Higher Ejection Fraction Research Articles

Arrival by ambulance in acute heart failure: insights into the mode of presentation from Acute Studies of Nesiritide in Decompensated Heart Failure (ASCEND-HF)

ObjectivesLimited data exist assessing the relationship between ambulance versus self-presentation and outcomes in patients with acute heart failure (AHF).SettingClinical trial sites in North America.Participants1068 patients enrolled in the Acute Studies...

Clinical and electrocardiographic predictors of T wave oversensing in patients with subcutaneous ICD

BackgroundT wave oversensing (TWOS) is a major drawback of the subcutaneous implantable cardioverter defibrillator (S-ICD). Data on predictors of TWOS in S-ICD recipients are limited.We sought to investigate predictors of TWOS in a cohort of patients receiving an S-ICD at our institution. MethodsS-ICD recipients at our center were identified retrospectively and stratified based on the presence or absence of TWOS. Clinical and electrocardiographic parameters were collected and compared between the 2 groups. ResultsNinety-two patients underwent an S-ICD implantation at our institution between April 2010 and January 2015. Six (6.5%) patients had TWOS. These patients were younger (38.1±13.7 vs. 52.3±16.1 years, p=0.04) and had higher left ventricle ejection fractions (48.5±14.9% vs. 28.4±12.2%, p<0.01) than patients without a history of TWOS. Baseline 12-lead electrocardiogram (ECG) parameters were not different between the 2 groups. Leads I, II, and avF (which mimic the sensing vectors of the S-ICD) were further inspected to identify ECG characteristics that could predict TWOS. The QRS amplitude in ECG lead I was significantly smaller in the TWOS group than in the non-TWOS group (3.7 vs. 7.4mV, p=0.02). ConclusionIn this study, younger age, higher ejection fraction, and lower QRS amplitude were associated with TWOS. These findings could help identify patients referred for S-ICD at high-risk of TWOS.

Left Main Stenting in Comparison With Surgical Revascularization

This study has reported 10-year clinical follow-up of patients enrolled in the prospective, randomized LE MANS (Left Main Stenting) trial. The very long-term outcome after left main stenting in comparison with surgical revascularization remains unknown. In this prospective, multicenter trial, we randomly assigned 105 patients with unprotected left main coronary artery stenosis with low and medium complexity of coexisting coronary artery disease according to SYNTAX (Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery) score to percutaneous coronary intervention (PCI) with stenting (n = 52) or coronary artery bypass grafting (CABG) (n = 53). Drug-eluting stents were implanted in 35%, whereas arterial grafts to the left anterior descending artery were utilized in 81%. Currently, the mean long-term follow-up was collected at 9.8 ± 1.0 years. Follow up for all-cause mortality is complete, whereas the incidence of major adverse cardiovascular and cerebral events (MACCE) was reported from 90% of patients. Ambulatory follow-up was completed in 46 (43.9%) patients. At 10 years, there was a trend toward higher ejection fraction in stenting when compared with surgery (54.9 ± 8.3% vs. 49.8 ± 10.3%; p = 0.07). The mortality (21.6% vs. 30.2%; p = 0.41) and MACCE (51.1% vs. 64.4%; p = 0.28) were statistically not different between groups; however, numerically the difference was in favor of stenting. Similarly, there was no difference in the occurrence of myocardial infarction (8.7 vs. 10.4%; p = 0.62), stroke (4.3 vs. 6.3%; p = 0.68), and repeated revascularization rates (26.1% vs. 31.3%; p = 0.64). The probability of very long-term survival up to 14 years was comparable between PCI and CABG (74.2% vs. 67.5%; p = 0.34; hazard ratio: 1.45, 95% confidence interval: 0.67 to 3.13); however, there was a trend toward higher MACCE-free survival in the PCI group (34.7% vs. 22.1%; p = 0.06; hazard ratio: 1.71, 95% confidence interval: 0.97 to 2.99). In patients with unprotected left main coronary artery stenosis with low and medium complexity of coexisting coronary artery disease, stenting offers numerically, but statistically nonsignificant, favorable long-term outcome up to 10 years in terms of safety and efficacy outcome measures, therefore, constitutes an alternative therapy for CABG.

