A rare case of Takayasu Arteritis in young woman with heart failure - A case report

Takayasu arteritis (TA) is a rare, systemic, granulomatous primary vasculitis of medium and large arteries. The name comes from Dr. Mikito Takayasu, who reported the problem in 1905 for the first time. It is also called as Pulseless Disease or Aortic Arch Syndrome and usually seen before 40 years with female and male ratio being 10:1. Takayasu arteritis is a major cause of high blood pressure levels in teenagers and young adults. Around 75 percent of the people having Takayasu get diagnosed usually at an average age of 29 years though they begin to show the symptoms at their teenage years because the early symptoms of Takayasu are nonspecific and common. Heart failure as the first presentation of the TA is rare but has been reported. Angiographic studies help in the diagnosis of Takayasu and patients usually respond to steroid therapy. We report a 16 years old female presented with history of upper limb claudication, dyspnea, orthopnea, non palpable pulse in bilateral upper limbs with non recordable BP, lower limb with high blood pressure recordings and bilateral carotid Bruit present. Imaging studies revealed circumferential wall thickening of arch of aorta, bilateral carotids, left sub clavian, left axillary. 2D echo revealed global hypokinesia with severe left ventricular dysfunction. Takayasu arteritis with heart failure diagnosis was made and administration of steroids, diuretics and ACE inhibitor improved the condition.

Como eu faço o strain longitudinal do ventrículo direito com softwares automatizados 2D e 3D / My approach to right ventricular longitudinal strain with automated 2D and 3D software

A análise da deformação miocárdica ventricular direita tem surgido como uma ferramenta diagnóstica importante na detecção de disfunção sistólica ventricular direita inicial não detectada pelas técnicas ecocardiográficas convencionais. Além disso, é capaz de trazer informações diagnósticas e prognósticas adicionais aos parâmetros tradicionais de avaliação da função sistólica ventricular direita em diversas patologias. O método ecocardiográfico de escolha para sua avaliação é o strain longitudinal derivado do speckletracking. Ele tem se mostrado mais sensível para pequenas mudanças na função sistólica quando comparado à excursão sistólica do plano do anel tricúspide, estudo da onda s´ ao Doppler tecidual do anel tricúspide e variação da área fracional do ventrículo direito. O avanço da inteligência artificial e a presença de softwares com análise automatizada entram neste cenário visando tornar a aplicabilidade do método mais simples, rápida e com menor variabilidade inter e intraobservador. O objetivo deste artigo de revisão é demonstrar o passo a passo da técnica, desde a otimização e aquisição de imagens até a interpretação dos resultados, com figuras ilustrativas de casos selecionados.(AU)

Right ventricular strain analysis has emerged as an important diagnostic tool in the detection of early right ventricular systolic dysfunction not detected by conventional echocardiography techniques. Furthermore, it is capable of providing additional diagnostic and prognostic information to the traditional parameters for evaluating right ventricular systolic function in various pathologies. The echocardiography method of choice for its assessment is longitudinal strain derived from speckletracking. This method has been shown to be more sensitive for small changes in systolic function when compared to tricuspid annular plane systolic excursion, tissue Doppler imaging of the tricuspid annular s' wave, and right ventricular fractional area change. Advances in artificial intelligence and software with automated analysis have been introduced to this scenario with the aim of making the method simpler and quicker to apply, with lower inter- and intra-observer variability. The objective of this review article is to demonstrate the technique step by step, from image optimization and acquisition to interpretation of results, with illustrative figures of selected cases.(AU)

The Effectiveness of Coronary Artery Bypass Grafting in Patients with Left Ventricular Dysfunction

