Q-wave Research Articles

Electrocardiographic correlates of cardiac magnetic resonance findings in women with myocardial infarction with non-obstructive coronary arteries

BackgroundMyocardial infarction with nonobstructive coronary arteries (MINOCA) occurs in 6–15 % of MI patients. Cardiac magnetic resonance (CMR) imaging identifies MINOCA etiologies, but access may be limited. MethodsWe assessed associations between the index electrocardiogram (ECG) and CMR in MINOCA. Women with MI and < 50 % angiographic stenosis in all vessels were prospectively enrolled at 16 sites. CMR (median 6d from MI) was analyzed for late gadolinium enhancement (LGE), myocardial edema, and wall motion. We assessed ECGs for T-wave inversions (TWI), Q-waves (QW), ST-elevations (STE), ST-depressions (STD), and fragmented QRS complexes (fQRS). We calculated the DETERMINE score (# leads TWI + # fQRS +2*[# QW], excluding aVR, V1). ResultsAmong 112 women with interpretable ECG, 81.3 % (91/112) had abnormal ECG; 50 % (56/112) had ≥1 TWI. CMR was abnormal in 74.1 % (83/112), with LGE in 49.1 % (55/112) and myocardial edema in 61.6 % (69/112). DETERMINE score ≥ 3 was associated with abnormal CMR (adjusted odds ratio [aOR] aOR 6.06 [1.89, 24.6], p = 0.002) and LGE (aOR 3.10 [1.26, 8.00], p = 0.013), but not edema (aOR 1.86 [0.80, 4.43], p = 0.152). TWI was also associated with abnormal CMR and LGE after adjustment (aOR 3.13 [1.08, 10.1], p = 0.036, aOR 3.23 [1.27, 8.63], p = 0.013, respectively), but not edema (aOR 1.26 [0.54, 2.96], p = 0.589). Specificity for abnormal CMR was 0.83 for DETERMINE score ≥ 3 and 0.75 for TWI. No other ECG findings were associated with CMR abnormality. ConclusionDETERMINE score ≥ 3 and the presence of any TWI were associated with abnormal CMR and with LGE in MINOCA. Our findings demonstrate that the index ECG can provide insight on CMR findings but without sensitivity or specificity required to forgo the CMR. We reaffirm the central role of CMR in elucidating MINOCA pathophysiology.

Abstract 13906: Electrocardiographic Correlates of Cardiac MRI Findings in Women With MINOCA

Introduction: Myocardial infarction with nonobstructive coronary arteries (MINOCA) is identified in 6-15% of patients with MI and disproportionately affects women. Cardiac magnetic resonance (CMR) imaging is important to identify the cause of MINOCA but is restricted by its technical complexity and limited accessibility. The electrocardiogram (ECG), a simple, readily available tool, may predict features associated with abnormal CMR. Methods: Women with a diagnosis of MI and &lt;50% angiographic stenosis in all epicardial vessels were enrolled in the Women’s Heart Attack Research Program (HARP), a prospective, multicenter, observational study. Participants had CMR at a median of 6 days from MI (n=116). A CMR core laboratory interpreted images while blinded to clinical data and ECGs. Abnormal CMR findings included late gadolinium enhancement (LGE) or myocardial edema. The patient’s presenting ECG was analyzed. ECGs with ≥2 uninterpretable leads or with bundle branch block were excluded. ECGs were assessed for T-wave inversions (TWI), pathologic Q waves (QW), fractionated QRS (fQRS), and ST segment depression or elevation. The DETERMINE score is 2x the number of leads (#) with QW + # fQRS + # TWI, excluding leads V1 and aVR (maximum score 40). Results: (Figure, Table): Among 112 women with MINOCA, CMR abnormality was more likely in women with DETERMINE score ≥3 vs &lt;3 (86% vs 65%, p = 0.01). DETERMINE score ≥3 was associated with abnormal CMR on logistic regression (OR 3.4, p = 0.01). Patients with any TWI were more likely to have abnormal CMR than those with no TWI (84% vs 64%, p = 0.02), and were more likely to have LGE on CMR (61% vs 34%, p = 0.005). In those with a DETERMINE score of 0, CMR was abnormal in 62% vs 78% with DETERMINE score ≥1 (p=0.09), and LGE was present in 28% vs 54%, p = 0.01. Conclusion: ECG abnormalities were associated with abnormal CMR among women with MINOCA. The ECG may provide risk stratification for CMR, but the absence of QW, fQRS and TWI does not preclude CMR abnormality.

