Impaired Left Ventricle Function Research Articles

Analysis of left ventricle regional myocardial motion for cardiac radioablation: Left ventricular motion analysis.

Left ventricle (LV) regional myocardial displacement due to cardiac motion was assessed using cardiovascular magnetic resonance (CMR) cine images to establish region-specific margins for cardiac radioablation treatments. CMR breath-hold cine images and LV myocardial tissue contour points were analyzed for 200 subjects, including controls (n=50) and heart failure (HF) patients with preserved ejection fraction (HFpEF, n=50), mid-range ejection fraction (HFmrEF, n=50), and reduced ejection fraction (HFrEF, n=50). Contour points were divided into segments according to the 17-segment model. For each patient, contour point displacements were determined for the long-axis (all 17 segments) and short-axis (segments 1-12) directions. Mean overall, tangential (longitudinal or circumferential), and normal (radial) displacements were calculated for the 17 segments and for each segment level. The greatest overall motion was observed in the control group-long axis: 4.5±1.2mm (segment 13 [apical anterior] epicardium) to 13.8±3.0mm (segment 6 [basal anterolateral] endocardium), short axis: 4.3±0.8mm (segment 9 [mid inferoseptal] epicardium) to 11.5±2.3mm (segment 1 [basal anterior] endocardium). HF patients exhibited lesser motion, with the smallest overall displacements observed in the HFrEF group-long axis: 4.3±1.7mm (segment 13 [apical anterior] epicardium) to 10.6±3.4mm (segment 6 [basal anterolateral] endocardium), short axis: 3.9±1.3mm (segment 8 [mid anteroseptal] epicardium) to 7.4±2.8mm (segment 1 [basal anterior] endocardium). This analysis provides an estimate of epicardial and endocardial displacement for the 17 segments of the LV for patients with normal and impaired LV function. This reference data can be used to establish treatment planning margin guidelines for cardiac radioablation. Smaller margins may be used for patients with higher degree of impaired heart function, depending on the LV segment.

Fulminant Myocarditis Mimicking Myocardial Infarction in a Young Woman: A Challenging Diagnosis and Treatment

BACKGROUND: Fulminant myocarditis is a rare and serious condition with high mortality. It poses diagnostic challenges due to myocardial infarction-like symptoms and rapid deterioration. Timely diagnosis and access to advanced interventions are vital for optimal management and improved outcomes. CASE PRESENTATION: A 34-year-old woman presented with typical chest pain, ST changes, positive cardiac biomarkers, and impaired left ventricle function. The presumptive diagnosis was fulminant myocarditis complicated with cardiogenic shock, respiratory failure, and acute kidney injury. Leukocytosis and high anti-streptolysin O (ASO) titer suggested a recent streptococcal infection as a possible cause. Advanced intervention limitations hindered patient management. On the second day, the patient had a cardiac arrest. CONCLUSION: The diagnosis can be challenging due to the similarity of symptoms and signs to myocardial infarction, combined with the rapid deterioration of the patient’s condition. Prompt initiation of mechanical circulatory support is vital. However, its limited availability in developing countries hinders routine implementation, leading to unfavorable outcomes when life support measures are unavailable.

Left ventricular dysfunction, heart failure, and mortality risk factors in de novo pacemaker recipients and those requiring pacemaker generator replacement