Linguistic Ratification and Validation of Pediatric Quality of Life Inventory 3.0 Cardiac Module

Objective : On the basis of international requirements to create a Russian version of the international instrument Pediatric Quality of Life Inventory (PedsQL) 3.0 Cardiac Module, used for assessment of the quality of life in children with cardiovascular diseases. Methods : In a prospective study it was assessed the reliability of the questionnaire (calculating Cronbach's alpha coefficient), its validity — by comparing the responses of patients who had a different ejection fraction (construct validity), and comparing the responses on the scales of PedsQL Cardiac Module questionnaire with the scales of the common PedsQL Generic Core Scale questionnaire (convergent validity). The questionnaire sensitivity was determined by calculating the difference between the values of quality of life of children at the moment of their first hospitalization (1st point) and in 4 months after the initiation of combination therapy (2nd point). Results : The study involved 61 children with heart failure (chronic myocarditis — 25, dilated cardiomyopathy — 36). The median of the age of patients was 12 (4; 15) years. The questionnaire proved to be reliable (the values of Cronbach's alpha coefficient for different units ranged from 0.75 to 0.91) and satisfactory constructive and convergent validity. Therewith, children with ejection fraction <60% had lower values of quality of life than children with higher ejection fraction. Increase in assessment of quality of life in the course of the administered treatment pointed to the questionnaire sensitivity to changes in patients' condition. Conclusion : Satisfactory psychometric characteristics of the Russian version of PedsQL 3.0 Cardiac Module questionnaire allow to use it for research in the field of quality of life in children with heart failure.

Risk factor paradox in the occurrence of cardiac arrest in acute coronary syndrome patients.

ObjectiveTo compare patients without previously diagnosed cardiovascular risk factors) and patients with one or more risk factors admitted with acute coronary syndrome.MethodsThis was a retrospective analysis of patients admitted with first episode of acute coronary syndrome without previous heart disease, who were included in a national acute coronary syndrome registry. The patients were divided according to the number of risk factors, as follows: 0 risk factor (G0), 1 or 2 risk factors (G1 - 2) and 3 or more risk factors (G ≥ 3). Comparative analysis was performed between the three groups, and independent predictors of cardiac arrest and death were studied.ResultsA total of 5,518 patients were studied, of which 72.2% were male and the mean age was 64 ± 14 years. G0 had a greater incidence of ST-segment elevation myocardial infarction, with the left anterior descending artery being the most frequently involved vessel, and a lower prevalence of multivessel disease. Even though G0 had a lower Killip class (96% in Killip I; p < 0.001) and higher ejection fraction (G0 56 ± 10% versus G1 - 2 and G ≥ 3 53 ± 12%; p = 0.024) on admission, there was a significant higher incidence of cardiac arrest. Multivariate analysis identified the absence of risk factors as an independent predictor of cardiac arrest (OR 2.78; p = 0.019). Hospital mortality was slightly higher in G0, although this difference was not significant. By Cox regression analysis, the number of risk factors was found not to be associated with mortality. Predictors of death at 1 year follow up included age (OR 1.05; p < 0.001), ST-segment elevation myocardial infarction (OR 1.94; p = 0.003) and ejection fraction < 50% (OR 2.34; p < 0.001).ConclusionEven though the group without risk factors was composed of younger patients with fewer comorbidities, better left ventricular function and less extensive coronary disease, the absence of risk factors was an independent predictor of cardiac arrest.

Factores asociados a insuficiencia renal postoperatoria en cirugía de revascularización miocárdica

MotivationTo determine which medical history and surgical procedure factors are associated to the onset of postoperative kidney failure in patients undergoing myocardial revascularisation. MethodsCase-control cohort study carried out between January 2005 and December 2013 which included patients who had undergone elective myocardial revascularisation and showed postoperative kidney failure immediately after surgery and until discharge. Controls consisted of patients who had undergone elective myocardial revascularisation and did not develop postoperative kidney failure immediately after surgery. A logistic regression model was used to determine the factors associated to postoperative kidney failure. Associations were expressed as grounds of disparity with their corresponding confidence intervals. Resultsold age [OR 1.03 CI 95% (1.01-1.04)], preoperative presence of diabetes mellitus [OR 1.8 CI 95% (1.9-3.4)], cardiac insufficiency [OR 2.7 CI 95% (1.1-6.7)] and a longer perfusion time [OR 1.02 CI 95% (1.01-1.03)] were associated to a higher risk of postoperative kidney failure, while higher hematocrit [OR 0.86 CI 95% (0.82-0.91)] and higher ejection fraction [OR 0.94 CI 95% (0.92-0.96)] were associated with a decrease of the risk of postoperative kidney failure. ConclusionsIn patients who had undergone myocardial revascularisation, risk factors associated to postoperative kidney failure where comorbidities related to internal and external gradual kidney damage outside the context of the surgery. This implies that strategies to minimise this event should be focused on identifying these patients in a timely manner and offering appropriate nephroprotection.