ABSTRACT Introduction: Coronary artery bypass grafting (CABG) in patients with left ventricular dysfunction (LVD) remains a surgical challenge and is still controversial. The aim of this study was to evaluate the effectiveness of CABG in patients with LVD. Methods: This retrospective study included a total of 160 consecutive patients (133 males, 27 females, mean age 62.1±10.12 years [range 37 to 86 years]) who had a left ventricular ejection fraction (LVEF) ≤ 45% determined by echocardiography and underwent elective isolated CABG between September 2013 and December 2018. Preoperative echocardiographic data, such as ejection fraction, left ventricular (LV) end-systolic diameter, and LV end-diastolic diameter, were collected and evaluated. Preoperatively, 85 (53.13%) patients were in New York Heart Association functional class III or IV and the mean LVEF was 38.65±5.72% (range 20 to 45). Results: The overall hospital mortality was 5% (eight patients). Late follow-up was obtained in 152 (90%) cases (median follow-up time was 56,5 [3-87] months postoperatively). During follow-up, mortality developed in 11.3% (16 patients). Mean LVEF increased significantly from 38.78±5.59% before surgery to 43.29±8.46% after surgery (P<0.01). Mean late survival, freedom from coronary reintervention, and congestive heart failure rates were 86.3±3.3%, 88.7±3.9%, and 89.4±3.1%, respectively. Conclusion: In patients with LVD, CABG can be performed with low postoperative morbidity and mortality rates. Patients with LVD could benefit from coronary bypass surgery regarding postoperative LV systolic function and higher quality of life.

Analysis of the risk factors for extracorporeal membrane oxygenation use after surgical repair in patients with anomalous origin of the left coronary artery from the pulmonary artery combined with severe left ventricular dysfunction / 中国胸心血管外科临床杂志

@#Objective    To analyze the early outcomes of anomalous origin of the left coronary artery from the pulmonary artery (ALCAPA) patients with severe left ventricular dysfunction after surgical repair, and to explore the predictors for extracorporeal membrane oxygenation (ECMO) support for these patients. Methods    The clinical data of ALCAPA patients with severe left ventricular dysfunction (left ventricular ejection fraction<40%) who underwent coronary artery reimplantation in the pediatric center of our hospital from 2013 to 2020 were retrospectively analyzed. The patients were divided into an ECMO group and a non-ECMO group. Clinical data of the two groups were compared and analyzed. Results    A total of 64 ALCAPA patients were included. There were 7 patients in the ECMO group, including 4 males and 3 females aged 6.58±1.84 months. There were 57 pateints in the non-ECMO group, including 30 males and 27 females aged 4.34±2.56 months. The mortality of the patients was 6.25% (4/64), including 2 patients in the ECMO group, and 2 in the non-ECMO group. The postoperative complications rate was significantly higher in the ECMO group than that in the non-ECMO group (P=0.041). There were statistical differences in the cardiopulmonary bypass time [254 (153, 417) min vs. 106 (51, 192) min, P=0.013], aortic cross-clamping (ACC) time (89.57±13.66 min vs. 61.58± 19.57 min, P=0.039), and preoperative left ventricular end-diastolic diameter/body surface area (132.32±14.71 mm/m2 vs. 108.00±29.64 mm/m2, P=0.040) between the two groups. Multivariate logistic regression analysis showed that ACC time was an independent risk factor for postoperative ECMO support (P=0.005). Receiver operating characteristic (ROC) curve analysis showed that the area under the ROC curve was 0.757, the sensitivity was 85.70%, specificity was 66.70%, with the cut-off value of 66 min. Conclusion    ACC time is an independent risk factor for postoperative ECMO support. Patients with an ACC time>66 min have a significantly higher risk for ECMO support after the surgery.

Influência do Exercício Físico sobre a Mecânica de Contração do Ventrículo Esquerdo após Infarto do Miocárdio / Influence of Physical Training after a Myocardial Infarction on Left Ventricular Contraction Mechanics

