Advanced Left Ventricular Dysfunction Research Articles

Obstructive sleep apnea and non-sustained ventricular tachycardia in patients with advanced chronic kidney disease and mild left ventricular dysfunction

Obstructive sleep apnea and non-sustained ventricular tachycardia in patients with advanced chronic kidney disease and mild left ventricular dysfunction

Frequency and Implications of Ischemia Prior to Ventricular Tachyarrhythmia in Patients Treated With a Wearable Cardioverter Defibrillator Following Myocardial Infarction.

Autopsy studies imply that recurrent myocardial infarction (MI) accounts for the majority of sudden death early after acute MI, rather than primary arrhythmia. However, diagnosis of recurrent MI by autopsy is challenging and excludes electrocardiographic data to adjudicate arrhythmic causes. We examined the frequency of ischemia prior to treated ventricular tachycardia/fibrillation (VT/VF) and outcomes in patients using the wearable cardioverter defibrillator (WCD) following acute MI. Primary arrhythmia, rather than ischemia, is a frequent contributor to sudden death following MI. All patients treated for VT/VF over a 6-year period while wearing a WCD following acute MI with advanced left ventricular dysfunction (ejection fraction ≤35%) were included. Patients with ST-segment changes ≥0.1 mV before VT/VF were classified ischemic. Demographics and clinical outcomes were compared between those with ischemia-mediated vs primary arrhythmia. Among 273 patients fulfilling study criteria, 15.4% had ischemia prior to VT/VF. Clinical and WCD use characteristics did not significantly differ between ischemic and primary VT/VF groups. Termination of VT/VF by WCD treatment approximated 96% in both groups. Survival 24 hours post-treatment was 88% and 84% (P = 0.54) for patients with and without ischemic VT/VF, respectively. Furthermore, 30-day cumulative survival for those with and without ischemic VT/VF was 77% and 70%, respectively (P = 0.57). Ischemia is an infrequent cause of VT/VF following MI, contradicting previous study conclusions that recurrent MI is responsible for most post-MI sudden death. Etiology of VT/VF, however, did not influence defibrillation success or survival, which was high for both groups.

Cardiac surgery improves survival in advanced left ventricular dysfunction: multivariate analysis of a consecutive series of 4491 patients over an 18-year period.

Risks of cardiac surgery in patients with poor [ejection fraction (EF) ≤ 30%] and very poor left ventricular (LV) function (EF ≤ 20%) may be considered high due to increased mortality. We examine our results in this cohort of patients. Data were prospectively collected and retrospectively analysed from 4491 consecutive patients referred for cardiac surgery over 18 years (July 1993-June 2012). Univariate predictors of in-hospital postoperative mortality were analysed by the appropriate tests. Variables with P < 0.1 were entered into multivariable logistic-regression model to identify predictors of in-hospital postoperative mortality, with data presented as odds ratios; P < 0.05 was statistically significant. Data on long-term survival and cardiac-specific mortality were obtained from the UK Office for National Statistics; the date of last follow-up was 13 October 2013 for the alive patients. Univariate predictors influencing cardiac death were determined by log-rank method. Variables with P < 0.1 were entered into multivariable Cox regression model to determine independent predictors of long-term survival, with data presented as hazard ratios; P < 0.05 was statistically significant. Cardiac surgery was performed on 3890 consecutive patients (74.7% male, age 68.7 ± 8.1 years); 601 patients did not undergo surgery. Postoperative hospital mortality was 2.9% (n = 112/3890). Predictors of postoperative hospital mortality included age ≥ 70 years, female sex, hypertension, LVEF < 50%, neurological dysfunction, previous cardiac surgery, early time period 1993-1997, emergency procedures and triple procedures. All patients were followed until the date of last follow-up or date of death, with a median follow-up of 8.1 ± 7.6 years and a total follow-up of 33 208 years. There were 533 (13.7%) postoperative early and late deaths from cardiac causes. Predictors of long-term survival free from cardiac death included LVEF > 50%. Predictors of postoperative cardiac deaths in the long-term follow-up included older age, diabetes, neurological dysfunction, LVEF < 50%, non-coronary artery bypass surgery, early time period of surgery (1993-1997) and redo-cardiac surgery. Cardiac surgery provides long-term survival benefit in all subsets of LV function, including advanced LV dysfunction.