Multiple differences between patients who initiate fish oil supplementation post–myocardial infarction and those who do not: the TRIUMPH Study

The utility of fish oil supplements (FOS) in patients who survive an acute myocardial infarction (MI) remains controversial, with randomized trials showing less benefit than observational studies would suggest. The differences in the characteristics of MI patients who use FOS in routine clinical care are unknown but may help explain this discrepancy. We used data from a 24-site registry study in which extensive information was available on 4340 MI patients at admission and 1, 6, and 12 months postdischarge. After excluding those using FOS at admission (n = 651), those who died before the 1-month follow-up visit (n = 63), and those with missing data at 1 month (n = 1228), 2398 remained. Of them, 377 (16%) started FOS within 1 month of their MI. We analyzed 53 patient characteristics associated with FOS use. We observed differences (P < .001) in 20 demographic, socioeconomic, treatment, disease severity, and health status domains. The FOS users were more likely than nonusers to be white, married, financially secure, highly educated, and eating fish. They also had a higher ejection fraction at discharge, were more likely to have had in-hospital percutaneous coronary interventions, and were more likely to have participated in cardiac rehabilitation programs. The FOS users were less likely to have a history of diabetes, alcohol abuse, stroke, MI, and angina. In conclusion, post-MI patients who initiate FOS within 1 month of discharge in routine clinical practice differ substantially from those who do not. These differences are strongly associated with a better post-MI prognosis and may illuminate several sources of unmeasured confounding in observational studies.

Clinical effect of recombinant human brain natriuretic peptide combined with levosimendan on acute myocardial infarction complicated by heart failure

Objective To evaluate the efficacy and safety of recombinant human brain natriuretic peptide (rh-BNP) combined with levosimendan on acute myocardial infarction complicated by heart failure. Methods Patients who suffered from anterior wall acute myocardial infarction (AMI) with heart failure (KillipⅡ~Ⅲ) within 12 to 24 hours after the onset of chest pain were randomized into two groups: the control group (n=30, receiving dobutamine and/or cedilanid) and the experimental group (n=30, receiving rh-BNP combined with levosimendan). The hemodynamics, parameters of laboratory tests and adverse events were observed before and after treatment. Results The experimental group showed that the respiratory rate (RR), heart rate (HR), systolic blood pressure (SBP), arterial blood gas oxygen saturation (SaO2), cardiac index (CI), extravascular lung water index (EVLWI) were significantly different between 2 h and sequential time points after treatment and pre-treatment (allP<0.05). The control group showed that RR, HR, SaO2, CI, EVLWI were significantly different between 6 h and sequential time points after treatment and pre-treatment (P<0.05 for all). There were significant differences in RR, HR, SBP, SaO2, CI, EVLWI at 2 h and 6 h after treatment between the two groups (P<0.05 for all). Parameters of RR, HR, CI, EVLWI at 72 h after treatment had differences between the experimental group and controls. Patients in the experimental group presented larger urine volume, lower level of plasma NT-pro BNP, higher left ventricular ejection fraction (LVEF) and shorter length of stay in CCU as compared with patients in the control group (P<0.05 for all). In adverse events monitoring in hepatic parameters, electrolyte level and coagulation function before and after treatment, there was no significant difference between the two groups. Conclusions Compared with the conventional treatment, the combination therapy with rh-BNP and levosimendon can improve the hemodynamics, increase the urine volume, decrease the level of plasma NT-proBNP and elevate LVEF significantly, so as to improve the clinical symptoms and shorten the hospital stay in patients with acute myocardial infarction complicated by heart failure. Key words: Myocardial infarction; Heart failure; Natriuretic peptide, brain

Abstract 19380: Synchronized Pulsatile Extracorporeal Life Support Preserves Left Ventricular Functions in Comparison With Continuous Extracorporeal Flow in Porcine Model of Cardiogenic Shock