Resumo Fundamento O exercício exerce um papel positivo na evolução da doença cardíaca isquêmica, melhorando a capacidade funcional e prevenindo o remodelamento ventricular. Objetivo Investigar o impacto do exercício sobre a mecânica de contração do ventrículo esquerdo (VE) após um infarto agudo do miocárdio (IAM) não complicado. Métodos Um total de 53 pacientes foram incluídos e alocados aleatoriamente em um programa de treinamento supervisionado (grupo TREINO, n=27) ou em um grupo CONTROLE (n=26) que recebeu recomendações usuais sobre a prática de exercício físico após um IAM. Todos os pacientes realizaram um teste cardiopulmonar e um ecocardiograma com speckle tracking para medir vários parâmetros da mecânica de contração do VE em um mês e cinco meses após o IAM. Um valor de p <0,05 foi considerado para significância estatística nas comparações das variáveis. Resultados Não foram encontradas diferenças nas análises dos parâmetros de strain circunferencial, radial ou longitudinal do VE entre os grupos após o período de treinamento. Após o programa, a análise da mecânica de torção revelou uma redução na rotação basal do VE no grupo TREINO em comparação ao grupo CONTROLE (5,9±2,3 vs. 7,5±2.9o; p=0,03), bem como na velocidade rotacional basal (53,6±18,4 vs. 68,8± 22,1 º/s; p=0,01), velocidade de twist (127,4±32,2 vs. 149,9±35,9 º/s; p=0,02) e na torção (2,4±0,4 vs. 2,8±0, º/cm; p=0,02). Conclusões A atividade física não causou melhora significativa nos parâmetros de deformação longitudinal, radial ou circunferencial do VE. No entanto, o exercício teve um impacto significativo sobre a mecânica de torção do VE, que consistiu em uma redução na rotação basal, na velocidade de twist, na torção, e na velocidade de torção, que pode ser interpretada como uma "reserva" de torção ventricular nessa população.

Abstract Background Exercise plays a positive role in the course of the ischemic heart disease, enhancing functional capacity and preventing ventricular remodeling. Objective To investigate the impact of exercise on left ventricular (LV) contraction mechanics after an uncomplicated acute myocardial infarction (AMI). Methods A total of 53 patients was included, 27 of whom were randomized to a supervised training program (TRAINING group), and 26 to a CONTROL group, who received usual recommendations on physical exercise after AMI. All patients underwent cardiopulmonary stress testing and a speckle tracking echocardiography to measure several parameters of LV contraction mechanics at one month and five months after AMI. A p value < 0.05 was considered statistically significant for the comparisons of the variables. Results No significant difference were found in the analysis of LV longitudinal, radial and circumferential strain parameters between groups after the training period. After the training program, analysis of torsional mechanics demonstrated a reduction in the LV basal rotation in the TRAINING group in comparison to the CONTROL group (5.9±2.3 vs. 7.5±2.9o; p=0.03), and in the basal rotational velocity (53.6±18.4 vs.68.8±22.1 º/s; p=0.01), twist velocity (127.4±32.2 vs. 149.9±35.9 º/s; p=0.02) and torsion (2.4±0.4 vs. 2.8±0.8 º/cm; p=0.02). Conclusions Physical activity did not cause a significant improvement in LV longitudinal, radial and circumferential deformation parameters. However, the exercise had a significant impact on the LV torsional mechanics, consisting of a reduction in basal rotation, twist velocity, torsion and torsional velocity which can be interpreted as a ventricular "torsion reserve" in this population.

Predictors of Left Ventricular Dysfunction after Percutaneous Primary Coronary Intervention in Acute Anterior Myocardial Infarction

Background: Primary percutaneous coronary intervention (PCI) has revolutionized the outcome and management of acute myocardial infarction. However, the occurrence of left ventricular dysfunction remains relatively common event following acute myocardial infarction and in associated with an adverse prognosis in these patients. this work aimed to investigate to the left ventricular dysfunction predictors following PCI for anterior myocardial infarction (AMI) using different parameters: Tissue Doppler imaging (TDI), Biomarkers (Troponin, CK-MB) and Echocardiography Methods: This research was conducted prospectively on 50 patients aged from 40 to 70 years old, presenting by first anterior myocardial infarction and treated with PCI. All cases were subjected to full history, full clinical examination, laboratory investigations, resting 12 leads electrocardiography, two dimensions echocardiography and tissue doppler imaging. Results: Highly statistically significant between EF baseline with EF on discharge and EF on discharge with after 3 months p-value was <0.001. Pre balloon dilatation, S wave of tissue Doppler imaging on discharge and S wave tissue Doppler imaging after 3 months were predictors for left ventricular systolic function. Conclusions: Persistent LV dysfunction following successful primary PCI is infrequent and is related to poor clinical outcomes at 3 months clinical follow-up. Tissue Doppler on discharge and after three months after myocardial infarction are independent predictors of LV dysfunction after anterior STEMI and can be used to predict occurrence of LV remodelling after 6 months.