Abstract Background Pacing the right ventricle (RV) can lead to adverse remodelling of the left ventricle (LV), LV dysfunction, increased risk of heart failure hospitalisation (HFH) and mortality. Despite RV pacing avoidance programming becoming commonplace, pacemaker patients remain at risk of pacing-induced cardiomyopathy. New pacing strategies and cardiac resynchronisation therapy are available therapeutic options, but it is unclear which patients should be targeted, and when. Purpose This study examined the effects of RV pacing on LV function, the risk of heart failure requiring hospitalisation and all-cause mortality in patients during the first 12 months of pacemaker therapy, compared to those at pacemaker generator replacement (PGR). Methods Data were obtained from a cohort of patients who underwent de novo pacemaker implantation between 2014 and 2017, and patients requiring PGR between 2008 and 2011 at a single tertiary UK hospital, with follow-up from 12 months. Clinical, echocardiographic, and pacemaker variables, medication, and past medical history data were collected. Predictors of a combined endpoint of all-cause mortality or HFH were assessed using cox-regression analysis, with predictors of impaired LV function analysed using multivariable regression analysis. Results 514 newly implanted (NI) patients (mean age, 75 years; 66% male) were recruited, and 491 patients (mean age, 76 years; 56% male) requiring PGR. After a mean follow up of 887 days, 79 NI patients (16%) were deceased (n=27) or had been hospitalised for HF (n=52), whereas after a mean follow up of 668 days, 56 patients after PGR (12%) were deceased (n=34) or had been hospitalised (n=22) for HF. After 12 months of pacemaker therapy, 182 (35%) NI patients had a LV ejection fraction (LVEF) <50%, which had a higher incidence at PGR of 197 (40%). Age was the only significant predictor of mortality or HFH for both NI and PGR (hazard ratio (HR), 1.068; 95% confidence interval (CI), 1.039 to 1.098; p<0.001 vs 1.035; 95% CI, 1.007 to 1.064; p=0.014), respectively). Univariate analysis revealed baseline LVEF (2.439; 95 percent CI, 1.279 to 4.659; p=0.007), RV pacing burden, medication and blood chemistry were significant predictors of the combined outcome at PGR but not at NI (Table 2). Multivariable analysis of predictors of LV impairment (<50% LVEF) showed history of MI (odds ratio (OR), 0.47; 95% CI, 0.29 to 0.78; p=0.003), RV pacing burden (1.01; 95% CI, 1.01 to 1.02; p<0.001) and creatinine (1.06; 95% CI, 1.02 to 1.10; p=0.004) were independently associated in both cohorts. Conclusions Our data suggest that there remains a similar subgroup of people from initial implantation to PGR at risk of LV impairment that might benefit from medication optimisation or novel pacing strategies. Further research is required to better identifying these people to direct more complex therapies to those with the most to gain. Funding Acknowledgement Type of funding sources: Public grant(s) – National budget only. Main funding source(s): The research is supported by a National Institute for Health Research (NIHR) clinician scientist fellowship (NIHRCS-2012-032). The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health. This research was supported by the NIHR Leeds Clinical Research Facility.

Assessment of subclinical left ventricle myocardial dysfunction using global myocardial work in type 2 diabetes mellitus patients with preserved left ventricle ejection fraction

BackgroundThe purpose of this study was to assess subclinical left ventricle (LV) myocardial dysfunction using global myocardial work (MW) in type 2 diabetes mellitus (T2DM) patients with preserved left ventricle ejection fraction (LVEF).MethodsSixty T2DM patients and 60 normal controls were enrolled in the study. Apical 4-, 3- and 2-chamber views were acquired by two-dimensional echocardiography. Peak systolic myocardial global longitudinal strain (GLS), global myocardial work index (GWI), global constructive work (GCW), global wasted work (GWW), and myocardial work efficiency (GWE) were determined by speckle-tracking echocardiography (STE).ResultsThe GLS values in the T2DM patients were significantly lower than those in normal controls (p < 0.001). The GWW in T2DM patients was significantly greater than that in normal controls, while GWI, GCW and GWE was significantly lower (p < 0.001). Receiver operating characteristic (ROC) analysis showed there were no significant different difference between GWW, GWE and GLS in the area under the curves (AUCs). In T2DM patients, fasting plasma glucose was positively correlated with GWW but negatively correlated with GWE, and GLS was negatively correlated with GWI and GCW.ConclusionFrom the research, we found that global MW as new technique could detect the subclinical LV myocardial dysfunction and confirm that the impaired LV function in T2DM patients with preserved LV systolic function.

Relationship of Microvascular Obstruction with Global and Regional Myocardial Function Determined by Cardiac Magnetic Resonance after ST-Segment Elevation Myocardial Infarction

