摘要:

Background—In some patients with heart failure, &bgr;-blockers can improve left ventricular (LV) function and reduce morbidity and mortality. We hypothesized that gadolinium-enhanced cardiovascular magnetic resonance imaging (CMR) can predict reversible myocardial dysfunction and remodeling in heart failure patients treated with &bgr;-blockers.Methods and Results—Forty-five patients with chronic heart failure underwent CMR. Contrast imaging using gadolinium was performed to obtain high-resolution spatial maps of myocardial scarring and viability. Cine imaging was performed to assess LV function and morphology and was repeated in 35 patients after 6 months of &bgr;-blockade. Gadolinium CMR demonstrated scarring in 30 of 45 patients (67%). Scarring was found in 100% of patients with ischemic cardiomyopathy (28 of 28) but in only 12% with nonischemic cardiomyopathy (2 of 17). In the 35 patients who were maintained on &bgr;-blockers and had a second study, there was an inverse relation between the extent of scarring at baseline and the likelihood of contractile improvement 6 months later (P<0.001). For instance, contractility improved in 56% (674 of 1207) of regions with no scarring but in only 3% with >75% scarring (8 of 232). Multivariate analysis showed that the amount of dysfunctional but viable myocardium by CMR was an independent predictor of the change in ejection fraction (P=0.01), mean wall motion score (P=0.0007), LV end-diastolic volume index (P=0.007), and LV end-systolic volume index (P≤0.0001).Conclusions—For heart failure patients treated with &bgr;-blockers, gadolinium-enhanced CMR predicts the response in LV function and remodeling.

ISSN:0009-7322    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

Background—Survivors of aborted sudden death attributable to ventricular arrhythmias in the presence of coronary artery disease are at risk for recurrences. The substrate underlying these arrhythmias is not clear, and therefore the relation between ischemia, viability, scar tissue (and revascularization), and the incidence of ventricular arrhythmias (and survival) was studied over up to 3 years.Methods and Results—One hundred fifty-three survivors of sudden death underwent stress-rest perfusion imaging. Patients with ischemic/viable myocardium (n=73) were revascularized if possible. Final antiarrhythmic therapy was based on the outcome of electrophysiological testing or left ventricular ejection fraction (LVEF). Implantation of a defibrillator was performed in 112 (72%) patients. During 3-year follow-up, 15 cardiac deaths occurred and 42 (29%) patients had recurrent ventricular arrhythmias. Patients with events (death or recurrence) exhibited more often a severely depressed LVEF (≤30%), more extensive scar tissue, and less ischemic/viable myocardium on perfusion imaging and less frequently underwent revascularization. Multivariate analysis identified extensive scar tissue and LVEF ≤30% as the only predictors of death/recurrent ventricular arrhythmias.Conclusions—In patients with aborted sudden death, extensive scar tissue and severely depressed LVEF are the only predictors of death or recurrent ventricular arrhythmias. These patients should be considered for implantation of a defibrillator.

ISSN:0009-7322    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

Background—Idiopathic left bundle-branch block (LBBB)–like ventricular tachycardia (VT) is considered to originate in the right ventricular outflow tract (RVOT) or from the aortic root. Both regions are derived from the embryonic outflow tract. We now report that also the pulmonary trunk can give rise to VT, suggesting a common etiology of these tachycardias.Methods and Results—We studied 6 patients with symptomatic idiopathic LBBB-VT using electrophysiological mapping techniques. The VT origin was determined by analyzing the electrograms and the angiographic location of the catheter tip at the successful ablation site or the earliest activation site. Eight VTs were induced. Two VTs, with a mean earliest endocardial activation time of −5 and −20 ms and optimal pace mapping, were successfully ablated in the RVOT. In the remaining 6 VTs, the earliest activation site was found in the pulmonary artery, and, at this site, a sharp potential was present −38±12 ms before the QRS in 5 VTs. The mean earliest endocardial activation time in the RVOT was −1±2 ms. Ablation was attempted in 5 of 6 VTs and resulted in an acutely successful procedure. After a mean follow-up of 10±4 months, 1 of 5 patients had a recurrence.Conclusions—The site of origin of idiopathic LBBB-VT can be in the root of the pulmonary artery, suggesting a myocardial connection from this site to the RVOT. If no good criteria for ablation in the RVOT are found, detailed mapping of the pulmonary artery should be performed.