Association between early Q-waves and microvascular injury in patients with ST-elevation myocardial infarction and primary percutaneous coronary intervention

Abstract Funding Acknowledgements Type of funding sources: None. Background Pathological early Q-waves (QW) are associated with adverse outcomes in patients with ST-segment elevation myocardial infarction (STEMI). It is still not clear how admission Q-waves are related to microvascular injury (microvascular obstruction (MVO) and intramyocardial haemorrhage (IMH)) observed by cardiovascular magnetic resonance (CMR) after primary percutaneous coronary intervention (pPCI) for STEMI. Aim to determine the association between admission Q-waves and microvascular injury in STEMI patients treated with primary PCI. Methods This prospective study included 98 STEMI patients who underwent pPCI within 12 hours and had no contraindication of CMR investigation. Admission 12-lead electrocardiography was evaluated for the presence of pathological QW, defined as a depth of &amp;gt;0,1 mV and a QW duration of &amp;gt; 30 ms. The patients underwent a cardiac magnetic resonance imaging scan at 6 (interquartile range [IQR]: 5-7) days after pPCI to determine infarct characteristics including MVO (late gadolinium enhancement) and IMH (T2* mapping). Results The 98 first-attack STEMI patients included 87 men and 11 women with a mean age of 55,6 ± 9,7 years in this study. Early QW was observed in 23 (23,5%) patients. These patients were more frequent smokers (p = 0,041), had a significantly more frequent left anterior descending artery as culprit lesion (p = 0,03), and had higher rates of pre-interventional TIMI flow 0 (p = 0,001). Patients with QW was related to larger infarct size (21% vs. 8% of left ventricular mass, p = 0,002), lower ejection fraction (44% vs. 51%, p = 0,004), and larger MVO (53% vs. 32%, p = 0,001) and IMH (34% vs. 17%, p = 0,003). Q-waves remained associated with both MVO (odds ratio: 5,13, 95% confidence interval: 1,98 to 11,2, p &amp;lt; 0,001) and IMH (odds ratio: 3,66, 95% confidence interval: 1,06 to 7,21, p &amp;lt; 0,001) after adjusting for potential confounders (total ischemia time, ST-segment elevation, pre-interventional TIMI flow 0). Conclusions Admission Q-waves in the ECG were as independent early markers of microvascular obstruction and intramyocardial haemorrhage in STEMI patients undergoing pPCI.

Validation of black blood late gadolinium enhancement (LGE) for evaluation of myocardial infarction in patients with or without pathological Q-wave on electrocardiogram (ECG).

The pathological Q-wave (QW) is an important indicator of infarcted myocardial volume indicating a worse prognosis compared to non-Q-wave (NQW) infarctions. Traditional classification divides infarcts into transmural and non-transmural based on QW and NQW. This view has been challenged by the advent of late gadolinium enhancement (LGE) MR imaging. Conventional LGE (Conv-LGE) detection of subendocardial MI is limited by bright blood pool. Dark Blood LGE imaging (DB-LGE) nulls the blood pool improving the conspicuity and accuracy of detection of subendocardial infarcts. We hypothesize that improved detection of subendocardial enhancement with DB-LGE will result in improved correlation of electrocardiogram (ECG) and extent of infarction. Sixty-four clinically confirmed infarction patients were enrolled in this prospective study. All the participants underwent cardiac MR imaging including conv-LGE and DB-LGE. Twelve-lead ECG were performed on the same day. The patients were divided into QW and NQW groups by one experienced cardiologist. MI quantitation was by MI% (the ratio of MI volume to whole myocardial volume) and transmural grading, compared using paired t-test and Wilcoxon-test, respectively. The image quality obtained by Conv-LGE and DB-LGE were evaluated according to the signal intensity ratio (SIR) and contrast-to-noise ratio (CNR). Fifty-six subjects were enrolled in the final analysis [23 (41%) QW and 33 (59%) NQW infarcts]. For the QW cohort, both sequences classified infarcts as transmural in 21/23 (91%) subjects and subendocardial in 2/23 (9%). For the NQW cohort, both sequences classified infarcts as transmural in 16/33 (48%) subjects and subendocardial in 17/33 (52%). Using BB-LGE there were significant differences in detecting subendocardial infarcts in QW and NQW cohorts (Z=-5.85, P<0.001). The MI% of QW group was greater than in NQW group (24.2±10.3 vs.15.9±9.8, P=0.003). Compared to Conv-LGE, BB-LGE provided higher CNR and SIR between infarcted myocardium and blood pool (6.3±2.6 vs. 2.1±1.3, P<0.001; 5.4±1.9 vs. 1.3±0.2, P<0.001). BB-LGE detected more subendocardial infarcted segments in the QW group and NQW group (Z=-4.24, P<0.001; Z=-5.57, P<0.001). The larger MI% was displayed in BB-LGE than in Conv-LGE in both QW group and NQW group (24.2±10.3 vs. 22.6±10.3, P<0.001; 15.9±9.8 vs.14.6±9.6, P=0.001). Compared to conventional LGE, DB-LGE can provide more accurate detection and characterization of infarction in terms of transmurality and subendocardial extent. This is important for evaluating QW and NQW MIs. Due to nulling the high signal of blood pool, DB-LGE can effectively improve the identification of subendocardial MI which may be missed on conventional LGE. Therefore, in both QW and NQW MIs, DB-LGE detects more subendocardial MIs and larger MI% is found. This may facilitate more accurate quantitative MR assessment of both QW and NQW MIs and further empower LGE volume as a predictive biomarker.