ObjectiveTo investigate the impact of microvascular obstruction (MVO) on the global and regional myocardial function by cardiac magnetic resonance feature-tracking (CMR-FT) in ST-segment-elevation myocardial infarction (STEMI) patients after percutaneous coronary intervention. MethodsConsecutive acute STEMI patients who underwent cardiac magnetic resonance imaging 1 - 7 days after successful reperfusion by percutaneous coronary intervention treatment were included in this retrospective study. Based on the presence or absence of MVO on late gadolinium enhancement images, patients were divided into groups with MVO and without MVO. The infarct zone, adjacent zone, and remote zone were determined based on a myocardial 16-segment model. The radial strain (RS), circumferential strain (CS), and longitudinal strain (LS) of the global left ventricle (LV) and the infarct, adjacent, and remote zones were measured by CMR-FT from cine images and compared between patients with and without MVO using independent-samples t-test. Logistic regression analysis was used to assess the association of MVO with the impaired LV function. ResultsA total of 157 STEMI patients (mean age 56.66 ± 11.38 years) were enrolled. MVO was detected in 37.58% (59/157) of STEMI patients, and the mean size of MVO was 3.00 ±3.76 mL. Compared with patients without MVO (n = 98), the MVO group had significantly reduced LV global RS (t = −4.30, P < 0.001), global CS (t = 4.99, P < 0.001), and global LS (t = 3.51, P = 0.001). The RS and CS of the infarct zone in patients with MVO were significantly reduced (t = −3.38, P = 0.001; t = 2.64, P = 0.01; respectively) and the infarct size was significantly larger (t = 8.37, P < 0.001) than that of patients without MVO. The presence of LV MVO [OR = 4.10, 95%CI: 2.05 – 8.19, P < 0.001) and its size [OR = 1.38, 95% CI: 1.10–1.72, P=0.01], along with the heart rate and LV infarct size were significantly associated with impaired LV global CS in univariable Logistic regression analysis, while only heart rate (OR=1.08, 95%CI: 1.03 – 1.13, P=0.001) and LV infarct size (OR=1.10, 95%CI: 1.03 - 1.16, P=0.003) were independent influencing factors for the impaired LV global CS in multivariable Logistic regression analysis. ConclusionThe infarct size was larger in STEMI patients with MVO, and MVO deteriorates the global and regional LV myocardial function.

Takotsubo syndrome in status epilepticus –case report

Takotsubo syndrome, also known as stress cardiomyopathy, apical ballooning syndrome or “broken heart syndrome,” is a sudden, transient cardiac condition in which left ventricular dysfunction occurs. Stressors that can induce takotsubo syndrome include both emotional and physical triggers of any kind. The authors present a case of a male patient with nonconvulsive status epilepticus and symptoms suggesting takotsubo syndrome. Echocardiographic examination revealed akinesis of the midsegment and apical segment of the left ventricle, and impaired left ventricle function, but no coronary artery disease was found on cardiac angiography. The clinical symptoms, and echocardiographic and laboratory abnormalities, resolved gradually simultaneously with neurological improvement.

Caractéristiques de l’atteinte cardiaque au cours de la granulomatose éosinophilique avec polyangéite

Aim of the studyOur study aimed to identify the characteristics of cardiac involvement in eosinophilic granulomatosis with polyangiitis (EGPA). MethodsWe conducted a retrospective analytic study including EGPA cases diagnosed between 2000 and 2019 in an internal medicine department. Diagnosis was made according to the 1990 American College of Rheumatology criteria and the 2012 Chapel Hill Concensus. ResultsEleven EGPA cases were included, 64% of patients were female. Median age at diagnosis was 52 years [42–58]. Heart damage revealed EGPA in 55% of cases with a significant predominance of women (p=0.015). The main cardiac manifestations were myocarditis, ischemic cardiomyopathy due to small vessel vasculitis, cardiac tamponade and intracardiac thrombus. Cardiac magnetic resonance imaging (MRI) mainly showed subendocardial hyposignal in early infusion and late enhancement in the same areas, nodular by locations, associated with impaired left ventricle function and micro-infarctions by distal vasculitis. Cardiac damage was associated to ANCA negativity in 83.3% of cases. The median Birmingham Vasculitis Activity Score version3 (BVAS v3) was 16 [10–17]. Under conventional treatment, no relapses had occurred. The median vasculitis damage index (VDI) was 2 [1–2.3] and the mortality rate was zero after a mean follow-up of 43 months. ConclusionCardiomyopathy is a frequent revealing mode of EGPA. A late onset asthma and hypereosinophilia should guide the diagnosis. As ANCA research often turns out to be negative, histological evidence is recommended in this context. The contribution of cardiac MRI in the diagnosis of EGPA remains to be defined.