Outcome analysis in patients with multi vessel coronary artery disease and left ventricular ejection fraction after percutaneous coronary intervention: single center experience

Background: The present study evaluated the changes in baseline left ventricular function and clinical symptoms in multi-vessel coronary artery disease patients after multi-vessel percutaneous coronary intervention.Methods: This was a prospective, observational study conducted at Medical Super-speciality Hospital, Kolkata, India, between August 2017 and August 2019. The study included 48 patients who were diagnosed with ≥2 coronary artery stenosis of ≥50% in native coronary arteries with left ventricular ejection fraction (LVEF) <40%. Echocardiography was performed before and after 3 months of the procedure to observe LVEF. Canadian Cardiovascular Society (CCS) score was calculated before and after 3 months after PCI.Results: Mean age of the patients was 61.89±9.96 years and 89.6% patients were male. Mean LVEF before and after angioplasty was 34.9±4.95% and 42.06±8.78%, respectively (p=0.001). CCS score before and after angioplasty was 2.89 and 1.83, respectively (p=0.001).Conclusions: The results displayed significant improvement in clinical symptoms as well as LVEF after PCI in patients with multi-vessel disease with LVEF <40%. These results will be helpful to conduct larger randomized trials with long term follow-up in order to prove the safety and effectiveness of PCI in such patients over coronary artery bypass grafting.

Experiencia con sacubitril/valsartán en una clínica de falla cardiaca / Experience with sacubitril/valsartan in a heart failure clinic

Resumen Objetivo: describir las características y el comportamiento clínico de pacientes tratados con sacubitril/valsartán en una clínica de falla cardiaca de un hospital de alta complejidad. Métodos: se analizaron en retrospectiva 56 pacientes en manejo con sacubitril/valsartán, entre enero de 2017 y mayo de 2018. A los tres meses de inicio del tratamiento, 87% de los pacientes fueron evaluados. Se determinaron cambios en clase funcional, fracción de eyección ventricular izquierda (FEVI) y presión arterial sistólica y diastólica. Se registraron reingresos hospitalarios por falla cardiaca, mortalidad cardiovascular y eventos adversos asociados a la medicación. Resultados: la edad promedio fue 71,3 años; 51,7% correspondían al sexo masculino, 73% tenía etiología isquémica, 35% clase funcional NYHA II y 60% NYHA III antes de iniciar el tratamiento con sacubitril/valsartán. Al finalizar el seguimiento, 57% mejoró su clase funcional y 81,7% se encontraba en clase funcional NYHA II (IC95%, -0,52 a-0,18; p=0,0002). Hubo mejoría significativa en los valores de FEVI respecto a los basales (IC95%, 4,27 a 11,86; p=0,0002). Se observó una disminución significativa de la presión arterial tanto sistólica como diastólica (p<0,01). Un paciente presentó muerte súbita (2%) y uno hospitalización por falla cardiaca (2%). Ningún paciente descontinuó la terapia por efectos adversos. Conclusión: sacubitril/valsartán es una terapia útil en pacientes con falla cardiaca sintomática y FEVI reducida. La población evaluada tenía un perfil demográfico y clínico semejante al del ensayo clínico PARADIGM-HF, lo cual sugiere que los desenlaces clínicos son similares en la población colombiana.