Introduction: Veno-arterial extracorporeal life support (ECLS) is increasingly used for the therapy of rapidly progressing or severe cardiogenic shock. However, it has been repeatedly shown that increased afterload associated with ECLS significantly deteriorates left ventricular (LV) performance. Recently, new ECG-synchronized pulsatile cardiac assist system was introduced that offers full circulatory support with increased diastolic and decreased systolic extracorporeal flow. The aim of the present study was to compare the parameters of LV function during standard continuous flow ECLS support and ECG-synchronized pulsatile flow ECLS in cardiogenic shock. Methods: Ten female swine (body weight 45 kg) underwent ECLS implantation under general anesthesia and artificial ventilation. Subsequently, acute cardiogenic shock with signs of tissue hypoperfusion was induced by global myocardial hypoxia. Hemodynamic and cardiac performance parameters were then measured at different levels of continuous or pulsatile ECLS flow (ranging from 1 L/min to 4 L/min) using arterial and venous catheters, a pulmonary artery catheter and a LV pressure-volume loop catheter. Results: Myocardial hypoxia resulted in a decline in mean (±SD) cardiac output to 2.3±1.2 L/min, systolic blood pressure to 61±7 mmHg and LV ejection fraction (EF) to 21±7%. Synchronized pulsatile flow was associated with significant reduction of LV end-systolic volume (ESV), increase in LV stroke volume (SV), and higher EF at all ECLS flow levels in comparison with continuous ECLS flow (Figure 1). At selected ECLS flow levels, pulsatile flow reduced also LV end-diastolic pressure (EDP), end-diastolic volume (EDV), and systolic pressure (SP) (Figure 1). Conclusion: Our results indicate that ECG-synchronized pulsatile ECLS flow preserves LV function in comparison with standard continuous-flow ECLS in cardiogenic shock.

Abstract 13694: Hsf1 Attenuates Pressure Overload Induced-cardiac Fibrosis via Inhibiting Smad3 Phosphorylation and Nuclear Translocation

Introduction: Heat shock transcription factor 1 (HSF1) is an intrinsic cardioprotective factor against cardiac hypertrophy. However, little is known about the role of HSF1 in cardiac fibrosis. Here we hypothesize that HSF1 reverses pressure overload induced-cardiac fibrosis via inhibiting Smad3 phosphorylation and nuclear translocation. Methods: Human tissue samples were collected from the left ventricles of dilated cardiomyopathy patients undergoing heart transplant and normal heart donors for control and were interrogated via western blot and realtime-PCR. A HSF1 transgenic (TG) mouse was generated. Transverse aortic constriction (TAC) was performed with wild type (WT) mice as control and cardiac structure and function were measured by echocardiography and pathological test. Cardiomyocytes (CMs) isolated from neonatal mice were imposed with mechanical stretch (MS) in vitro. Results: HSF1 phosphorylation at Ser230 was significantly decreased in failing hearts (55% vs normal hearts) characterized with significant cardiac fibrosis manifested with increased expression of collagen III and connective tissue growth factor (CTGF) . WT mice and TG mice were subjected to TAC. After 4 weeks of TAC, WT mice developed a remarkable maladaptive hypertrophy and cardiac fibrosis in comparison to WT mice. TG mice exhibited a smaller LV end-diastolic diameter (LVEDD), higher ejection fraction (EF), decreased LV weight/tibial length (LW/TL) and CMs cross sectional area (CSA), less interstitial and perivascular fibrosis, as well as preserved expression of collagen III and CTGF compared to WT mice. TG mouse hearts also showed reduced phosphorylation and nuclear translocation of Smad3 than WT mice. MS was found to significantly inhibit HSF1 phosphorylation, but promoted the Smad3 phosphorylation and nuclear translocation in CMs. Co-Immunoprecipitation showed that HSF1 directly binds Smad3 in CMs in vitro, which was decrease by MS or treatment with KNK437 (HSF1 inhibitor). TG mice demonstrate more of HSF1 and Smad3 binding and less phosphorylation and nuclear translocation of Smad3 compared to WT mice after TAC. Conclusion: HSF1 attenuates pressure overload induced-cardiac fibrosis by inhibiting Smad3 phosphorylation and nuclear translocation.