ON-PUMP VERSUS OFF-PUMP CORONARY ARTERY BYPASS GRAFTING in PATIENTS with POOR LEFT VENTRICULAR FUNCTION

Background: There is an increase in the number of patients with severely impaired left ventricle function who referred for CABG. Many studies showed that surgical intervention for those high-risk patients has high survival and wonderful outcome compared to medical treatment. Aim of work: This study aimed to evaluate our experience with coronary artery bypass surgery in patients with EF [ 25% up to 40%] either to perform surgery using off or on-pump technique and try to conclude which technique may be safer regarding cardiac function. Patients and Methods: This prospective observational patient cohort study from August 2017 to July 2019 enclosed forty consecutive patients divided into 2 teams every 20 patients either off or on pump technique according to surgeons' expertise. Pre-, intra- and post-operative data were collected for all patients. All survivors were subjected to a 6-months follow-up clinically and by Echocardiograghy assessment. Results: Improvement of ejection fraction [EF] was encountered in our study; the mean 6-months operative EF improved for each team by [36% versus 37%] for off-pump and on-pump interventions, respectively. There was no statistically important difference in the information collected for each technique [p-value>0.05] regarding most points of comparison. Conclusion: Results of CABG in high-risk patients were acceptable with on-pump and off-pump techniques with nearly comparable results in our study, at least in the early 6-months after intervention. Intra-aortic balloon usage is valuable when indicated.

Right and left ventricular interactions, strain, and remodeling in repaired pulmonary stenosis patients with preserved right ventricular ejection fraction: A cardiac magnetic resonance study.

Right ventricular dilation and dysfunction is a common long-term complication in patients with repaired pulmonary stenosis (rPS). Additionally, abnormal right and left ventricular interactions have been reported in right-sided heart defect after intervention, including in pulmonary stenosis. To analyze ventricular strain, remodeling, and left and right ventricular interactions in rPS patients with preserved right ventricular ejection fraction (RVEF) compared with healthy children using cardiac magnetic resonance. A cross-sectional study. In all, 34 rPS patients and 10 healthy children volunteers (controls). 3.0T/2D balanced steady-state free precession (2D b-SSFP) cine, late gadolinium enhancement (LGE), and 2D phase contrast (2D-PC). Pulmonary regurgitation (PR) fractions of the main pulmonary artery, biventricular volumes, masses, function, and cardiac strain. Mann-Whitney U-test, t-test, Pearson correlation coefficients, Spearman's correlation coefficients, and intraclass correlation coefficients analysis were performed. For group analysis, the right ventricular (RV) global circumferential strain and radial strain were significantly increased in patients when compared with controls (-13.57 ± 2.69 vs. -5.91 ± 3.16, P < 0.001; 25.31 ± 8.12 vs. 9.87 ± 5.32, P < 0.001, respectively). The fraction of PR displayed moderate correlation with right ventricular end-diastolic volume index (RVEDVi) (r = 0.452, P = 0.022). RVEDVi and mass index were larger in patients vs. control (104.92 ± 27.46 vs. 85.15 ± 11.98, P = 0.016; 18.28 ± 4.95g/m2 vs. 11.67 ± 2.14 g/m2 , P < 0.001, respectively). Patients presented with preserved left ventricular ejection function, but was lower than healthy controls (60.89% ± 4.89% vs. 65.95% ± 4.56%, P = 0.006). Regional circumferential strain of segment 3 of left ventricle (LV) were significantly decreased in patients (-7.79 ± 6.52 vs. -13.56 ± 3.22, P = 0.003). Compensated increased RV strain, myocardial remodeling of RV, and adverse right and left ventricular interactions occur in rPS patients with preserved RVEF. The decreased interventricular septum strain may lead to impaired LV function due to RV dilation as a result of PR. 3 Technical Efficacy Stage: 3 J. Magn. Reson. Imaging 2020;52:129-138.

P908 The novel predictor for mortality in patients with functional mitral regurgitation: the modified MIDA-Score