Abstract Objective: The aim of this study is to describe the characteristics and clinical behaviour of patients treated with sacubitril/valsartan in a heart failure clinic of a high complexity hospital. Methods: A retrospective analysis was performed on a total of 56 patients on treatment with sacubitril/valsartan, between January 2017 and May 2018. At three months from the start of the treatment, 87% of the patients were evaluated. Changes were observed in functional class, left ventricular ejection fraction (LVEF), and systolic and diastolic arterial pressure. A record was made of hospital re-admissions due to heart failure, cardiovascular mortality, and adverse events associated with the medication. Results: The mean age of the patients was 71.3 years, of which 51.7% were male. An ischaemic origin was found in 73%. NYHA II and NYHA III functional class was observed 35% and 60%, respectively, before starting the treatment with sacubitril/valsartan. At the end of follow-up, 57% improved their functional class, and 81.7% were found to be in NYHA II functional class (95% CI; -0.52 to -0.18:=0.0002). There was a significant improvement in the LVEF values compared to baseline (95% CI; 4.27 to 11.86; P=0.0002). A significant decrease was observed in both systolic and diastolic blood pressure (P<0.01). There was sudden death in one (2%) patient and one (2%) patient admitted due to heart failure. None of the patients stopped the therapy due to secondary effects. Conclusion: Sacubitril/valsartan is a useful therapy in patients with symptomatic heart failure and a decreased LVEF. The population evaluated had a demographic and similar clinical signs and symptoms to the PARADIGM-HF clinical trial, which suggests that the clinical outcomes are similar in the Colombian population.

Clinical results of Mini Maze procedure in atrial fibrillation patients with impaired left ventricular systolic function / 中国胸心血管外科临床杂志

@#Objective    To study the clinical results of Mini Maze procedure in atrial fibrillation patients with impaired left ventricular systolic function. Methods    From June 2010 to December 2017, 86 atrial fibrillation patients with impaired left ventricular systolic function received Mini Maze procedure including 54 males and 32 females, with an average age of 60.7±5.9 years. Among them, 12 were with paroxysmal, 27 were with persistent and 47 were with long-standing persistent atrial fibrillation. The mean atrial fibrillation duration was 6.5±4.8 years. CHA2DS2-VASc score was 2.2±1.1. The mean diameter of left atrium was 46.9±3.8 mm. The mean diameter of left ventricle was 51.7±4.6 mm. The preoperative ejection fraction was 42.2%±4.7%. All patients received Mini Maze procedure after general anesthesia. The ablation included 3 annular ablations and 3 linear ablations. The left atrial appendage was excised by Endo-Gia. Ablation of Marshall ligament and epicardial autonomic ganglions were made by an ablation pen. Results    Eighty-six patients successfully completed the procedure without transition to thoracotomy. There was no death during the perioperative period. Seventy-seven patients (89.5%) maintained sinus rhythm at discharge. Eighty patients were followed up for 27.2±12.1 months and 72 patients maintained sinus rhythm. The overall postoperative left ventricular ejection fraction was 47.1%±6.2%. The ejection fraction of the postoperative sinus rhythm group was 48.2%±5.8%, and the ejection fraction of the non-sinus group was 41.6%±5.8% (P<0.05). Multivariate regression analysis showed a left atrial diameter (HR=1.485, 95%CI 1.157-1.906, P<0.05) and an increase in ejection fraction over 10% (HR=18.800, 95%CI 1.674-189.289, P<0.05) were closely related to postoperative recurrence. Kaplan-Meier curve analysis showed that the recurrence rate of atrial fibrillation was significantly lower in patients with an increase in postoperative ejection fraction over 10% (P<0.05). Conclusion    Mini Maze procedure is safe and effective in the treatment of atrial fibrillation patients with left ventricular systolic dysfunction, which helps to improve left ventricular function to prevent the vicious circle of atrial fibrillation and heart failure.

Cardiopulmonary Exercise Testing in Patients with Implantable Cardioverter-Defibrillator: A Retrospective Study