Abstract 16673: Intramyocardial Injection of MSC-derived Extracellular Vesicles Confers Superior Cardiac Repair After a Reperfused Myocardial Infarction

Introduction: Stem cell-derived extracellular vesicles (EVs) are known to facilitate cell-to-cell communication. The potential of mesenchymal stem cell (MSC)-derived EVs for cardiac repair when compared with MSC whole cell injection remains unknown. Hypothesis: We hypothesized that therapy with MSC-EVs after a reperfused myocardial infarction (MI) will result in greater improvement in LV structure and function compared with injection of MSCs. Methods: EVs were collected by sequential centrifugation from culture supernatants of murine bone marrow MSCs. We used tunable resistive pulse sensing technology (TRPS), flow cytometry, real-time qRT-PCR and mass spectrometry to analyze MSC-EVs. Wild-type (C57BL/6) mice underwent a 30-min coronary occlusion followed by reperfusion, and 48 h later received intramyocardial injection of vehicle (PBS, n=14), MSCs (n=14), or MSC-EVs (n=14). Echocardiography was performed 4 d prior to MI (BSL) and at 48 h and 30 d after injection. Mice were sacrificed after 30 d. Results: MSC-EVs were noted to be small vesicles with average size of 233.0 ± 70.2 nm (Fig), and expressed MSC-specific markers, including CD29, CD90.2, CD105, Sca-1 and CD49e (Fig). MSC-EVs were enriched in mRNAs, miRNAs and proteins from donor MSCs; and carried transcripts of genes regulating cardiac/vascular differentiation, such as GATA-4, Nkx2.5, Tie-2, and GATA-2. In vivo, LV ejection fraction (EF) was significantly and similarly reduced in all groups at 48 h after MI (Fig). At 30 d after MI, mice injected with MSC-EVs exhibited significantly higher EF (Fig) and smaller LV end-diastolic volume compared with vehicle-treated and MSC-injected mice. Conclusions: We conclude that MSC-EVs represent natural nanocarriers capable of transferring bioactive contents and inducing cardiac repair following intramyocardial injection after MI in vivo. The use of MSC-EVs may potentially improve the outcomes of cell therapy in humans.

Glucose and fatty acid metabolism in infarcted heart from streptozotocin-induced diabetic rats after 2weeks of tissue remodeling.

BackgroundThe effects of streptozotocin (STZ)-induced diabetes on heart metabolism and function after myocardial infarction (MI) remodelling were investigated in rats.MethodsFifteen days after STZ (50 mg/kg b.w. i.v.) injection, MI was induced by surgical occlusion of the left coronary artery. Two weeks after MI induction, contents of glycogen, ATP, free fatty acids and triacylglycerols (TG) and enzyme activities of glycolysis and Krebs cycle (hexokinase, glucose-6-phosphate dehydrogenase, phosphofructokinase, citrate synthase) and expression of carnitine palmitoyl-CoA transferase I (a key enzyme of mitochondrial fatty acid oxidation) were measured in the left ventricle (LV). Plasma glucose, free fatty acids and triacylglycerol levels were determined. Ejection fraction (EF) and shortening fraction (SF) were also measured by echocardiography.ResultsGlycogen and TG contents were increased (p < 0.05) whereas ATP content was decreased in the LV of the non-infarcted diabetic group when compared to the control group (p < 0.05). When compared to infarcted control rats (MI), the diabetic infarcted rats (DI) showed (p < 0.05): increased plasma glucose and TG levels, elevated free fatty acid levels and increased activity of, citrate synthase and decreased ATP levels in the LV. Infarct size was smaller in the DI group when compared to MI rats (p < 0.05), and this was associated with higher EF and SF (p < 0.05).ConclusionsSystolic function was preserved or recovered more efficiently in the heart from diabetic rats two weeks after MI, possibly due to the high provision of glucose and free fatty acids from both plasma and heart glycogen and triacylglycerol stores.

The Influence of Different Operating Conditions on the Blood Damage of a Pulsatile Ventricular Assist Device.

Because of pulsatile blood flow's benefit for myocardial recovery, perfusion of coronary arteries and end organs, pulsatile ventricular assist devices (VADs) are still widely used as paracorporeal mechanical circulatory support devices in clinical applications, especially in pediatric heart failure patients. However, severe blood damage limits the VAD's service period. Besides optimizing the VAD geometry to reduce blood damage, the blood damage may also be decreased by changing the operating conditions. In this article, a pulsatile VAD was used to investigate the influence of operating conditions on its blood damage, including hemolysis, platelet activation, and platelet deposition. Three motion profiles of pusher plate (sine, cosine, and polynomial), three stroke volumes (ejection fractions) (56 ml [70%], 42 ml [52.5%], and 28 ml [35%]), three pulsatile rates (75, 100, and 150 bpm), and two assist modes (copulsation and counterpulsation) were implemented respectively in VAD fluid-structure interaction simulations to calculate blood damage. The blood damage indices indicate that cosine motion profile, higher ejection fraction, higher pulsatile rate, and counterpulsation can decrease platelet deposition whereas increase hemolysis and platelet activation, and vice versa. The results suggest that different operating conditions have different effects on pulsatile VAD's blood damage and may be beneficial to choose suitable operating condition to reduce blood damage in clinical applications.