Abstract EuroSCORE and STS-Score are used to assess surgical risk in patients with valvular heart diseases. The MIDA- Score has been recently published as a representative predictor for short- and long-term prognosis in patients with degenerative mitral regurgitation (DMR). The adequate assessment of long-term prognosis in patients with functional MR is scarce. We aim to adapt this classical score system for patients with FMR. We retrospectively included 105 patients with FMR who underwent transcatheter mitral regurgitation therapy (TMVR) between January 2014 and August 2016 in our center. Due to the different underlying pathomechanisms of FMR, annular dilatation and impaired left ventricle function, and more elderly patient population we adapted some cut-off values to FMR patients (Age &amp;gt; 65 to Age &amp;gt; 75; LV-EF ≤ 60% to LV-EF ≤ 45%; sPAP≥50mmHg to sPAP≥45mmHg). Moreover, according to Cox proportional hazard analysis of our patient collective we re-calculated the weights of the risk factors: Age 2 points, Symptoms 1 point, atrial fibrillation 2 points, left atrial diameter 1 point, right ventricle systolic pressure 2 points, left ventricle end-systolic diameter 2 points, left ventricle ejection fraction 2 points. We defined three risk groups according to total points from the risk factors; Grade 1 (0-4 points): low risk, Grade 2 (5-9 points): moderate risk, Grade 3 (10-12 points): high risk. We retrospectively included 105 patients (76.7 ± 8.8 years, 50,6% female) with symptomatic (functional NYHA class &amp;gt; II ) moderate-to-severe FMR (PISA: 0.7 ± 0.4cm, VC width: 0.8 ± 0.3cm, EROA: 0.22cm2, RegVol: 38.1 ± 19.2ml) at surgical high risk (EuroSCORE II: 5.4 ± 3.8%, STS-Score: 4.7 ± 2.8%). We found all-cause mortality 7% at one-year follow-up. 34.1% of our collective were hospitalized. The classical MIDA Score was not significantly correlated with mortality and rehospitalization in patients with FMR at follow-up (p = 0.5); however, the modified MIDA score was found to be a strong predictor for mortality and rehospitalization in patients with FMR (AUC: 0.89). According to multivariate analysis, the modified MIDA score was found to be superior compared to the other conventional score systems (The modified MIDA-Score HR: 4.1, p = 0.021; EuroSCORE II; HR: 1.2, p = 0.004, STS-Score; HR: 1.7, p = 0.005). We performed Cox proportional hazard analysis to assess the weighting factor of the predictors. As a result of this, we found age (HR: 2,95, p = 0.03) as the most reliable parameter to predict the combined outcome. The 12,5% of grade 1, 27% grade 2, 57% grade 3 patients showed combined endpoint. According to regression analysis, the modified score &amp;gt;9 points found to be a strong predictor for high mortality and rehospitalization (OR: 3.35, p = 0.011). We found the modified MIDA Score sufficient and extensive to assess outcomes in patients with FMR. The modified MIDA Score offers a sufficient promising tool to predict individual prognosis in patients with FMR.

Myocardial Blood Flow Quantified by Low-Dose Dynamic CT Myocardial Perfusion Imaging Is Associated with Peak Troponin Level and Impaired Left Ventricle Function in Patients with ST-Elevated Myocardial Infarction

ObjectiveTo investigate the association of myocardial blood flow (MBF) quantified by dynamic computed tomography (CT) myocardial perfusion imaging (MPI) with troponin level and left ventricle (LV) function in patients with ST-segment elevated myocardial infarction (STEMI).Materials and MethodsThirty-five STEMI patients who successfully had undergone reperfusion treatment within 1 week of their infarction were consecutively enrolled. All patients were referred for dynamic CT-MPI. Serial high-sensitivity troponin T (hs-TnT) levels and left ventricular ejection fraction (LVEF) measured by echocardiography were recorded. Twenty-six patients with 427 segments were included for analysis. Various quantitative parameters derived from dynamic CT-MPI were analyzed to determine if there was a correlation between hs-TnT levels and LVEF on admission and again at the 6-month mark.ResultsThe mean radiation dose for dynamic CT-MPI was 3.2 ± 1.1 mSv. Infarcted territories had significantly lower MBF (30.5 ± 7.4 mL/min/100 mL versus 73.4 ± 8.1 mL/min/100 mL, p < 0.001) and myocardial blood volume (MBV) (2.8 ± 0.9 mL/100 mL versus 4.2 ± 1.1 mL/100 mL, p = 0.044) compared with those of reference territories. MBF showed the best correlation with the level of peak hs-TnT (r = −0.682, p < 0.001), and MBV showed a moderate correlation with the level of peak hs-TnT (r = −0.437, p = 0.026); however, the other parameters did not show any significant correlation with hs-TnT levels. As for the association with LV function, only MBF was significantly correlated with LVEF at the time of admission (r = 0.469, p = 0.016) and at 6 months (r = 0.585, p = 0.001).ConclusionMBF quantified by dynamic CT-MPI is significantly inversely correlated with the level of peak hs-TnT. In addition, patients with lower MBF tended to have impaired LV function at the time of their admission and at 6 months.