Early Q-wave morphology in prediction of reperfusion success in patients with ST-segment elevation myocardial infarction treated with primary percutaneous coronary intervention – A cardiac magnetic resonance imaging study

BackgroundPathological Q-wave (QW) in the electrocardiogram (ECG) before primary percutaneous coronary intervention (primary PCI) is a strong prognostic marker in patients with ST-segment elevation myocardial infarction (STEMI). However, current binary QW criteria are either not clinically applicable or have a lack of diagnostic performance. Accordingly, we evaluated the association between duration, depth and area of QW and markers of the effect of reperfusion (reperfusion success). MethodsA total of 516 patients with their first STEMI had obtained an ECG before primary PCI and an acute cardiac magnetic resonance imaging (CMR) at day 1 (interquartile range [IQR], 1–1) and at follow-up at day 92 (IQR, 89–96). The largest measurable QW in ECG was used for analysis of duration, depth and area of QW (QW morphology). The QW morphology was evaluated as a continuous variable in linear regression models and as a variable divided in four equally large groups. ResultsThe QW morphology as four equally large groups was significantly associated with all CMR endpoints (p ≤ 0.001) and showed a linear relationship (p ≤ 0.001) with final infarct size (for QW duration, β = 0.47; QW depth, β = 0.41 and QW area, β = 0.39), final infarct transmurality (for QW duration, β = 0.36; QW depth, β = 0.26 and QW area, β = 0.23) and final myocardial salvage index (for QW duration, β = −0.34; QW depth, β = −0.26 and QW area, β = −0.24). ConclusionAlthough modest, the QW morphology in STEMI patients showed significant linear association with markers of reperfusion success. Hence, it is suggested that the term pathological is not used as a dichotomous parameter in patients with STEMI but rather evaluated on the basis of extent.

P949Early QW duration, depth and area in prediction of reperfusion success in patients with ST-segment elevation myocardial infarction treated with primary percutaneous coronary intervention - a CMR study

Abstract Background Pathological Q-wave (QW) in the electrocardiogram (ECG) before primary percutaneous coronary intervention (primary PCI) is a strong prognostic marker in patients with ST-segment elevation myocardial infarction (STEMI). However, current QW criteria are either not clinical applicable or have a lack of diagnostic performance. Furthermore, the term “pathological” QW is debatable given that even patients with large pathological QW do have substantial myocardial salvage index. Accordingly, we evaluated the association between QW duration, depth, area (QW morphology) and non-viable myocardium, myocardial salvage index as well as microvascular obstruction (myocardial salvage index and microvascular obstruction are considered reperfusion success) using cardiac magnetic resonance imaging (CMR). Methods A total of 516 patients with their first STEMI had obtained an ECG before primary PCI and an additional CMR performed acute at day 1 (interquartile range [IQR], 1–1) and at follow-up at day 92 (IQR, 89–96). The largest measurable QW in ECG was used for analysis of QW morphology. A new QW criteria (Copenhagen QW criteria) composite of duration and depth as well as a new QW area criteria were made using ROC-analysis, and were compared with modified Minnesota criteria. Results The QW morphology was strongly associated to all CMR endpoints (p≤0.0001) and showed a strong linear correlation with final infarct size, final transmurality and final myocardial salvage index (p≤0.0001). The diagnostic performance of QW morphology, Copenhagen QW criteria and QW area criteria was over-all comparable to the modified Minnesota criteria in prediction of non-viable myocardium. Conclusion QW morphology in STEMI patients has a strong linear association with reperfusion success. The larger final infarct size, final transmurality or lower final myocardial salvage index the larger QW morphology. Hence, it is suggested that the term pathological is not used as a dichotomous condition in patients with STEMI but rather evaluated on the basis of extent. Acknowledgement/Funding Rigshospital Research Fund