Cardiopulmonary exercise testing is widely used in the evaluation of patients with left ventricular dysfunction, and some of these patients have an implantable cardioverter-defibrillator (ICD). However, this test presents specific challenges because of the susceptibility to ventricular arrhythmias during maximal levels of exercise. Objective: To evaluate the safety of cardiopulmonary exercise testing in patients with ICD. Methods: The study included patients with ICD who underwent cardiopulmonary exercise testing between 2007 and 2015. The tests were completed once the electronic devices were programmed. The maximum allowed heart rate reached during exercise was 10 beats below the first therapy zone programmed. Results: The study included 69 patients with mean age 53.7 ± 10.8 years, including 68% men. Exercise time was 8.7±2.3 minutes, with peak oxygen consumption of 13.3 ± 4.3 ml.kg-1.min-1. Peak heart rate was 62.9 ± 13.4% of the maximum rate predicted, with all patients taking specific medication. Ventricular arrhythmia was observed in 29% of the patients, and paired ventricular extrasystoles, ventricular bigeminism or non-sustained ventricular tachycardia were observed in only 14.5% of the patients. There was no sustained ventricular arrhythmia resulting in ICD therapy or other complications, such as inappropriate therapies. The frequency of severe events was 0%, 95% CI (0 - 5.2%). Conclusion: In the sample of patients evaluated, the cardiopulmonary exercise testing was shown to be safe during its performance in a hospital setting, following the safety standards

Correlation of troponin-I level with left ventricular systolic dysfunction after first attack of non-ST segment elevation myocardial infarction

Background: Coronary Heart Disease (CHD) is the most common category of the heart disease and is found to be the single most important cause that leads to premature death in the developed world. Recognizing a patient with ACS is important because the diagnosis triggers both triage and management. cTnI is 100% tissue-specific for the myocardium and it has shown itself as a very sensitive and specific marker for AMI. Ventricular function is the best predictor of death after an ACS. It serves as a marker of myocardial damage and provides information on systolic function as well as diagnosis and prognosis. The study aimed at investigating the impact of LVEF on elevated troponin-I level in patients with first attack of NSTEMI.Methods: This cross-sectional analytical study was conducted in the department of cardiology in Mymensingh Medical College Hospital from December, 2015 to November, 2016. Total 130 first attack of NSTEMI patients were included considering inclusion and exclusion criteria. The sample population was divided into two groups: Group-I: Patients with first attack of NSTEMI with LVEF: ≥55%. Group-II: Patients with first attack of NSTEMI with LVEF: <55%. Then LVEF and troponin-I levels were correlated using Pearson’s correlation coefficient test.Results: In this study mean troponin-I of group-I and group-II were 5.53±7.43 and 16.46±15.79ng/ml respectively. It was statistically significant (p<0.05). The mean LVEF value of groups were 65.31±10.30% and 40.17±4.62% respectively. It was statistically significant (p<0.05). The echocardiography showed that patients with high troponin-I level had low LVEF and patients with low troponin-I level had preserved LVEF. Analysis showed that patients with highest level of troponin-I had severe left ventricular systolic dysfunction (LVEF <35%) and vice versa-the patients with the lowest levels of troponin-I had preserved systolic function (LVEF ≥55%). In our study, it also showed that the levels of troponin-I had negative correlation with LVEF levels with medium strength of association (r= -0.5394, p=0.001). Our study also discovered that Troponin-I level ≥6.6ng/ml is a very sensitive and specific marker for LV systolic dysfunction.Conclusions: The study has enabled the research team to conclude that the higher is the Troponin-I level the lower is the LVEF level and thus more severe is the LV systolic dysfunction in first attack of NSTEMI patients.

Hypoplastic internal carotid artery, renal artery stenosis, vertebral fusion anomaly: rare association-a case report

Hypoplastic internal carotid artery has been reported in about 100 patients, most being incidentally diagnosed. Association with other anomalies rarely described. Authors report 6-year-old male presenting failure to gain weight and precordial bulge from past 6 months, past history was significant-diagnosed to have right dysplastic kidney at 8 months age. Detailed investigations revealed left hypoplastic internal carotid artery, vertebral segment anamoly, right dysplastic kidney due to right renal artery stenosis. Child was treated medically and was clinically better at latest follow up. All cases with dysplastic kidney need to be searched for vertebral and carotid anomalies, left ventricular dysfunction.