Alamandine attenuates hypertension and cardiac hypertrophy in hypertensive rats

Oral administration of the peptide alamandine has antihypertensive and anti-fibrotic effects in rats. This work aimed to determine whether subcutaneous alamandine injection would attenuate hypertension and cardiac hypertrophy, and improve the function of a major target of hypertension-related damage, the left ventricle (LV), in spontaneously hypertensive rats (SHRs). This was examined in vivo in SHRs and normotensive rats subjected to 6-week subcutaneous infusion of alamandine or saline control, and in vitro in H9C2-derived and primary neonatal rat cardiomyocytes treated with angiotensin (Ang) II to model cardiac hypertrophy. Tail artery blood pressure measurement and transthoracic echocardiography showed that hypertension and impaired LV function in SHRs were ameliorated upon alamandine infusion. Alamandine administration also decreased the mass gains of heart and lung in SHRs, suppressed cardiomyocyte cross-sectional area expansion, and inhibited the mRNA levels of atrial natriuretic peptide and brain natriuretic peptide. The expression of alamandine receptor Mas-related G protein-coupled receptor, member D was increased in SHR hearts and in cardiomyocytes treated with Ang II. Alamandine inhibited the increases of protein kinase A (PKA) levels in the heart in SHRs and in cardiomyocytes treated with Ang II. In conclusion, the present study showed that alamandine administration attenuates hypertension, alleviates cardiac hypertrophy, and improves LV function. PKA signaling may be involved in the mechanisms underlying these effects.

Acute and long-term outcomes of percutaneous balloon aortic valvuloplasty for the treatment of severe aortic stenosis.

This study aimed to evaluate the indications, short- and long-term outcomes of balloon aortic valvuloplasty (BAV) in patients with severe aortic stenosis (AS). A cohort of 112 patients with AS underwent 114 BAV procedures between October 2012 and July 2015 in two Polish interventional cardiology centers. Clinical and echocardiographic data were prospectively collected within 1, 6, and 12 months follow-up. BAV was performed as a bridge to TAVI (51.8%), surgical aortic valve replacement (AVR, 5.4%), before urgent noncardiac surgery (8.0%), for symptom relief (33.0%) and cardiogenic shock (1.8%). Periprocedural, in-hospital, 1-, 6-, 12-month mortality were 2.7%; 8.9%; 8.9%; 16.9%; 22.3%, respectively. Serious periprocedural adverse events occurred in 18.8% of patients. After the procedure, mean aortic valve area (AVA) increased from 0.59 ± 0.18 to 0.82 ± 0.24 cm2 , mean peak aortic valve gradient (pAVG) decreased from 94.0 ± 27.6 to 65.4 ± 20.0 mm Hg, mean aortic gradient decreased from 58.0 ± 17.8 to 40.5 ± 14.6 mm Hg, P < 0.05 for all. Left ventricular ejection fraction (LVEF) increased from median (interquartile range) of 53.5 (30 - 64) to 60 (45 - 65)% after 1 month (P < 0.05). In patients with impaired left ventricle function (LVEF <40%), LVEF significantly improved (median increase of 16%) after 1 and 6 months (P < 0.05). At 12 months patients had higher AVA, pAVG, and LVEF as compared to baseline (P < 0.05). BAV is a useful procedure in high-risk AS patients, where achieved effects can be sufficient in bridging patients for TAVI/AVR. © 2016 Wiley Periodicals, Inc.

The role of heart rate in the left ventricular twist response to increased arterial blood pressure: a 'stiff' challenge?

The role of heart rate in the left ventricular twist response to increased arterial blood pressure: a 'stiff' challenge?

Ultra-acute increase in blood glucose during prehospital phase is associated with worse short-term and long-term survival in ST-elevation myocardial infarction.

BackgroundThe current study was to investigate the blood glucose changes in ultra-acute phase in patients with ST-elevation myocardial infarction (STEMI) and its associations with patient outcome.MethodsThis study was a retrospective population-based observational study utilizing prospectively collected registry data complemented with laboratory data. All adult patients with STEMI treated by emergency medical services (EMS) in the city of Helsinki from January 2006 to December 2010 were included in the study. Both prehospital and hospital admission glucose values were available from 152 (32%) of all STEMI patients (n = 469).ResultsChange in blood glucose from prehospital phase to emergency department admission was significantly higher in non-survivors within 30 days compared to survivors (+1.2 ± 5.1 vs. -0.3 ± 2.4 mmol/l [mean ± SD], P = 0.03). Furthermore, the 3-year survival rate was significantly lower in patients with an evident (≥2 mmol/l) rise in blood glucose (P = 0.02). In patients with impaired left ventricle function (best ejection fraction < 40%), blood glucose increased more compared to patients without it (1.2 ± 2.9 vs. 0.4 ± 2.7 mmol/l, P = 0.01). Increase in glucose was correlated with peak myocardial creatinine kinase (r = 0.17, P = 0.04) as a marker of increased size of infarct, but not with glycosylated haemoglobin A1C as a marker of chronic hyperglycaemia (r = −0.12, P = 0.27).ConclusionsIn patients with STEMI, ultra-acute hyperglycaemia during prehospital phase is associated with increased mortality, impaired cardiac function and increased size of infarct.