Application of ECG fragmentation QRS wave in the diagnosis of acute myocardial infarction

Objective To investigate the clinical value of fragmentation of QRS wave in the diagnosis of acute myocardial infarction. Methods A total of 83 patients with acute myocardial infarction diagnosed by coronary angiography in the First People's Hospital of Jiande were selected in the research (observation group), including 41 patients with acute ST elevation myocardial infarction(observation group A), 42 patients with non-ST elevation acute myocardial infarction(observation group B). And 80 healthy subjects were selected as control group.The changes of fragmented QRS wave were compared among three groups, the efficacy of fragmented QRS wave in the diagnosis of acute myocardial infarction were observed. Results The incidence rate of fragmented QRS wave in the observation group was 71.1%, which was significantly higher than 10.0% in the control group, the difference was statistically significant(χ2=12.541, P 0.05). Conclusion The fragmentation of QRS wave in the diagnosis of acute myocardial infarction has high application value, but also can not ignore the pathological Q wave function, the index can be used to diagnose the disease combined with clinical practice, help to improve the accuracy of diagnosis. Key words: Electrocardiography; QRS wave; Myocardial infarction; Diagnosis

Prognosis and first diagnostic ECG in STEMI patients referred to the emergency medical system for primary PCI

BackgroundPathological Q waves (QWs) in the first ECG recorded at hospital admission has been found to correlate with myocardial damage and mortality in STEMI patients. We investigated the association between new QWs recorded in the pre-hospital setting and adverse outcome during the hospital stay. MethodsA pre-hospital ECG was recorded in 248 patients with STEMI who underwent primary PCI. Patients were divided into two groups based on the presence (n = 44, QWs) or absence (n = 204, non-QWs) of new QWs. ResultsPatients with new QWs had a higher prevalence of anterior infarct, cardiogenic shock and a lower LV ejection fraction. In-hospital mortality was higher in patients with new QWs. The percentage of patients with new QWs increased progressively with increasing pain to ECG time. ConclusionsNew QWs provide rapid prognostic information in the pre-hospital phase of STEMI by identifying patients at risk of adverse outcome during the hospital stay.

Association Between Early Q Waves and Reperfusion Success in Patients With ST-Segment-Elevation Myocardial Infarction Treated With Primary Percutaneous Coronary Intervention: A Cardiac Magnetic Resonance Imaging Study.

Pathological early Q waves (QW) are associated with adverse outcomes in patients with ST-segment-elevation myocardial infarction (STEMI). Primary percutaneous coronary intervention (PCI) may therefore be less beneficial in patients with QW than in patients without QW. Myocardial salvage index and microvascular obstruction (MVO) are markers for reperfusion success. Thus, to clarify the benefit from primary PCI in STEMI patients with QW, we examined the association between baseline QW and myocardial salvage index and MVO in STEMI patients treated with primary PCI. The ECG was assessed before primary PCI for the presence of QW (early) in 515 STEMI patients. The patients underwent a cardiac magnetic resonance imaging scan at day 1 (interquartile range [IQR], 1-1) and again at day 92 (IQR, 89-96). Early QW was observed in 108 (21%) patients and was related to smaller final myocardial salvage index (0.59 [IQR, 0.39-0.69] versus 0.65 [IQR, 0.46-0.84]; P<0.001) and larger MVO (1.4 [IQR, 0.0-5.4] versus 0.0 [IQR, 0.0-2.4]; P<0.001) compared with non-QW. QW remained associated with both final myocardial salvage index (β=-0.12; P=0.03) and MVO (β=0.18; P=0.001) after adjusting for potential confounders. Patients presenting with their first STEMI and early QW in the ECG had smaller myocardial salvage index and more extensive MVO than non-QW despite treatment within 12 hours after symptom onset. However, final myocardial salvage index in patients with QW was substantial, and patients with QW still benefit from primary PCI. URL: http://www.clinicaltrials.gov. Unique identifier: NCT01435408.