Levosimendan confers perioperative renoprotection in severe patients undergoing cardiac surgery: A systematic review and meta-analysis / 中国胸心血管外科临床杂志

@#Objective    To evaluate the effect of levosimendan on acute kidney injury (AKI) in patients with left ventricular dysfunction (preoperative left ventricular ejection fraction≤40.0%) undergoing cardiac surgery. Methods    A systematic review and meta-analysis was conducted based on a comprehensive search of the randomized controlled trial (RCT) from PubMed, EMbase and The Cochrane Library (up to Jan 2018). The clinical endpoints included the incidence of AKI and need for renal replacement therapy (RRT), mortality, mechanic ventilation (MV) duration and intensive care unit (ICU) stay. Random-effect model was used for the potential clinical inconsistency. All analyses were performed by RevMan 5.3 and Stata 12.0. Results    Thirteen trials with a total of 2 046 patients were selected. Compared with controls, levosimendan significantly reduced the incidence of postoperative AKI (OR=0.44, P=0.000 1, I2=0%), the risk of RRT (OR=0.63, P=0.02, I2=0%) and the mortality (OR=0.49, P<0.000 1, I2=0%). Levosimendan also shortened the postoperative MV duration (WMD=–5.62, P=0.07, I2=93%) and ICU stay (WMD=–1.50, P=0.005, I2=98%). Conclusion    The present meta-analysis suggests that perioperative levosimendan for patients with left ventricular ejection fraction≤40.0%undergoing cardiac surgery reduces the incidence of AKI, RRT and death, as well as shortens MV duration and ICU stay.

Left ventricular dysfunction among chronic kidney disease patients: a cross sectional study

Background: There is a significant worldwide burden of CKD; which is likely to increase further. Cardiovascular diseases constitute major cause of morbidity and mortality in CKD. LV dysfunction may be present despite the asymptomatic phase during the early stages of CKD. Thus, early detection of LV dysfunction and targeted interventions can improve prognosis in CKD.Methods: This cross-sectional study was conducted among 250 CKD admitted patients. Echocardiographic examination was done to determine the systolic and diastolic function of LV. For LV systolic function ejection fraction and % fractional shortening were calculated and for LV diastolic function E/A, E/E’, E deceleration time and IVRT were measured.Results: Among 250 study subjects, 112 (47.8%) had systolic dysfunction and 138 (55.2%) had diastolic dysfunction. The prevalence of systolic as well as diastolic dysfunction increased significantly (P<0.05) with deteriorating renal function (39.1% for CKD stage 1 and 67.8% for stage 5 for systolic dysfunction, 34.8% for CKD stage 1 and 77.8% for stage 5 for diastolic dysfunction).Conclusions: LV systolic and diastolic dysfunctions are significantly prevalent among CKD patients which increase with increasing severity of CKD. Hence, it is important to routinely screen these patients for LV dysfunction. The use of echocardiography can detect LV dysfunction at an early stage among the high-risk population of CKD to help plan appropriate strategies to slow the progression of cardiac dysfunction and improve prognosis.

Prediction of reciprocal ST segment changes in determining the extent of coronary artery disease in ST segment elevation myocardial infarction: An angiographic correlation

Background: In patient with history suggestive of myocardial infarction, ST segment elevation in ECG is supportive of MI. Mechanism of reciprocal changes is still a debate. The reason for ST segment depression has been extensively investigated, with conflicting results. Possible hypothesis for the mechanism of reciprocal changes are concomitant stenosis of other vessels or merely a benign electrical activity. Objectives: To identify reciprocal ST Segment depression in ST segment elevation acute myocardial infarction and predict the extent of coronary artery disease by correlating with coronary angiography, to assess left ventricular dysfunction in patient with and without reciprocal ST Segment changes. Materials and methods: The study was conducted over 18 months among 80 patients who were admitted to FMMCH with STEMI. They were analyzed in two groups with 40 patients with anterior wall MI and 40 patients with Inferior wall MI with reciprocal changes and those without reciprocal changes. Results: Among the 80 patients, 57% belonged to age 45-65 years, with male was to female ratio was 4:1. Reciprocal changes seen in multi vessel disease were statistically significant (p value 0.000). Sayyid Mohammed Khilar, Nima, Neha Khilar. Prediction of reciprocal ST segment changes in determining the extent of coronary artery disease in ST segment elevation myocardial infarction: An angiographic correlation. IAIM, 2018; 5(7): 45- 49. Page 46 Cases with reciprocal changes 42.5% had severe LV dysfunction (p value 0.03) which was statistically significant. Reciprocal changes seen in multi vessel disease were statistically significant (p value 0.0). Conclusion: This study showed statistical significant positive correlation between reciprocal ST segment changes, multi vessel coronary artery disease and severity of left ventricular dysfunction. Emphasizing the need for urgent evaluation and treatment patients with reciprocal ST segment changes among the patient with ST elevation myocardial infarction.