Assessment of Left Ventricular Diastolic Dysfunction Based on the Intraventricular Velocity Difference by Vector Flow Mapping

The diastolic intraventricular velocity difference represents diastolic function of the left ventricle (LV). Here we analyzed the LV diastolic intraventricular velocity difference in patients with impaired LV function based on the ventricular flow rate profile by vector flow mapping. Patients with LV diastolic dysfunction were divided into 2 groups: chronic heart failure with restricted filling (group 1; n = 27) and hypertension with abnormal relaxation (group 2; n = 34). Healthy participants were identified as controls (group 3; n = 22). Left ventricular inflow color Doppler findings were analyzed by the vector profile model with the vector flow mapping technology offline. The flow velocity rates at the base and apex of the LV were measured from vector profiles with the vector flow mapping technology. The diastolic intraventricular velocity difference was calculated from flow velocity rates. The diastolic intraventricular velocity difference calculated from vector flow mapping was significantly lower in both groups with LV diastolic dysfunction than the control group (mean ± SD, 79.95 ± 9.88 cm/s in controls versus 40.35 ± 6.80 cm/s in group 1 and 48.50 ± 6.03 cm/s in group 2; P < .001 for both). The diastolic intraventricular velocity difference had a significant association with the ejection fraction (P = .0002) and deceleration time (P = .0306). The peak atrial contraction velocity was negatively related to the diastolic intraventricular velocity difference (P = .0003). The diastolic intraventricular velocity difference derived from the LV velocity rate by the vector profile model on vector flow mapping can be potentially used for quantitative assessment of LV diastolic function. Vector flow mapping proved to be clinically practical for reflecting LV diastolic dysfunction in pathologic states.

Correlation between Left Ventricular Global and Regional Longitudinal Systolic Strain and Impaired Microcirculation in Patients with Acute Myocardial Infarction

We investigated the correlation between left ventricular global and regional longitudinal systolic strain (GLS and LRS) and coronary flow reserve (CFR) assessed by transthoracic echocardiography (TTE) in patients with a recent acute myocardial infarction (AMI). Furthermore, we investigated if LRS and GLS imaging is superior to conventional measures of left ventricle (LV) function. In a consecutive population of first time AMI patients, who underwent successful revascularization, we performed comprehensive TTE. GLS and LRS were obtained from the three standard apical views. Assessment of CFR by TTE was performed in a modified apical view using color Doppler guidance. The study population consisted of 183 patients (51 females) with a median age of 63 [54;70] years. Eighty-nine (49%) patients had a non-ST elevation myocardial infarction and 94 (51%) patients had a ST elevation myocardial infarction. The GLS was -15.2 [-19.3;-10.1]% in the total population of 183 patients. Total wall motion score index (WMSI) in the population was 1.19 [1;1.5]. Eighty-five patients suffered from culprit lesion in left anterior descending artery (LAD). The CFR in these patients was 1.86 [1.36;2.35] and the GLS was -14.3 [-18.9; -9.8]%. A significant difference was observed in the LRS in LAD territory in culprit LAD infarction patients with a CFR ≤ 2 (-9.6 [-13.77;-6.44]) compared with the LRS in LAD territory in culprit LAD infarction patients with a CFR > 2 (-19.33 [-21.1;-16.5]), P < 0.0001. We found no significant difference between WMSI in LAD territory in culprit LAD infarction patients with a CFR ≤ 2 (1.56 [1.06;2.23]) compared with WMSI in LAD territory in culprit LAD infarction patients with a CFR > 2 (1.37 [1.03;2.11]); P = 0.18. The same pattern was observed in both circumflex coronary artery (CX) and right coronary artery (RCA) territories. In the total population, we found a strong correlation between CFR and GLS (r = -0.85, P < 0.0001). This was also seen in the multivariate regression model adjusting for possible confounders including WMSI (P < 0.001). In this study, we have shown a close association between myocardial deformation in patients with a recent AMI and the degree of diminished microcirculation. We found that both GLS and LRS correlated with CFR. We conclude that GLS and LRS are significantly better tools to assess impaired CFR and LV function after a recent AMI, than conventional echocardiographic measurements.