MORTALITY PREDICTORS IN PATIENTS REFERRED FOR BUT NOT UNDERGOING TRANSCATHETER AORTIC VALVE REPLACEMENT

Although transcatheter aortic valve replacement (TAVR) has expanded the proportion of patients with aortic stenosis (AS) who are candidates for valve replacement, some patients remain untreated, and their outcomes are not clear. We evaluated 172 consecutive patients with severe symptomatic AS referred for TAVR who declined (n = 55) or were not candidates for (n = 117) intervention. We examined clinical and echocardiographic variables associated with mortality. There were 77 deaths, and mean follow-up was 17.9 ± 10.9 months for survivors. Mortality rate at 1 and 2 years was 39.2% and 52.6%, respectively. There was a significant difference in mortality rate between patients who declined the procedure and those who were not candidates (p = 0.001), with 1-year mortality rates of 20.6% and 48.4%, respectively. On multivariate analysis, 4 variables were independently associated with all-cause mortality: New York Heart Association Class IV heart failure (hazard ratio [HR] 2.6, 95% confidence interval [CI] 1.6 to 4.2, p <0.001), glomerular filtration rate <48 ml/min (HR 2.1, 95% CI 1.3 to 3.4, p = 0.002), albumin <3.9 g/dl (HR 1.9, 95% CI 1.2 to 3.1, p = 0.007), and ejection fraction <50% (HR 1.9, 95% CI 1.4 to 3.0, p = 0.01). In this new era with expanded treatment options, patients with severe symptomatic AS who remain untreated after referral for TAVR experience a mortality rate of 39% at 1 year. The presence of advanced heart failure, renal dysfunction, low albumin, and/or left ventricular dysfunction identifies patients at higher risk of mortality.

Intestinal Microbiota-Dependent Phosphatidylcholine Metabolites, Diastolic Dysfunction, and Adverse Clinical Outcomes in Chronic Systolic Heart Failure

BackgroundTrimethylamine-N-oxide (TMAO) has been linked to increased cardiovascular risk. We aimed to determine the prognostic value of TMAO and its dietary precursors, choline and betaine, in heart failure (HF). Methods and ResultsIn 112 patients with chronic systolic HF with comprehensive echocardiographic evaluation, we measured plasma TMAO, choline, and betaine by mass spectrometry. Median (interquartile range) TMAO levels, choline, and betaine levels were 5.8 (3.6–12.1) μmol/L, 10.9 (8.4–14.0) μmol/L, and 43.8 (37.1–53.0) μmol/L, respectively, and were correlated with each other (all P < .0001 for both). TMAO levels were significantly higher in patients with diabetes mellitus (9.4 [4.9–13.2] vs 4.8 [3.4–9.8] μmol/L; P = .005) and in subjects with New York Heart Association functional class III or greater (7.0 [4.7–14.8] vs 4.7 [3.4–11.3] μmol/L; P = .02). Elevated TMAO, choline, and betaine levels were each associated with higher plasma N-terminal pro–B-type natriuretic peptide (NT-proBNP) levels and more advanced left ventricular diastolic dysfunction, but not systolic dysfunction or inflammatory and endothelial biomarkers. Higher choline (hazard ratio [HR] 1.64, 95% CI 1.22–2.20; P = .001), betaine (HR 1.51, 95% CI 1.10–2.08; P = .01), and TMAO (HR 1.48, 95% CI 1.10–1.96; P = .01) predicted increased risk for 5-year adverse clinical events (death/transplantation). Only higher TMAO levels predicted incident adverse clinical events independently from age, estimated glomerular filtration rate, mitral E/septal Ea, and NT-proBNP levels (HR 1.46, 95% CI 1.03–2.14; P = .03). ConclusionElevated plasma TMAO, choline, and betaine levels are each associated with more advanced left ventricular diastolic dysfunction and portend poorer long-term adverse clinical outcomes in chronic systolic HF. However, only higher plasma TMAO was associated with poor prognosis after adjustment for cardiorenal indices.