Acute outcome of treating patients admitted with electrical storm in a tertiary care centre

BackgroundElectrical storm (ES) is a life threatening emergency. There is little data available regarding acute outcome of ES. AimsThe study aimed to analyze the acute outcome of ES, various treatment modalities used, and the factors associated with mortality. MethodsThis is a retrospective observational study involving patients admitted with ES at our centre between 1/1/2007 and 31/12/2013. Results41 patients (mean age 54.61 ± 12.41 years; 86.7% males; mean ejection fraction (EF) 44.51 ± 16.48%) underwent treatment for ES. Hypokalemia (14.63%) and acute coronary syndrome (ACS) (14.63%) were the commonest identifiable triggers. Only 9 (21.95%) patients already had an ICD implanted. Apart from antiarrhythmic drugs (100%), deep sedation (87.8%), mechanical ventilation (24.39%) and neuraxial modulation using left sympathetic cardiac denervation (21.95%) were the common treatment modalities used. Thirty-three (80.49%) patients could be discharged after a mean duration of 14.2 ± 2.31 days. Eight (19.5%) patients died in hospital. The mortality was significantly higher in those with EF < 35% compared to those with a higher EF (8 (42.11% vs 0 (0%), p = 0.03)). There was no significant difference in mortality between those with versus without a structural heart disease (8 (21.1% vs 0 (0%), p = 0.32)). Comparison of mortality an ACS with ES versus ES of other aetiologies (3 (50%) vs 5 (14.29) %, p = 0.076)) showed a trend towards significance. ConclusionWith comprehensive treatment, there is reasonable acute survival rate of ES. Hypokalemia and ACS are the commonest triggers of ES. Patients with low EF and ACS have higher mortality.

Right ventricular function in dilated cardiomyopathy: women are the stronger sex!

Heart failure is mostly caused by disease of the left ventricle, but the right ventricle may play a more important role in functional capacity and prognosis of heart failure patients than is often realised. Thus, right ventricular (RV) function has been well established to be a better marker for exercise capacity than left ventricular (LV) function in both ischaemic and dilated cardiomyopathy (DCM) [1], and is correlated with clinical status and outcome in patients with ischaemic LV dysfunction [2]. Interestingly, for a comparable degree of LV dysfunction, RV function is even worse in patients with idiopathic DCM as compared with patients with ischaemic cardiomyopathy [3, 4] and, also in this patient group, is a predictor for outcome [5]. It is increasingly recognised that development, progression, prognosis and potentially also treatment of cardiovascular disease are not only dependent on the severity of disease, but are also influenced by age and gender. A potential explanation for the effect of gender on cardiovascular morbidity may be that RV function differs between men and women, with women generally having a smaller right ventricle with a higher ejection fraction (EF) [6]. Indeed, it is shown that, although the incidence of pulmonary hypertension is higher in females than males, in patients with established disease the prognosis is better in female than male patients, and that this is caused by a better preservation of RV function and a better response of the RV function to therapy, despite similar changes in the pulmonary vasculature [7]. In the present issue of the Netherlands Heart Journal, Martinez-Selles and co-workers investigated whether differences in RV function between male and female patients could explain, at least in part, why women with DCM have a better prognosis than men. They found that RV dysfunction was only present in patients with more severe LV dysfunction (LVEF < 35) and that particularly in the group of patients with the worst LV function (LVEF < 25 %), RVEF was higher in women than men [8]. Although larger studies are required to establish causality between the effect of gender, better RV function and decreased mortality, this is a provocative study that further suggests that, also in DCM, the right ventricle plays an important role. Future studies should address whether improved RV function is correlated with improved exercise capacity, and try to identify the mechanism behind the improvement in RV function. Interestingly, in rats with pulmonary hypertension, improved outcome in female rats as compared with their male counterparts was associated with reduced RV fibrosis. As the degree of fibrosis in the left ventricle has been shown to be of predictive value for worsening of LV dysfunction in DCM [9], it would be very interesting to measure late gadolinium enhancement in magnetic resonance imaging to show a potential predictive value of RV fibrosis.