Preoperative diagnosis and surgical treatment of anomalous origin of the left coronary artery from the pulmonary artery

Objective To investigate the preoperative diagnosis, surgical treatment and results of anomalous origin of the left coronary artery from the pulmonary artery(ALCAPA). Methods We retrospectively analyzed the clinical data of 9 patients with ALCAPA who had undergone surgical treatment in Shanxi Children′s Hospital from June 2010 to March 2014. Results There were 3 males and 6 females, aged from 4 months to 4 years old and 6 months, average age(1.14±1.33)years, body weight from 5.6 to 18.0 kg, average weight(8.06±3.99) kg.Echocardiography and spiral CT angiography were performed in all patients, one of which underwent cardiac catheter angiography.The cases of mitral regurgitation were mild in 2 cases, mild to moderate in 5 cases, and moderate to severe in 2 cases.Electrocardiogram showed abnormal Q wave, ST segment change and T wave inversion in lead Ⅰ, AVL and V4-6 in 9 cases.The X-ray sign was significant heart enlargement(C/T ratio 0.56-0.73, mean 0.61±0.05). Echocardiography indicated ALCAPA, significant enlargement of left ventricle and decreased myocardial contractility(ejection fraction less than 50%). End diastolic diameter of left ventricle were more than 35 mm in 8 cases and aneurysm formation of left ventricular apex in 1 case.One case was confirmed ALCAPA by catheter angiography.Six cases had radioactive nuclide myocardial imaging, which showed different degree of myocardial infarction.All patients underwent reimplantation of left coronary artery into the aorta, mitral valvoplasty in 7 patients.One case died for low cardiac output syndrome.Others recovered and discharged.Postoperative complications included low cardiac output syndrome in 2 cases, pneumonia in 3 cases and supraventricular tachycardia in 1 case.During a follow-up of 3 months to 2 years, well development, good heart function, mitral valve regurgitation and ejection fraction improved in all case. Conclusion Echocardiography has important value in diagnosis of ALCAPA, which are confirmed by spiral CT angiography and catheter angiography.Preoperative nuclide examination for determinant of survival myocardium is helpful for surgery and prognosis.Reimplantation of left coronary artery into the aorta is the most ideal surgical procedure. Key words: Anomalous origin of the left coronary artery from the pulmonary artery; Preoperative diagnosis; Surgical treatment

Silent Myocardial Infarction Differs by Race and Sex

Silent myocardial infarction (SMI) is defined as pathologic Q-waves without history of typical cardiac symptoms. To learn more, researchers used data

Clinical characteristics of postoperative myocardial infarction in patients undergoing off-pump coronary artery bypass grafting

Objective To assess the clinical characteristics of postoperative myocardial infarction(PMI) in patients undergoing off-pump coronary artery bypass grafting(OPCAB). Methods Two hundred and sixty-six patients undertook OPCAB in the Shandong Provincial Chest Hospital from January 2008 to June 2015 were selected, there were 22 cases clinical diagnosis of PMI as PMI group, 44 cases patients whose general information matched MI group were selected as no PMI group.The data of two groups including preoperative records and postoperative symptoms, electrocardiogram(ECG), cTnI and echocardiography change were compared. Results There were no significant differences about preoperative indexes between the two groups(P>0.05). Incidences of severe chest pain and new pathological Q-waves and elevated ST segments were significantly higher in PMI group than those in no PMI group(90.9%(20/22) vs.18.2%(8/44), 27.3%(6/22) vs.4.5%(2/44), 95.4%(21/22) vs.27.3%(12/44)), the differences were significant(P<0.005). Peak serum levels of cTnI during the first 24 h after operation were significantly higher in patients of PMI group than those in no PMI group, the difference was significant((4.52±2.81) μg/L vs.(0.26±0.22) μg/L, P=0.04). There was no significant difference in the incidence of myocardial segmental motion. Conclusion It is difficult to predict coronary artery bypass grafting after myocardial infarction.It has great value of postoperative ECG, the patient complained in diagnosis of postoperative myocardial infarction.CTn is a very sensitive indicator, but its diagnosis clinical myocardial infarction boundary value still need to be open to question. Key words: Coronary artery bypass; Off-pump; Myocardial infarction; Troponin

Clinical characteristics and cardiac imaging features of patients with cardiac amyloidosis