Update on tricuspid regurgitation

Although commonly detected by transthoracic echocardiography, tricuspid regurgitation (TR) has been somehow neglected, and recent data have emerged on the need for careful examination of the tricuspid valve. Functional or secondary TR is the most frequent etiology of tricuspid valve pathology in western countries and is related to tricuspid annular dilation and leaflet tethering. The prognostic role of TR associated with organic left-sided valvular heart disease is well known. However, the value of functional TR in outcome stratification of patients with advanced left ventricular dysfunction is less clear. Surgical tricuspid repair has been avoided for years, because of the misconception that TR should disappear once the primary left-sided problem is treated; this results in a large number of untreated patients with functional TR. Over the past few years, many investigators have reported evidence in favor of a more aggressive surgical approach to functional TR. Consequently, interest has been growing in the pathophysiology and treatment of functional TR. The purpose of this article is to provide a comprehensive review of TR incorporating a description of valve anatomy, etiological factors, pathophysiology, epidemiological data, natural history, clinical evaluation, along with a discussion of the important role in prognostic stratification and a summary of management guidelines.

OP-145 THE INFLUENCE OF PERSONAL ANXIETY ON 16-YEARS INCIDENCE OF MYOCARDIAL INFARCTION MEDIATED BY SOCIAL STATUS IN FEMALE POPULATION IN RUSSIA

Introduction: Surgical revascularization in patients with (CAD) and advanced left ventricular dysfunction has historically carried a high perioperative mortality and morbidity; however, with advances in surgical techniques and myocardial protection methods the safety of CABG surgery in those patients with poor ventricular function has been demonstrated. Those high risk patients are particularly in danger of inability to be weaned from the cardiopulmonary bypass after cardiac surgery; in those patients inotropic agents are used first, followed by the intra aortic balloon pump, if required. Objectives: The aim of the study is to assess the impact of Enoximone administration to poor cardiac function IHD patients undergoing CABG, on short term clinical outcomes. Methods: Between June 2006 and June 2011, 215 patients with ischemic heart disease with poor function i.e. ejection fraction below 30% undergoing coronary artery bypass surgery; operated upon them in Ain Shams University hospitals in Egypt. The study population was divided into two groups: • Group A consisted of 104 patients who received Enoximone (phosphodiesterase inhibitor type 3) immediately after crossclamp removal and continue till the end of the ITU stay. • Group B consisted of 111 patients who did not receive Enoximone. Exclusion criteria were hemodynamic instability, associated surgically significant valvular lesions and severe co-morbidities (renal and hepatic failure, cancer, autoimmune disease).

Diminished Global Arginine Bioavailability as a Metabolic Defect in Chronic Systolic Heart Failure

BackgroundSystemic alterations in arginine bioavailability occur in heart failure (HF) patients with more advanced myocardial dysfunction and poorer clinical outcomes, and they improve with beta-blocker therapy. Methods and ResultsWe measured fasting plasma levels of L-arginine and related biogenic amine metabolites in 138 stable symptomatic HF patients with left ventricular ejection fraction ≤35% and comprehensive echocardiographic evaluation. Long-term adverse clinical outcomes (death and cardiac transplantation) were followed for 5 years. Lower global arginine bioavailability ratio (GABR; ratio of L-arginine to L-ornithine + L-citrulline) was associated with higher plasma natriuretic peptide levels, more advanced left ventricular diastolic dysfunction, and more severe right ventricular systolic dysfunction (all P < .001). Patients taking beta-blockers had significantly higher GABR than those not taking beta-blockers (0.86 [interquartile range (IQR) 0.68–1.17] vs 0.61 [0.44–0.89]; P < .001). Subjects with higher GABR experienced fewer long-term adverse clinical events (hazard ratio 0.61 [95% confidence interval 0.43–0.84]; P = .002). In an independent beta-blocker naïve patient cohort, GABR increased following long-term (6 month) beta-blocker therapy (0.89 [IQR 0.52–1.07] to 0.97 [0.81–1.20]; P = .019). ConclusionsIn patients with chronic systolic heart failure, diminished global L-arginine bioavailability is associated with more advanced myocardial dysfunction and poorer long-term adverse clinical outcomes. GABR levels improved with beta-blocker therapy.

Evaluation of myocardial viability in patients with coronary heart disease complicated with advanced left ventricular dysfunction

Review of the literature on myocardial viability evaluation at the stage of surgical treatment planning in patients with coronary heart disease complicated with advanced left ventricular dysfunction is presented. In significant number of patients myocardial revascularization may improve regional and global heart function, and lead to further clinical improvement. The underlying pathophysiology involves different types of reversible myocardial dysfunction (hibernation, stunning), which may co-exist within the same patient’s myocardium. Potentially reversible left ventricular dysfunction is characterized by preserved cell membrane integrity and cardiomyocyte metabolism (sufficient to maintain cellular functions and cell membrane integrity in conditions of chronic or repetitive ischemia). Another important objective when assessing myocardial viability - pre-operative evaluation of post-infarction aneurysms in patients with severe left ventricular dysfunction. Results of clinical trials assessing the effectiveness of surgical revascularization in patients with ischemic cardiomyopathy as well as the results of the clinical trial on surgical treatment of ischemic heart failure are presented. A spectrum of non-invasive methods of myocardial viability evaluation, including the most studied nuclear, allows to identify cases of reversible left ventricular dysfunction in patients with congestive heart failure and to make a prognosis on success of the surgical treatment.