Influence of ejection fraction on outcomes and efficacy of spironolactone in patients with heart failure with preserved ejection fraction.

While mineralocorticoid receptor antagonists (MRAs) have been shown to benefit patients with reduced left ventricular ejection fraction (LVEF), spironolactone did not reduce the primary endpoint of cardiovascular death, heart failure hospitalization, or aborted cardiac arrest in patients with heart failure with preserved ejection fraction (HFpEF) in the TOPCAT trial, which enrolled patients with LVEF of 45% or greater. We utilized data from TOPCAT to assess the relationship between LVEF as well as outcomes and efficacy of spironolactone. We assessed differences in baseline characteristics and outcomes across LVEF categories in 3444 patients with HFpEF, and determined whether LVEF modified the treatment effect of spironolactone. Ejection fraction ranged from 44 to 85%. Patients with higher ejection fraction were older, more likely to be female, less likely to have a history of myocardial infarction, and more likely to have a history of hypertension and diabetes. The incidence of the primary endpoint and cardiovascular death was highest in patients at the lower end of the ejection fraction spectrum. Ejection fraction modified the spironolactone treatment effect, particularly in the patients enrolled in the Americas, for the primary outcome (P = 0.046) and for heart failure hospitalization (P = 0.039), with stronger estimated benefits of spironolactone at the lower end of the ejection fraction spectrum with respect to the primary endpoint (LVEF <50%: HR 0.72, 95% CI 0.50, 1.05; LVEF ≥60%: HR 0.97, 95% CI 0.76, 1.23) and heart failure hospitalization (LVEF <50%: HR 0.76, 95% CI 0.46, 1.27; LVEF ≥60%: HR 0.98, 95% CI 0.74, 1.30). In patients with HFpEF enrolled in TOPCAT, patient characteristics and outcomes varied substantially by LVEF. The potential efficacy of spironolactone was greatest at the lower end of the LVEF spectrum. NCT00094302.

A Multicenter, Randomized, Trial Comparing Urapidil and Nitroglycerin in Multifactor Heart Failure in the Elderly

Multifactor heart failure is a common life-threatening event in elderly patients and often complicated by concomitant hypertension and diabetes mellitus (DM). The aim of this study was to evaluate whether α1-blocker, urapidil, provides additional therapeutic benefits compared to nitroglycerin (NG) in treatment of multifactor heart failure complicated by hypertension and DM in elderly patients. Seventy-two elderly consecutive patients were randomized into 2 groups that received treatment with urapidil or NG. All patients were monitored for blood pressure (BP) and heart rate and received tests for metabolic activity and cardiovascular function. Patients receiving urapidil had significantly lower systolic BP than their counterparts in NG group (P < 0.05). Moreover, patients in urapidil group showed lower N-terminal pro-B-type natriuretic peptide levels but higher ejection fraction (t = 2.206, P < 0.05), cardiac index (t = 3.13, P < 0.05) and left end-diastolic volume (t = -3.104, P < 0.05) compared to NG group. Although both urapidil and NG decreased fasting plasma glucose (FPG) levels, there was no significant difference of FPG levels between these 2 groups. Urapidil demonstrated better efficacy than NG on lowering and stabilizing systolic BP, attenuating cardiac afterload and improving cardiac function. Both NG and urapidil significantly reduced FPG levels in multifactor heart failure patients with DM. Urapidil is a therapeutic option for the multifactor heart failure patients complicated with hypertension and DM.

S-Nitrosoglutathione Reductase Deficiency Enhances the Proliferative Expansion of Adult Heart Progenitors and Myocytes Post Myocardial Infarction.