To summarize the clinical characteristics and cardiac imaging features by focusing the diagnostic value of MRI in patients with cardiac amyloidosis (CA). A total of 31 cases with pathologically proven CA from January 2013 to December 2014 were included in this retrospective study. Patients expressed typical disease manifestations at a late age (54±11) years. Majority patients were male (20 cases, 64.5%) in this cohort. Blood pressure was normal, 13 cases (42.9%) presented with edema in lower limbs, 12 cases (38.7%) with chest distress and dyspnea and 9 cases (29.0%) with abdominal pain and diarrhea. Electrocardiogram (ECG) features were as follows: 20 cases (64.5%) with low voltage in limb leads, 20 cases (64.5%) with poor R-wave progression in precordial leads, 17 cases (54.8%) with pseudo-necrotic Q wave and 27 cases (87.1%) with ST-T changes. Echocardiography examination showed that 25 (80.6%) of 31 cases were with left atrial enlargement, 22 cases (71%) with increased ventricular septal thickness and 12 cases (38.7%) with myocardial ground-glass opacity, 24 cases (77.4%) presented restrictive left ventricular filling pattern, 14 cases (45.2%) showed impaired left ventricular systolic function and 10 cases (32.3%) expressed abnormal left ventricular eject function (<50%). Cardiac MRI features were as follows: among 31 patients, 7 patients underwent cardiac MRI. Left ventricular and interventricular septum hypertrophy were vsulized in 6 cases, increased thickness of interatrial spetum in 3 cases, left atrial enlargement in 4 cases and right atrial enlargement in 3 cases. MRI also revealed a distinct diffuse delayed gadolinium enhancement of subendocardial and interventricular septum in 3 cases, 1 of which was with delayed enhancement of interatrial spetum. Clinically, CA diagnosis should be considered for patients with manifestations of chest distress and edema in lower limbs, ECG features of low voltage in limb leads, poor R-wave progression and pseudo-necrotic Q wave, myocardial hypertrophy with myocardial ground-glass opacity in echocardiography and a characteristic MRI pattern of diffuse subendocardial delayed gadolinium enhancement even without the pathological proof.

Independent predictors of left ventricle aneurysm formation in acute period of q-wave myocardial infarction

З ціллю визначити незалежні предиктори формування гострої аневризми серця обстежено 235 хворих на Q-інфаркт міокарда. Встановлено, що незалежними предикторами формування аневризми лівого шлуночка є тривалість інтервалу QT, індекс сферичності, індекс локальної скорочувальної здатності, час уповільнення потоку раннього діастолічного наповнення лівого шлуночка, рівень матриксної металопротеїнази-9, інтерлейкіну-6 та протеїну С

Electrocardiographic changes of labrador dogs with age

A study of electrocardiographic changes of Labrador dogs with age was performed which showed that the P amplitude of older dogs was significantly higher than P amplitude of younger dogs. The Q wave amplitude was found to be decreasing with the advancement of age. QRS complex and R-R were significantly higher in group 2 dogs that group 1 dogs. Highest heart rate was recorded in group 1 dogs. Pulse rate of group 2 dogs was significantly higher as compared to group 1,3, and 4 dogs.

Etiology and prognosis of 183 cases with primary dilated cardiomyopathy

Objective To explore the etiology, clinical features and outcomes predictors of pediatric dilated cardiomyopathy(DCM). Methods The clinical findings and follow-up data of 183 pediatric DCM patients who were diagnosed during Jan.2008 to Dec.2012 were analyzed. Results In the 183 patients, the cause of 24 cases(13.1%)was known; but the etiology of 132 follow-up cases remain unknown, 85 were male(64.0%) and 47 were female(36.0%); 33 cases(25.0%) recovered, 62 cases(47.0%)died, and 37 cases(28.0%) remained the same.The median age of onset was 8 months(ranged from 1 day to 15 years). The onset age of the patients who had recovered was younger than the dead(P<0.001) and the unchanged patients(P=0.008). For the dead cases, the heart function on diagnosis was worse than the cured(P<0.001) and the unchanged patients(P=0.015); the left ventricular ejection fraction(LVEF) and the left ventricular fractional shortening(LVFS) detected by ultrasonic cardiogram were significantly lower than those of the cured(P=0.006, 0.009) and the unchanged (P=0.013, 0.006); the cases with mode-rate and serious mitral regurgitation(MR) were also more than the other groups(P=0.003, 0.004); The cases in the unchanged group were less than those of the cured group and the dead group whose serum concentration of cardiac troponin I was≥0.10 μg/L(P=0.002, 0.004). For the 159 cases with the unknown cause, 1-year survival rate was 67% and 5-year survival rate was 46%.By multivariable analysis, LVFS[hazard ratios(HR)0.890, 95% confidence interval (CI)0.836-0.948, P<0.001], moderate and serious MR[HR 3.580, 95%CI 2.030-6.315, P<0.001], malignant ventricular arrhythmia[HR 2.062, 95%CI 1.009-4.213, P=0.047], abnormal Q wave[HR 4.044, 95%CI 1.851-8.832, P<0.001]were associated with increased risk of death. Conclusions Twenty-five percent pediatric idiopathic DCM patients with the unknown cause recovered after proper treatment, and nearly 50.0% patients died; 1-year survival rate was 67.0% and 5-year survival rate was 46.0%.Three months after onset, the patients whose left ventricular function improved obviously had a better outcome.Risk factors for death include LVFS, moderate and serious MR, malignant ventricular arrhythmia, abnormal Q wave. Key words: Dilated cardiomyopathy; Etiology; Outcomes; Child