ISSN:0009-7322    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

Background—The objective of this study was to describe the electrophysiological characteristics, anatomic distribution, and long-term outcome after focal ablation (RFA) of pulmonary vein (PV) atrial tachycardia (AT). Both atrial fibrillation (AF) and AT may be due to a rapidly firing focus in the PVs. Whether these represent two aspects of the same process is unknown.Methods and Results—Twenty-seven patients with 28 PV(16%) ATs of a consecutive series of 172 undergoing RFA for focal AT are reported. The mean age was 39±16 years, with symptoms for 9±14 years resistant to 1.7±0.8 medications. AT occurred spontaneously or with isoproterenol in all patients and was not inducible with PES in any. The distribution of PV ATs was right superior PV, 11; left superior PV, 11; left inferior PV, 5; and right inferior PV, 1; 26of 28 foci (93%) were ostial. RFA was successful in 28 of 28 PV ATs acutely. RFA was focal in 25 of 28, with PV isolation of a single target vein in 3. There were 4 recurrences at a mean of 3.3 months. Repeat RFA was performed in all 4 and successful in 3 of 4. All but one recurrence occurred from the same site. Long-term success was achieved in 26 of 27 (96%) patients at mean follow-up of 25±22 months. No patients have had subsequent development of AF or AT from a different site.Conclusions—PV AT has a distribution similar to PV AF, with a propensity to upper veins. However, the majority of foci are ostial, and only a small percentage occur from deep in the PV. Focal RFA is associated with high long-term success, with freedom from both AT from other sites and from AF. PV AT is a localized process and therefore may be different from PV AF.

ISSN:0009-7322    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

Background—Atrial mechanical “stunning” develops after cardioversion of atrial fibrillation (AF) and is implicated in the genesis of thromboembolic complications. However, the mechanisms responsible for this phenomenon are poorly understood. Whether atrial mechanical dysfunction caused by AF can be reversed by pacing at increased rates or by pharmacological agents is unknown.Methods and Results—Twenty-six patients with AF undergoing cardioversion were dichotomized prospectively on the basis of the duration of arrhythmia as short-duration (1 to 6 months) or long-duration (≥3 years) AF. Left atrial appendage emptying velocities (LAAEVs) and spontaneous echocardiographic contrast (LASEC) were assessed by transesophageal echocardiography during AF, after reversion to sinus rhythm, during atrial pacing at cycle lengths of 750 to 250 ms, after a postpacing pause, and with isoproterenol. In patients with short-duration AF, LAAEV decreased (42.0±2.7 to 18.5±2.0 cm/s;P<0.0001) and LASEC increased (0.9±0.3 to 2.2±0.3;P<0.01) with termination of AF; pacing increased LAAEV (48.3±4.1 cm/s;P<0.0001) and decreased LASEC (1.5±0.3;P<0.01); isoproterenol increased LAAEV (73.3±7.8 cm/s;P<0.0001) and decreased LASEC (0.3±0.2;P<0.01); and the postpacing pause increased LAAEV (68.3±3.8 cm/s;P<0.0001). In contrast, patients with long-duration AF demonstrated a significantly attenuated response of atrial mechanical function at each time point. With termination of AF, LAAEV decreased (19.1±2.6 to 8.2±1.0 cm/s;P=0.003) and LASEC increased (2.0±0.2 to 3.3±0.2;P<0.01); pacing increased LAAEV (18.4±2.7 cm/s;P<0.0001) and decreased LASEC (2.3±0.2;P<0.01); isoproterenol increased LAAEV (26.1±3.9 cm/s;P=NS to equivalent atrial rate) and decreased LASEC (1.0±0.3;P<0.01); and the postpacing pause increased LAAEV (27.2±2.4 cm/s;P=0.007).Conclusions—Atrial pacing at increased rates and isoproterenol can reverse atrial mechanical stunning associated with short-duration AF. In contrast, long-duration AF is associated with an attenuated response to these maneuvers. These findings suggest a functional contractile apparatus in the mechanically remodeled atrium caused by AF; however, with longer durations of AF, additional factors may determine atrial mechanical function.

