊扩张术纠正瓣膜狭窄,其次行VSD封堵术,再次行PDA封堵术,最后行ASD封堵术。术后3d、1个月、6个月分别行经胸超声心动图(TTE)、X线检查评价治疗效果。结果34例复合型先天性心脏病患者均一次性治疗成功。术中未发生任何重要并发症。术后即刻TTE和造影示ASD,VSD,PDA所有封堵器位置良好,无残余分流。16例ASD合并PS者,跨肺动脉瓣平均压差由术前52.6±20.5mmHg下降到术后14.3±9.5mmHg(1mmHg=0.133kPa),差异有统计学意义(P<0.05)。2例Lutembacher综合征患者,超声心动图测量二尖瓣瓣口面积分别由二尖瓣球囊扩张术前1.0和1.2cm2增加到术后1.9和2.0cm2,平均左房压分别由29和26mmHg降至8和7mmHg。对于1例Taussig-Bing畸形合并PDA者,用18mmASD伞成功封堵16mmPDA,降低肺动脉压,改善患者症状,为二次手术创造条件。术后72h、1个月、6个月TTE示所有患者各水平分流均消失,左心房、左心室进行性地缩小,所有封堵器位置固定良好,无移位及脱落;同时行X线检查,肺血均明显减少,房室内径均明显恢复。结论复合型先天性心脏病经导管同期介入治疗虽较单纯型复杂,技术要求相对较高,但如指征掌握恰当,治疗策略合理,操作规范,同样可获得良好的治疗效果。     

Three methods for evaluation of left atrial volume.

AIM: To compare and contrast 3 different echocardiographic methods used to measure left atrial (LA) volume: biplane area length (AL), biplane modified Simpson (SIMP), and prolate ellipse (PE) methods. METHODS AND RESULTS: A review of consecutive patients who presented to our outpatient echocardiography laboratory for a resting transthoracic study between April 2006 and May 2006 was performed. Echocardiograms were reexamined and LA volume measured using the AL, SIMP, and PE methods. Of 102 consecutive patients evaluated, 97 had a measure of LA volume using all 3 methods. A significant difference in the measurement of mean +/- SD LA volume was noted among the 3 different methods: 37 +/- 16 mL/m(2) for AL, 34 +/- 14 mL/m(2) for SIMP, and 27 +/- 12 mL/m(2) for PE. The PE method yielded routinely smaller values compared with either the AL or SIMP method (P < 0.001). Differences increased with increased LA volume. The SIMP method derived consistently smaller (<5 mL/m(2)) values than those of the AL method, consistent across the full range of LA volumes. CONCLUSION: Significant differences exist among these 3 commonly used methods for measuring LA volume. Standardization of the measurement of LA volume is recommended.     

单纯收缩期高血压患者脉搏波传导速度与心率变异性

目的研究单纯收缩期高血压患者主动脉脉搏波传导速度与心率变异性特别是低频部分(LF)的关系,评估这两个指标与心血管危险度的相关性。方法选取单纯收缩期高血压(ISH,n=89)患者及双期高血压(DH,n=98)患者,应用 SUN-8800动脉硬化检测仪检测颈股动脉脉搏波传导速度(cfPWV)及颈桡动脉脉搏波传导速度(crPWV),采用5 min 短程频域分析法分析其心率变异性(HRV)指数。89例 ISH 根据危险程度分为低危(n=3)、中危(n=17)、高危(n=35)以及极高危(n=34)4组,观察不同危险程度组间 cfPWV、crPWV 及 HRV 指数与心血管危险程度的相关性。结果 ISH 的 cfPWV 明最高于 DH[ISH:(399.6±48.2)cm/s 比 DH:(374.3±39.7)cm/s,P<0.01],而两组 crPWV 无明显差异[ISH:(371.5±37.5)比 DH:(363.5±31.5)cm/s,P>0.05];ISH 的心率变异指数、LF 以及 LF/HF 明显高于 DH[ISH:(3.28±0.86)log ms~2比 DH:(2.93±0.59)log ms~2,P<...     

Individual quality of life in adults with congenital heart disease: a paradigm shift.