Anomalous origin of the left coronary artery from the pulmonary artery in infants: clinical features and the perioperative treatment strategies

To investigate the clinical features and individualized treatment strategies for infants with anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA). Data of 25 less than 1-year-old infants with ALCAPA who presented at Guangdong Cardiovascular Institute between 2006 and 2013 were retrospectively reviewed. The patients' cardiac function was evaluated with echocardiography during follow-up. Most patients presented with symptoms of heart failure, such as tachypnea, diaphoresis, poor feeding, failure to thrive etc. Electrocardiogram showed abnormal q wave in 23 patients and ST-T segment change in 16 patients.Echocardiography showed dilated left ventricle in 25 patients, endocardial hyperplasia in 5 patients, dilated right coronary artery and extensive collateralization between the right and left coronary artery systems in 11 patients. The left ventricular ejection fraction (LVEF) was (45.5±13.9)% (25%-77%). The left ventricular fractional shortening (LVFS) was (22.0±7.3)% (12%-38%). Twenty one patients underwent cardiovascular CT scan. Left coronary artery originated from left posterior sinus in 9 patients, from right posterior sinus in 1 patient, from lower main pulmonary artery in 5 patients, from the bifurcation of main pulmonary artery in 1 patient.Five patients showed ambiguous left coronary artery origination.Sixteen patients were misdiagnosed in other primary or secondary hospitals in 17 patients who were transferred to our tertiary hospital, only 1 case who underwent angiography was diagnosed correctly. Two patients were misdiagnosed in 8 patients first-presented in our hospital. Their diagnoses were corrected after reexamining with echocardiography and cardiovascular CT scan. The preoperative therapies included using inotropic agents, diuretics and vasodilators according to cardiac function. Two patients underwent left coronary artery orifice ligation. Twenty three patients underwent reimplantation of left coronary artery to reconstruct dual coronary system. Patients of NYHA IV with moderate mitral regurgitation (MR) and NYHA III with severe MR underwent mitral annuloplasty. If LVEF was less than 30% after weaning from cardiopulmonary bypass, blood pressure could not be maintained with medication, or lactates increased progressively, extracorporeal membrane oxygenation (ECMO) was demanded. Two patients showed low cardiac output syndrome immediately after surgical procedures, died from refractory ventricular fibrillation even with ECMO.In survived 23 patients during the early stage after surgeries, duration of ventilation was 7-500 hours, 11 of them were supported with ventilator for less than 60 hours. The mean length of hospital stay was (23.4±13.9) d (8-65 d). The follow-up duration ranged from 1-91 months (median 28.5 months). One case was lost to follow up. The patient died from infection 3 months after discharge. The cardiac functions of the remaining 22 patients were improved. The size of left ventricle of 14 patients recovered to normal. LVEF increased to the normal level in 20 cases. No patient underwent redo procedure. The accurate diagnosis can be made based on history, electrocardiogram, echocardiography and other imaging diagnostic tools.Individualized treatment strategy is helpful for seriously sick infants. Aggressive ECMO support can increase surviving rate for patients with postoperative low cardiac output syndrome.

The clinical analysis of hypertrophic cardiomyopathy in children

Objective To investigate the clinical characteristics, diagnosis, treatment and prognosis of hypertrophic cardiomyopathy (HCM) in children. Methods Twenty-five cases of children confirmed with HCM in Beijing Children′s Hospital from October 2000 to September 2013 were analyzed retrospectively through their clinical manifestations, laboratory tests, treatment and prognosis. Results HCM was found to be more common in older children. The average age of the patients in the studied cases was 8 years and 9 months and the male to female ratio was 3.1∶1. Their clinical manifestations were as the follows: 5 cases with shortness of breath and fatigue, 4 cases with chest tightness and long breath, 3 cases with precordial discomfort, 5 cases with cough and wheezing and found to have cardiac abnormalities, 8 cases found with asymptomatic heart murmurs with no other symptom, 2 cases with syncope episodes, 6 cases with a clear HCM family history, 3 cases with a family history of infant deaths (specific condition not clear). ECG: 18 cases showing left ventricular and/or right ventricular hypertrophy and ST-T changes, 3 cases showing abnormal Q waves, 2 cases showing ST-T changes, 2 cases with Ⅰ° atrio-ventricular block, 1 case with left bundle branch block, and 1 case with left anterior division block. Cardiac enzymes were elevated in 5 cases. Chest X-rays showed enlarged heart shadow in 17 cases. Echocardiography revealed non-obstructive hypertrophic cardiomyopathy in 23 cases and obstructive hypertrophic cardiomyopathy in 2 cases. Left ventricular systolic function was decreased in 2 cases, and diastolic dysfunction in 3 cases. Twenty-one patients took oral metoprolol, 1 patient took verapamil, 1 patient took propranolol and 2 patients took no medication. The follow-up period of 2 months to 13 years witnessed 2 cases of death and 23 cases of survival. Conclusion HCM in children lacks specific clinical manifestations and the conditions of the patient are usually severe with progressive development. HCM is one of the main reasons of sudden death in adolescent, with poor prognosis. Key words: Hypertrophic cardiomyopathy; Children