Effect of intracoronary (IC) transplantation of autologous bone marrow-derived mesenchymal stem cells (BMSC) in patients with advanced left ventricular systolic dysfunction

In the absence of cardiac transplantation programs and high cost of CRT-ICD in our community, large numbers of no-option HF patients (pts) for revascularization are still markedly symptomatic. IC-BMSC appears as promising option. 33 (27 males) with chronic HF, LVEF ⩽ 35 and mean age 46 y divided into 2 groups, 17 BMSC pts and 16 pts control. Both were maintained on maximum tolerated medications (follow-up 258 + 47 days). NYHA function class (NYHAFC), six minutes walking test (6MWT), LVESD, LVEDD, 2D-LVEF, systolic (S) and earlydiastolic (E) mitral annulus velocities by TDI evaluated. BMSC were obtained and selectively IC injected. Both groups showed improvement in NYHAFC from 3 to 2, P < 0.001 in BMSC, P < 0.04 for control. 6MWT marginally improved in BMSC from 348 ± 91 to 406 ± 87 meters (m) P < 0.06 while no improvement was noticed in control (361 ± 47 to 336 ± 110M, PNS). LVESD significantly decreased from 6.1 ± 0.8 to 5.7 ± 0.7 cm in BMSC, P < 0.028 while no changes occurred in the control group from 6.7 ± 1.0 to 6.6 ± 1.1 cm, PNS. No changes occurred in LVEDD from 7.1 ± 0.9 to 6.9 ± 0.7 cm in BMSC and from7.6 ± 1.1 to 7.56 ± 1.1 cm in control, PNS for both. No significant changes in LVEF occurred in control (26 ± 6 to 27 ± 7% PNS), while a trend for improvement occurred BMSC from 29 ± 6 to 33 ± 10%, P < 0.059. Mitral S wave showed trend for increase in MBSC (from 4.8 ± 1.5 to 5.3 ± 1.2 cm/s P < 0.058 while no changes occurred in control (5.2 ± 1.7 to 5.2 ± 1.5 cm/s). Mitral E wave showed non-significant increase from 5.7 ± 2.5 to 6.3 ± 2.6 cm/s in BMSC, non-significant decrease was noticed in control from 7.6 ± 2.4 to 7.1 ± 2.7 cm/s, PNS for both. There was no procedure related morbidity or mortality in the BMSC group. On top of standard and maximum tolerated medical treatment for chronic systolic HF, the addition of intracoronary autologous BMSC is feasible, safe and associated with subjective and objective functional improvement with trend towards improvement in parameters of LV performance.

Coronary artery bypass in women: what is really different?

Background: In our study, we evaluated the effects of female gender on mortality and morbidity rates of coronary artery bypass grafting (CABG). Methods: A total of 460 patients (351 males, 109 females; mean age 60.3±11.2 years; range 16 to 83 years) who underwent CABG in our clinic between December 2006 and September 2009 were included in our study. Patients were grouped according to their gender and compared. Results: Twenty-four percent of the patients were female and they were older than male patients (p=0.03). Diabetes mellitus (p=0.01) and hypertension (p=0.005) were found more frequently in female patients while chronic obstructive pulmonary disease (p=0.015) and peripheral artery disease (p=0.003) were found more frequently in male patients. Coronary endarterectomy (p=0.01) was performed more frequently in female patients. The rates of postoperative atrial fibrillation (p=0.04) and bleeding that required revision (p=0.02) were higher in male patients. The mortality rates were 3.6% (n=4) for female patients and 1.4% (n=5) for male patients. Coronary endarterectomy and advanced left ventricular dysfunction were statistically significant factors for mortality in female patients. The estimated survival rate of the discharged female patients at 55 months was 94.7% while the estimated survival rate of the discharged male patients at 61 months was 94.1%. Conclusion: Based on our findings, the female patients were older and had higher rates of diabetes mellitus and hypertension. The in-hospital mortality rate of the female patients was almost two times higher than in male patients. However, there was no significant difference between the long-term survival rates of female and male patients after CABG.