Smoking Status on Outcomes After Percutaneous Coronary Intervention

The effect of smoking on prognosis among patients undergoing percutaneous coronary intervention (PCI) is controversial, and data on the importance of smoking cessation or reductions were lacking. Smoking cessation or reductions could reduce the risk of adverse outcomes in patient after PCI. There were 19 506 consecutive patients who had undergone successful PCI between April 2004 and January 2010 followed. Extensive data, including self-reported smoking habits, were obtained at baseline and during follow-up. Compared with post-PCI quitters and persistent smokers, the nonsmokers and pre-PCI quitters were older and had a higher prevalence of comorbid factors such as hypertension and impaired left ventricle function. The adjusted hazard ratios for mortality were 2.52 (95% confidence interval [CI]: 1.92-3.30) for nonsmokers, 0.52 (95% CI: 0.32-0.84) for pre-PCI quitters, and 0.11 (95% CI: 0.06-0.22) for post-PCI quitters, compared to persistent smokers. With respect to additional revascularizations, a higher risk was observed among the quitters (1.70 [95% CI: 1.40-2.08] for pre-PCI quitters and 1.59 [95% CI: 1.36-1.85] for post-PCI quitters) as well as the nonsmokers (1.40 [95% CI: 1.20-1.64]). Among persistent smokers, each reduction of 5 cigarettes/day was associated with a 72% decline in mortality risk (P < 0.001) but did not reach statistical significant for repeated revascularizations (0.80 [95% CI: 0.46-1.37], P = 0.4132). Despite a higher risk of revascularization, the cessation of smoking either before or after PCI is beneficial in all-cause mortality. The apparent smoker's paradox may be explained by the differences in baseline risk or the reduced sensitivity to adverse outcomes as well as the reluctance to seek medical help among smokers.

Lack of Microsomal Prostaglandin E 2 Synthase-1 in Bone Marrow–Derived Myeloid Cells Impairs Left Ventricular Function and Increases Mortality After Acute Myocardial Infarction

Microsomal prostaglandin E(2) synthase-1 (mPGES-1), encoded by the Ptges gene, catalyzes prostaglandin E(2) biosynthesis and is expressed by leukocytes, cardiac myocytes, and cardiac fibroblasts. Ptges(-/-) mice develop more left ventricle (LV) dilation, worse LV contractile function, and higher LV end-diastolic pressure than Ptges(+/+) mice after myocardial infarction. In this study, we define the role of mPGES-1 in bone marrow-derived leukocytes in the recovery of LV function after coronary ligation. Cardiac structure and function in Ptges(+/+) mice with Ptges(+/+) bone marrow (BM(+/+)) and Ptges(+/+) mice with Ptges(-/-) BM (BM(-/-)) were assessed by morphometric analysis, echocardiography, and invasive hemodynamics before and 7 and 28 days after myocardial infarction. Prostaglandin levels and prostaglandin biosynthetic enzyme gene expression were measured by liquid chromatography-tandem mass spectrometry and real-time polymerase chain reaction, immunoblotting, immunohistochemistry, and immunofluorescence microscopy, respectively. After myocardial infarction, BM(-/-) mice had more LV dilation, worse LV systolic and diastolic function, higher LV end-diastolic pressure, more cardiomyocyte hypertrophy, and higher mortality but similar infarct size and pulmonary edema compared with BM(+/+) mice. BM(-/-) mice also had higher levels of COX-1 protein and more leukocytes in the infarct, but not the viable LV, than BM(+/+) mice. Levels of prostaglandin E(2) were higher in the infarct and viable myocardium of BM(-/-) mice than in BM(+/+) mice. Lack of mPGES-1 in bone marrow-derived leukocytes negatively regulates COX-1 expression, prostaglandin E(2) biosynthesis, and inflammation in the infarct and leads to impaired LV function, adverse LV remodeling, and decreased survival after acute myocardial infarction.

An Infant Case of Dilated Cardiomyopathy Associated With Congenital Cytomegalovirus Infection

A 2-month-old infant with congestive heart failure was referred to the authors' hospital. Echocardiography exhibited a dilated left ventricle (LV), poor LV systolic function, and intraventricular thrombus. Laboratory data showed a normal creatinine phosphokinase level and negative troponin T test results. The congestive heart failure was managed using a beta-blocker, an angiotensin receptor blocker, and diuretics. Head computed tomography performed during the treatment course showed periventricular calcifications. Congenital cytomegalovirus infection was subsequently diagnosed. Fetal echocardiography performed during pregnancy showed impaired LV function, suggesting that the cardiomyopathy was associated with cytomegalovirus infection in utero.