Correlation between electrocardiogram, myocardial biomarkers and left ventricular dysfunction in acute anterior ST segment elevation myocardial infarction

To analyze the correlation between ST segment elevation, Q wave and peak biomarkers with left ventricular dysfunction in patients with acute anterior ST elevation myocardial infarction (STEMI). A total of 138 consecutive inpatients with acute anterior STEMI, left anterior descending branch as the convict vessel, from January 2009 to January 2012 in our hospital were enrolled in this study. They were divided into reperfusion (n = 92) and non-reperfusion group(n = 46). Clinical data, electrocardiogram, peak biomarkers, type B natriuretic peptide (BNP) were collected by physicians and the patients were followed up three months. The sum of the ST segments elevation, Q waves and Q wave leads in anterior STEMI were positive correlation with the Killip grades, myocardium biomarkers, BNP and left ventricle end diastolic diameters (LVEDD) [γ, 0.52-0.75, P < 0.01], while negative correlation with left ventricle ejection fraction (LVEF) [γ, -0.63--0.95, P < 0.01]. The sum of R wave altitude was negative correlation with myocardium biomarkers, BNP and LVEDD in three months after the onset of STEMI [γ, -0.48--0.79, P < 0.01], while positive correlation with LVEF [γ, 0.73-0.82, P < 0.01]. BNP, one of the best markers of left heart dysfunction, was found to be strongly negative correlation with LVEF in acute stage and three months after the onset of STEMI [γ , -0.92, -0.80, P < 0.01]. There are close correlations between electrocardiogram, myocardial biomarkers and left ventricular dysfunction in acute anterior ST segment elevation myocardial infarction, which may be strong predictors for the short-term prognosis.

Clinical features and prognostic factors in children with dilated cardiomyopathy

Objective To discuss the clinical features and prognostic factors in the children with dilated cardiomyopathy(DCM). Methods The clinical data of 45 cases of DCM, including 27 boys and 18 girls, from May 2007 to Nov. 2011 in Wuhan Children's Hospital were analyzed by retrospective medical record survey methods. The average age of onset was(19.20±18.98) months. Eight cases (17.8%) were of cardiac function gradeⅠ-Ⅱ, and 37 cases (82.2%) were of cardiac function grade Ⅲ-Ⅳ. The patients whose left ventricular ejection fraction (LVEF) and left ventricular fractional shortening (LVFS) increased by 10%-15% compared with those before treatment were defined as improved group, and the patient's LVEF and LVFS levels declined persistently or those of dead cases were defined as worsened group. There were 34 cases assigned as the improved group, 8 cases as the worsened group, and 5 out of 8 cases were dead. The age, occurrence of abnormal Q waves, cardiac function, LVEF and LVFS in the 2 groups were analyzed. Results The cardiac troponin, creatine kinase, creatine kinase isoenzyme in the cardiac function grade Ⅲ-Ⅳ group were significantly higher than those in the cardiac function gradeⅠ-Ⅱ group (all P<0.01). There were 11 patients who had abnormal Q waves by electrocardiogram when they were diagnosed. The LVEF and LVFS levels in the cardiac function gradeⅠ-Ⅱ group were significantly higher than those in the cardiac function grade Ⅲ-Ⅳ group (all P<0.05). There were statistically significant differences in age on diagnosed, proportion of newly diagnosed cases age ≤1 year old, occurrence of abnormal Q waves, cardiac function in grade Ⅲ-Ⅳ, LVEF and LVFS levels between the improved group and the worsened group (all P<0.05). Conclusions Most of the children with DCM were diagnosed more when they were ≤ 1 year old, mostly with cardiac function grade Ⅲ-Ⅳ. The occurrence of abnormal Q waves, cardiac function grade, LVEF and LVFS levels could be used as important prognostic indicators for DCM. Key words: Dilated cardiomyopathy; Abnormal Q waves; Cardiac function; Left ventricular ejection fraction; Left ventricular shortening fraction