Myocardial viability assessment

The prognosis for patients with chronic coronary artery disease and severe left ventricular dysfunction is poor, despite advances in different therapies. The assessment of myocardial viability has become an important aspect of the diagnosis, prognosis and management of patients with ischemic cardiomyopathy. Patients with left ventricular dysfunction, with a substantial amount of severely ischemic myocardium are at highest risk, and are likely to benefit from coronary revascularization. Patients with predominantly scar tissue should be treated medically. Multiple imaging techniques have been developed to assess viable and nonviable myocardium by evaluating perfusion, cell membrane integrity, glucose metabolism, fibrosis and contractile reserve. PET FDG-F18, myocardial perfusion scintigraphy (with (201)Tl and (99m)Tc), dobutamine stress echocardiography and more recently magnetic resonance have been extensively evaluated for assessment of viability and prediction of clinical outcome after coronary revascularization. In general, nuclear imaging techniques have a higher sensitivity for the detection of viability, whereas techniques evaluating contractile reserve have higher specificity (with lower sensitivity). Magnetic resonance has a high diagnostic accuracy for assessment of the transmural extent of myocardial scar tissue. The aim of this article is to review the role of Nuclear Medicine in assessing myocardial viability and risk stratification in patients with advanced left ventricular dysfunction, and to compare it with other imaging modalities.

Abstract 9184: Reduction in Mortality among Patients with Left Bundle Branch Block Treated with Cardiac Resynchronization Therapy: Results from the MADIT-CRT Trial

MADIT-CRT demonstrated a reduction in a composite endpoint, first occurrence of worsening heart failure or death, in mildly symptomatic patients with advanced left ventricular dysfunction receiving cardiac resynchronization therapy combined with an ICD (CRT-D) relative to similar patients receiving only an ICD in an average 2.4 year follow-up. Mortality in the short-term follow-up was not different between treatment groups. With additional follow-up, averaging 3.6 years since device implant, 191 deaths occurred among the 1820 enrollees. Among all study patients and among the 536 patients with baseline conduction defects other than left bundle branch block (LBBB), death rates were still not different in subjects receiving CRT-D or ICD. Among the 70% of patients with left bundle branch block (LBBB; n=1281) at baseline, extended follow-up revealed a statistically significant reduction in death (p=0.047) in patients receiving CRT-D relative to those receiving ICD alone (see Kaplan-Meier graph). The Forest plot shows the consistency of reduction in mortality with CRT-D therapy in almost all LBBB subgroups, especially in females. In conclusion, extended follow-up in MADIT-CRT showed that CRT-D reduced mortality in mildly symptomatic patients with LBBB, sinus rhythm, EF ≤30%, and QRS≥130 msec. This life-saving benefit of CRT-D was evident in almost all LBBB subgroups, but it was not seen in any of the subgroups of patients without LBBB.

Systematic review of pregnancy in women with inherited cardiomyopathies

Pregnancy exposes women with inherited cardiomyopathies to increased risk for heart failure and arrhythmias. In this paper, we review the clinical course and management of pregnant women with the following inherited cardiomyopathies: hypertrophic cardiomyopathy, dilated cardiomyopathy, arrhythmogenic right ventricular cardiomyopathy, left ventricular non-compaction cardiomyopathy, and restrictive cardiomyopathy. We also discuss peripartum cardiomyopathy. Pregnancy is generally well tolerated in asymptomatic patients with inherited cardiomyopathies. However, worsening of the clinical condition can occur during pregnancy, despite intensive medical treatment. If prior cardiac events, poor functional class (New York Heart Association class III or IV), or advanced left ventricular systolic dysfunction are present, the risk of maternal cardiac complications during pregnancy are markedly increased. The postpartum condition is generally no worse than the antepartum condition, but no long-term follow-up studies have been reported. Preconception evaluation and counselling are important aspects of managing women with inherited cardiomyopathies. Genetic counselling and DNA testing should be offered to all women following the diagnosis of an inherited cardiomyopathy.