BackgroundMammalian heart regenerative activity is lost before adulthood but increases after cardiac injury. Cardiac repair mechanisms, which involve both endogenous cardiac stem cells (CSCs) and cardiomyocyte cell-cycle reentry, are inadequate to achieve full recovery after myocardial infarction (MI). Mice deficient in S-nitrosoglutathione reductase (GSNOR−⁄−), an enzyme regulating S-nitrosothiol turnover, have preserved cardiac function after MI. Here, we tested the hypothesis that GSNOR activity modulates cardiac cell proliferation in the post-MI adult heart.Methods and ResultsGSNOR−⁄− and C57Bl6/J (wild-type [WT]) mice were subjected to sham operation (n=3 GSNOR−⁄−; n=3 WT) or MI (n=41 GSNOR−⁄−; n=65 WT). Compared with WT,GSNOR−⁄− mice exhibited improved survival, cardiac performance, and architecture after MI, as demonstrated by higher ejection fraction (P<0.05), lower endocardial volumes (P<0.001), and diminished scar size (P<0.05). In addition, cardiomyocytes from post-MI GSNOR−⁄− hearts exhibited faster calcium decay and sarcomeric relaxation times (P<0.001). Immunophenotypic analysis illustrated that post-MI GSNOR−⁄− hearts demonstrated enhanced neovascularization (P<0.001), c-kit+ CSC abundance (P=0.013), and a ≈3-fold increase in proliferation of adult cardiomyocytes and c-kit+/CD45− CSCs (P<0.0001 and P=0.023, respectively) as measured by using 5-bromodeoxyuridine.ConclusionsLoss of GSNOR confers enhanced post-MI cardiac regenerative activity, characterized by enhanced turnover of cardiomyocytes and CSCs. Endogenous denitrosylases exert an inhibitory effect over cardiac repair mechanisms and therefore represents a potential novel therapeutic target.

Comparison of influence of high thoracic epidural anesthesia and central analgesia on hemodynamic during on-bypass coronary artery bypass grafting

Objective. Despite some advantages, the use of high thoracic epidural anesthesia (HTEA) during cardiac operations may be discouraged by fear of adverse hemodynamic effects. Aim. To compare the hemodynamic effects of HTEA and central analgesia (CA) during on-bypass CABG.Methods. 132 patients were assigned into two groups – study group (n = 85), where the surgery was carried out under HTEA and control group (n = 47) - where the surgery was carried out under CA. Data of the intraoperative monitoring and trans-oesophageal cardiac ultrasound - cardiac index (CI), stroke index (SI), ejection fraction (EF) and index of systemic vascular resistance (ISVR) were obtained.Results. After induction and sternotomy patients in the study group had higher EF - 57(53, 65)% vs 54 ± 7% (p = 0,013) and 55 ± 8 vs 52 ± 9%, (p = 0,031). After sternotomy CI and SI in the study group were also higher, respectively 2,42 (2,0;3,1) vs 2,23±0,63 l · min-1 · m-2, (p = 0,041) and 43 (34;46) vs 37±10 ml · m-2 (p = 0.014).Conclusion. We concluded that HTEA has advantages over CA by its influence on hemodynamics.

Ventricular function and cardiac reserve in contemporary Fontan patients

Background/objectiveTotal cavopulmonary connection (TCPC) has been the preferred treatment for patients with univentricular hearts. Current TCPC-techniques are the intra-atrial lateral tunnel (ILT) and the extracardiac conduit (ECC). We aimed to determine ventricular function during rest and stress, and to compare results for both techniques and for left (LV) versus right ventricular (RV) dominance. Methods99 patients, aged 12.5±4.0years underwent echocardiography and magnetic resonance imaging (MRI), and 69 patients underwent stress MRI. ResultsEchocardiography showed impaired systolic and diastolic function. MRI parameters were comparable between ILT and ECC at rest. During dobutamine there was a decrease in end-diastolic volume (EDVi) (91±21 vs. 80±20ml/m2 p<0.001). Ejection fraction (EF) and cardiac index (CI) during dobutamine were lower for ILT patients (59±11 (ILT) vs. 64±7% (ECC), p=0.027 and 4.2±1.0 (ILT) vs. 4.9±1.0L/min/m2 (ECC), p=0.006), whereas other parameters were comparable. TEI-index was higher in ILT-patients (0.72±0.27 (ILT) vs. 0.56±0.22 (ECC), p=0.002). Diastolic function was frequently impaired in patients with a dominant RV (67% (RV) vs. 39% (LV), p=0.011). Patients with dominant LV's had smaller end-systolic volume (ESVi) (40±13 (LV) vs. 47±16 (RV) ml/m2, p=0.030) and higher EF (55±8 (LV) vs. 49±9ml/m2 (RV), p=0.001) and contractility (2.3±0.8 (LV) vs. 1.9±0.7mmHg/ml/m2 (RV), p=0.050) during rest and higher EF during dobutamine (63±8 (LV) vs. 58±10ml/m2 (RV), p=0.043). ConclusionVentricular function is relatively well preserved in modern-day Fontan patients. With dobutamine stress there is a decrease in EDVi. ECC patients have higher CI and EF during stress. Patients with a dominant RV have lower systolic, including impaired contractility, and diastolic function.