ISSN:0009-7322    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

Background—Heart rate-corrected QT interval (QTc) is the traditional method of assessing the duration of repolarization. Prolonged heart rate-corrected QT interval is associated with higher risk of mortality in patients with coronary heart disease (CHD) and in the general population. However, the QTc is typically not evaluated when QRS duration is ≥120 ms, because increased QRS duration (QRSd) contributes to QT interval prolongation. In these circumstances, the JT interval has been proposed as a more valid way to assess ventricular repolarization.Methods and Results—To allow for variation in heart rate, corrected JT interval (JTc) was defined as QTc−QRSd. Using data from the Atherosclerosis Risk in Communities Study, JTc and QTc were compared for their prognostic associations with incident CHD events among 14 696 men and women who were CHD-free at baseline, having either normal conduction or wide QRS complex. Among individuals with normal QRS duration, logistic regression adjusted for age, hypertensive status, diabetes, race, systolic blood pressure, smoking, HDL and LDL cholesterol, R-R interval, and menopausal status in women showed QTc and JTc were nonpredictive of future coronary events in men but significant in women. In individuals with wide QRS complex (QRSd ≥120 ms), similar analyses showed JTc had a significant prognostic advantage compared with QTc in men but not in women, among whom only 11 events occurred.Conclusions—The JTc is a simple measurement that is a significant independent predictor of incident CHD events in men with wide QRS complex.

ISSN:0009-7322    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

Background—The edge-to-edge technique is an accepted method for the surgical repair of a regurgitant mitral valve. This study reports the initial use of an endovascular technology that enables a double-orifice edge-to-edge mitral valve repair without cardiopulmonary bypass in an animal model.Methods and Results—Adult pigs (n=14) were anesthetized, and left thoracotomy was performed for epicardial echo imaging. Using femoral vein access, a steerable guide catheter was placed transseptally into the left atrium. An implantable clip designed to grasp and approximate the middle scallops of the anterior and posterior mitral leaflets was introduced through the guide catheter. The clip was opened in the left atrium, advanced through the mitral orifice, and retracted to grasp the leaflet edges. When a functional double-orifice valve was confirmed by echo, the clip was closed to coapt the leaflets and detached from the delivery catheter. Before final clip detachment, echo demonstrated a double orifice in all 14 animals. In 2 studies, the clip released from the anterior mitral leaflet. Retrospective analysis of echo images indicated an incomplete grasp of the anterior leaflet. Immediate postmortem examination revealed that the clip successfully approximated the middle scallops of the anterior and posterior leaflets in all 12 double-orifice studies.Conclusions—This study demonstrates for the first time that an endovascular system can be successfully used to perform the edge-to-edge repair technique in a nondiseased porcine model. This technique is potentially applicable as a percutaneous catheterization laboratory procedure for the treatment of mitral regurgitation in humans.

ISSN:0009-7322    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

Background—Hyperglycemia (HG) and hyperinsulinemia (HI) may be factors enhancing the atherosclerotic complications of diabetes. We hypothesized that specific feeding of C57BL/6 apolipoprotein (apo) E−/−mice would alter their metabolic profiles and result in different degrees of neointima (NI) formation. We additionally hypothesized that an insulin-sensitizing agent (rosiglitazone) would prevent the development of type 2 diabetes and reduce neointima formation after carotid wire injury measured at 28 days.Methods and Results—Fasting glucose and insulin levels were elevated in the Western diet (WD) group, with a trend toward higher insulin levels and euglycemia in the fructose diet (FD)–fed mice. NI formation was exaggerated in the WD group compared with the FD or chow control groups. In the WD mice given rosiglitazone, glucose and insulin levels remained normal and NI formation was significantly reduced, as was NI macrophage content.Conclusions—These findings demonstrate that apoE−/−mice fed a WD develop type 2 diabetes with an exaggerated NI response to injury. FD mice maintain euglycemia but develop insulin resistance, with an intermediate degree of NI growth compared with chow diet controls. Rosiglitazone prevents the development of hyperglycemia and hyperinsulinemia and normalizes the insulin release profile in the apoE−/−, WD-fed mouse and significantly reduces NI formation by 65% after carotid wire injury while reducing macrophage infiltration. These data support the hypothesis that type 2 diabetes in the setting of elevated cholesterol accelerates the response to vascular injury and suggest that agents that improve insulin sensitivity may have therapeutic value in reducing restenosis in type 2 diabetes.