Autonomic nervous system in heart failure: an endless area of research/ The preserved autonomic functions may provide the asymptomatic clinical status in heart failure despite advanced left ventricular systolic dysfunction

Autonomic nervous system in heart failure: an endless area of research/ The preserved autonomic functions may provide the asymptomatic clinical status in heart failure despite advanced left ventricular systolic dysfunction

Effects of Exercise Training in Patients With Chronic Heart Failure and Advanced Left Ventricular Systolic Dysfunction Receiving .BETA.-Blockers

It remains unclear whether patients with chronic heart failure (CHF) and advanced left ventricular (LV) dysfunction on β-blocker therapy benefit from exercise training (ET). We studied 45 CHF patients with advanced LV dysfunction [ejection fraction (LVEF) < 25%] and impaired exercise tolerance [normalized peak oxygen uptake (PVO₂) < 70%] receiving a β-blocker: 33 patients participated in a cardiac rehabilitation program with ET (ET group) and 12 did not (inactive control group). Exercise capacity, LV dimension and plasma B-type natriuretic peptide (BNP) were assessed before and after a 3-month study period. At baseline, both groups had markedly reduced LVEF (ET group 18 ± 4% vs. Control group 18 ± 5%, NS) and impaired exercise capacity (normalized PVO₂ 51 ± 10% vs. 55 ± 9%, NS). Although one patient in the ET group withdrew from the program due to worsening CHF, no serious cardiac events occurred during the ET sessions. After 3 months, the ET group (n = 24) had significantly improved PVO₂ by 16 ± 15% (1,005 ± 295 to 1,167 ± 397ml/min, P < 0.001), while the PVO₂ of the control group was unchanged. LV end-diastolic dimension decreased in both groups to a similar extent, but plasma BNP was significantly decreased only in the ET group (432 to 214 pg/ml, P < 0.05). The data indicate that in CHF patients with advanced LV dysfunction on β-blocker therapy, ET successfully improves exercise capacity and BNP without adversely affecting LV remodeling or causing serious cardiac complications.

Relation of Bundle Branch Block to Long-Term (Four-Year) Mortality in Hospitalized Patients With Systolic Heart Failure

There is controversy regarding type of bundle branch block (BBB) that is associated with increased mortality risk in patients with heart failure (HF). The present study was designed to explore the association between BBB pattern and long-term mortality in hospitalized patients with systolic HF. Risk of 4-year all-cause mortality was assessed in 1,888 hospitalized patients with systolic HF (left ventricular ejection function <50%) without a pacemaker in a prospective national survey. Cox proportional hazards regression modeling was used to compare mortality risk in patients with right BBB (RBBB; 10%), left BBB (LBBB; 14%), and no BBB (76%) on admission electrocardiogram. At 4 years of follow up, mortality rates were highest in patients with RBBB (69%), intermediate in those with LBBB (63%), and lowest in those without BBB (50%, p <0.001). Multivariate analysis demonstrated a significant 36% increased mortality risk in patients with RBBB versus no BBB (p = 0.002) but no significant difference in mortality risk for patients with LBBB versus no BBB (hazard ratio 1.04, p = 0.66). RBBB versus LBBB was associated with a 29% (p = 0.035) increased risk for 4-year mortality in the total population and with a 58% (p = 0.015) increased risk in patients with ejection fraction <30%. In conclusion, RBBB but not LBBB on admission electrocardiogram is associated with a significant increased long-term mortality risk in hospitalized patients with systolic HF. Deleterious effects of RBBB compared to LBBB appear to be more pronounced in patients with more advanced left ventricular dysfunction.

The preserved autonomic functions may provide the asymptomatic clinical status in heart failure despite advanced left ventricular systolic dysfunction