AIMS: During the last decade, a paradigm shift has emerged in the measurement of quality of life, from the use of standard questionnaires towards a more individualized approach. Therefore, this study examined individual quality of life in adults with congenital heart disease and explored potential differences with those reported by matched, healthy control subjects. METHODS AND RESULTS: We examined 579 adults with congenital heart disease. A subsample of 514 of these patients was matched for age, gender, educational level, and employment status with 446 healthy counterparts. Individual quality of life was assessed using the Schedule for the Evaluation of Individual Quality of Life-Direct Weighting (SEIQoL-DW). Twelve domains affecting patients' quality of life were identified. Family, job/education, friends, health, and leisure time were the most prominent quality of life domains. Significantly fewer patients than control subjects considered financial means and material well-being and future to be important determinants of quality of life. CONCLUSION: Assessment of quality of life in adults with congenital heart disease that focusses on the individual is appropriate for obtaining in-depth information on issues relevant for patients' quality of life. This represents a paradigm shift in the measurement of this concept.     

米力农对慢性充血性心力衰竭血液动力学即刻效应的多中心临床研究

采用随机双盲，安慰剂对照，自身交叉试验设计方案，观察了国产米力农对５７例慢性充血性心力衰竭的即刻血波动力学效应。用Ｓｗａｎ－Ｇａｎｚ导管法测量血液动力学指标。静脉注射米力农后，心脏指数由２．２０±０．６４增加到２．９５±０．７１Ｌ／ｍｉｎ·ｍ￣２，Ｐ＜０．０５，平均肺毛细血管楔嵌压由３．０３±０．９５降到２．０９±１．１０ｋＰａ（２２．７０±７．６４降到１５．５６±８．１３ｍｍＨｇ），Ｐ＜０．０５。安慰剂对血液动力学指标无明显影响。对慢性充血性心力衰竭，米力农具有强心和扩血管作用。     

急性冠状动脉综合征患者基质金属蛋白酶9基因多态性

目的 探讨基质金属蛋白酶9基因C1562T多态性与中国南方汉族人群冠心病的关系.方法 对经冠状动脉造影证实的急性冠状动脉综合征患者150例(急性冠状动脉综合征组)、稳定型心绞痛患者110例(稳定型心绞痛组)和同期冠状动脉造影阴性、排除冠心病诊断的患者70例(对照组)进行研究,采用酶联免疫吸附试验测定血浆基质金属蛋白酶9水平,采用聚合酶链反应-限制片长多态性技术分析基质金属蛋白酶9基因中C1562T基因多态性,比较各组的基因型和等位基因频率.结果 急性冠状动脉综合征组血浆基质金属蛋白酶9水平明显高于稳定型心绞痛组(P＜0.05)和对照组(P＜0.01),而稳定型心绞痛组与对照组比较,差异无统计学意义(P＞0.05).急性冠状动脉综合征组基质金属蛋白酶9基因CT、CT TT基因型频率以及T等位基因频率均高于对照组和稳定型心绞痛组(P＜0.05或0.01),稳定型心绞痛组与对照组各基因型和等位基因频率分布差异无统计学意义(P＞0.05).C1562T位点CT/TT基因型患者血浆基质金属蛋白酶9水平显著高于CC基因型患者(P＜0.01).结论 基质金属蛋白酶9基因C1562T多态性可能与中国南方汉族人群急性冠状动脉综合征有关,1562T等位基因是动脉粥样硬化斑块不稳定性的易感基因.     

Symptoms of advanced heart failure—A case for radiofrequency catheter ablation?

A sixty-year-old man with previous history of coronary artery disease was admitted due to progressive worsening of dyspnoea at exertion (NYHA III functional class) and no angina. Coronary angiography confirmed occlusion of the right coronary artery which was naturally bypassed by homocollaterals with TIMI 3 flow to the peripheral branches. The lesion was not technically suitable for percutaneous angioplasty. The left coronary artery was without stenosis. On echocardiography, both the left ventricle and the left atrium were dilated and hemodynamically significant mitral regurgitation was present. Surface ECG showed a left bundle branch block with repeated runs of monomorphic ventricular ectopic beats (PVC). Radiofrequency catheter ablation of the focus in the posteroseptal region of the left ventricle underneath the mitral valve was performed using electroanatomical mapping system. After the procedure, mitral regurgitation decreased and reverse remodeling of the left ventricle and the left atrium occurred with concomitant significant clinical improvement of the patient. The authors discuss several treatment strategies: mitral valve repair surgery combined with revascularization, implantation of a biventricular ICD system or elimination of the focus of monomorphic VT runs by radiofrequency catheter ablation as a possible causal approach in the treatment of PVC-induced cardiomyopathy.