ISSN:0009-7322    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

Background—Although abnormal l-arginine NO signaling contributes to endothelial dysfunction in the aging cardiovascular system, the biochemical mechanisms remain controversial. l-arginine, the NO synthase (NOS) precursor, is also a substrate for arginase. We tested the hypotheses that arginase reciprocally regulates NOS by modulating l-arginine bioavailability and that arginase is upregulated in aging vasculature, contributing to depressed endothelial function.Methods and Results—Inhibition of arginase with (S)-(2-boronoethyl)-l-cysteine, HCl (BEC) produced vasodilation in aortic rings from young (Y) adult rats (maximum effect, 46.4±9.4% at 10−5mol/L,P<0.01). Similar vasorelaxation was elicited with the additional arginase inhibitorsN-hydroxy-nor-l-arginine (nor-NOHA) and difluoromethylornithine (DFMO). This effect required intact endothelium and was prevented by 1H-oxadiazole quinoxalin-1-one (P<0.05 andP<0.001, respectively), a soluble guanylyl cyclase inhibitor. DFMO-elicited vasodilation was greater in old (O) compared with Y rat aortic rings (60±6% versus 39±6%,P<0.05). In addition, BEC restored depressed l-arginine (10−4mol/L)–dependent vasorelaxant responses in O rings to those of Y. Arginase activity and expression were increased in O rings, whereas NOS activity and cyclic GMP levels were decreased. BEC and DFMO suppressed arginase activity and restored NOS activity and cyclic GMP levels in O vessels to those of Y.Conclusions—These findings demonstrate that arginase modulates NOS activity, likely by regulating intracellular l-arginine availability. Arginase upregulation contributes to endothelial dysfunction of aging and may therefore be a therapeutic target.

ISSN:0009-7322    

出版商:OVID    

年代:2003

数据来源: OVID

摘要:

Background—This study was conducted to determine the effects of chronic pulmonary insufficiency (PI) on right (RV) and left (LV) ventricular function in young growing swine.Methods and Results—Six PI and 5 control animals were studied. PI was induced by transcatheter placement of stents across the pulmonary valve. Indices of systolic function (ejection fraction, cardiac output, and cardiac functional reserve), diastolic function (compliance), and myocardial contractility (the slope of the relationship of end-systolic pressure versus end-systolic volume [Emax] and the slope of the dP/dtmax–end-diastolic volume relationship [MdP/dt]) were assessed within 2 days of intervention and 3 months later. MRI was used to quantify PI and ventricular volumes. Conductance catheter techniques were used to obtain indices of contractility and diastolic compliance from pressure-volume relations at rest and under dobutamine infusion. In the PI group, pulmonary regurgitant fraction was 49.2±5.9% at 3-month follow-up. RV cardiac functional reserve was limited, diastolic function was preserved, and myocardial contractility was altered (Emax=2.6±0.3 mm Hg/mL for the PI group versus 3.5±0.4 mm Hg/mL for control;P<0.01). LV cardiac functional reserve was limited, ventricular compliance decreased, and myocardial contractility was preserved.Conclusions—In the young developing heart, chronic PI alters biventricular systolic function, RV myocardial contractility, and LV diastolic performance.

ISSN:0009-7322    

出版商:OVID    

年代:2003

数据来源: OVID