Autonomic dysfunction is an important marker of prognosis in congestive heart failure (CHF) and may determine the symptoms and progression of CHF. The aim of our study was to investigate whether preserved autonomic function assessed by heart rate variability (HRV) analyses is related to absence of CHF symptoms despite prominently reduced systolic function. The study had a cross-sectional observational design. Fifty patients with left ventricular ejection fraction (EF) below 40% were enrolled. The patients were divided into two groups according to their CHF symptomatic status as Group 1 (NYHA functional class I, asymptomatic group) and Group 2 (NYHA functional class ≥ II, symptomatic group). Plasma C-reactive protein (CRP), N-terminal proB-type natriuretic peptide (NT-proBNP) levels, echocardiographic parameters and HRV indices were measured while the patients were clinically stable in each group. Possible factors associated with the development of CHF symptoms were assessed by using multiple regression analysis. Baseline clinical characteristics and left ventricular EF were similar in the two groups. Serum CRP (15 ± 21 vs 7 ± 18 mg/L, p=0.011) and NT-proBNP levels (1935 ± 1088 vs 1249 ± 1083 pg/mL, p=0.020) were significantly higher in symptomatic group. The HRV parameters (SDNN: 78 ± 57 vs 122 ± 42 ms, p=0.001; SDANN: 65 ± 55 vs 84 ± 38 ms, p=0.024; SDNNi: 36 ± 41 vs 70 ± 46 ms, p<0.001; triangular index [Ti]: 17 ± 12 vs 32 ± 14, p<0.001) were also significantly depressed in symptomatic group. When multiple regression analysis was performed, only HRV indices of autonomic function were significantly associated with the asymptomatic status (SDNN, OR: 1.016, 95%CI: 1.002-1.031, p=0.028; SDNNi, OR: 1.030, 95%CI: 1.008-1.052, p=0.006; TI, OR: 1.088, 95%CI: 1.019-1.161, p=0.011). Preserved autonomic functions were shown to be associated with absence of CHF symptoms independently of angiotensin converting enzyme inhibitor/angiotensin receptor blocker's treatment and BNP levels and may be protective against the development of CHF symptoms despite advanced left ventricular systolic dysfunction.

Post-partum cardiogenic shock in a patient with permanent junctional re-entry tachycardia

Permanent junctional reciprocating tachycardia (PJRT) is a rareform of supraventricular arrhythmia, most often encountered inchildrenandadolescents,characterizedbyantegradeconductionoverthe atrio-ventricular node and retrograde conduction over a decre-mental accessory pathway [1]. In the majority of the patients theclinical scenario is dominated by frequent episodes of palpitations,often triggered by exercise. In about 20–30% of cases PJRT maybecome incessant and lead to advanced left ventricular systolic dys-function, that is generally reversible after restoration of stable sinusrhythm [1–3]. However, cardiogenic shock caused by PJRT has neverbeen reported.We describe the case of a young woman with a history of PJRTdating from late childhood; a totally benign clinical scenario character-ized by periodic recurrences of well-tolerated arrhythmias rapidlyturnedintoadramaticadvancedheartfailuresettingsoonafterpartum.This case underlines the importance of an accurate evaluation andmanagement of cardiac arrhythmias during pregnancy.A young woman was chronically treated with atenolol (50 mg) tomanage recurrences of PJRT episodes. On treatment she suffered rareand self-limiting, mildly symptomatic episodes. At the age of 32 shebecame pregnant and beta-blocker therapy was withdrawn to avoidgrowth restriction to the fetus. A 12-lead ECG performed in the firstweeks of pregnancy showed normal sinus rhythm, and an echocar-

Surgical Myocardial Revascularization of Patients with Ischemic Cardiomyopathy and Severe Left Ventricular Disfunction

OBJECTIVE:To determine long-term survival, identify preoperative factors predictive of a favorable outcome, and assess functional improvement after coronary artery bypass grafting in patients with advanced left ventricular dysfunction.METHODS:Between 1995 and 2001, 244 patients who underwent coronary artery bypass grafting and had a preoperative left ventricular ejection fraction less than or equal to 35% were included. left ventricular ejection fraction was determined by uniplanar or biplanar ventriculography during left heart catheterization. Indication for surgery was predominance of tissue viability. Functional improvement was evaluated through echocardiography and gated scintigraphy at exercise/rest. Survival was determined by Kaplan-Meier analysis.RESULTS:Mean left ventricular ejection fraction was 29±4% (ranged from 9% to 35%). An average of 3.01 coronary bypass grafts per patient were performed. In-hospital mortality was 3.7% (9 patients). The 4-year survival rate was 89.7%. Multivariate correlates of favorable short- and long-term outcome were preoperative New York Heart Association Funcional classification for congestive heart failure class I/II, lower PAsP, higher left ventricular ejection fraction and gated left ventricular ejection fraction Ex/Rest ratio >5%. Left ventricular ejection fraction rise from 32±5% to 39±5%, p <0.001. Gated left ventricular ejection fraction at exercise/rest increased markedly after surgery: from 27±8%/23±7% to 37±5%/31±6%, p <0.001.CONCLUSIONS:In selected patients with severe ischemic left ventricular dysfunction and predominance of tissue viability, coronary artery bypass grafting may be capable of implement preoperative clinical/functional parameters in predicting outcome as left ventricular ejection fraction and gated left ventricular ejection fraction at exercise/rest.