Improving Asymptomatic Left Ventricular Diastolic Dysfunction in Postmenopausal Hypertensive Women with Metabolic Syndrome: A Prospective, Open-Labeled, Randomized Controlled Trial / 中华医学杂志(英文版)

<p><b>Background</b>Postmenopausal women with metabolic syndrome (MetS) have increased cardiovascular morbidity and left ventricular diastolic dysfunction (LVDD). The various protective effects of astragalus membranaceus (AM) have been described in previous studies. Therefore, this study aimed to evaluate the effects of different doses of AM on diastolic function in postmenopausal hypertensive women with MetS.</p><p><b>Methods</b>This was a prospective, randomized controlled study. The postmenopausal hypertensive patients with MetS were enrolled from Lanzhou University Second Hospital from March 2014 to April 2015. Patients were divided into three groups: control group (received conventional medical treatment), AM Group 1 (received AM capsules at 5 g/d additionally), and AM Group 2 (received AM capsules at 10 g/d additionally). Echocardiographic and clinical characteristics were evaluated before and 12 months after treatment. Quantitative data were analyzed using unpaired t-test, analysis of variance, and multiple linear regression analysis.</p><p><b>Results</b>A total of 154 patients were subjected to final analysis. In the AM Group 2, significant improvements were noted in diastolic function 12 months after treatment than those of the control group, including the early diastolic mitral annular velocity (E'; 0.065 ± 0.007 m/s vs. 0.061 ± 0.008 m/s, P = 0.014), the ratio of the early diastolic mitral peak flow velocity to the late diastolic mitral peak flow velocity (E/A; 0.81 ± 0.05 vs. 0.80 ± 0.06, P = 0.012), the ratio of E' to the late diastolic mitral annular velocity (E'/A'; 0.56 ± 0.12 vs. 0.51 ± 0.13, P = 0.048), and the ratio of the early diastolic mitral peak flow velocity (E) to E' (E/E'; 10.70 ± 1.30 vs. 11.37 ± 1.73, P = 0.031). After treatment, E/E' (10.70 ± 1.30 vs. 11.24 ± 1.56, P = 0.021), deceleration time (DT; 261.49 ± 44.41 ms vs. 268.74 ± 53.87 ms, P = 0.046), and E'/A' (0.56 ± 0.12 vs. 0.52 ± 0.13, P = 0.019) values improved more significantly than those of AM Group 2 before treatment. Besides, waist circumference was positively correlated with E' (r = 0.472; P = 0.003) and E'/A' (r = 0.321; P = 0.047). In addition, the waist-to-hip ratio was a significant predictor of DT (r = 0.276; P = 0.041), E' (r = -0.590; P < 0.001), E/E' (r = 0.454; P = 0.004), and E'/A' (r = -0.377; P = 0.018).</p><p><b>Conclusions</b>Conventional medical plus AM therapy improved diastolic function. Moreover, WC and WHR might be risk factors for LVDD.</p><p><b>Chinese Clinical Trial Register</b>ChiCTR-TRC-11001747. http://www.chictr.org.cn/showprojen.aspx?proj=7798.</p>

Bone Marrow Mononuclear Cells Transfer for Patients after ST-Elevated Myocardial Infarction: A Meta-Analysis of Randomized Control Trials

PURPOSE: Results on the clinical utility of cell therapy for ST-elevated myocardial infarction (STEMI) are controversial. This study sought to analyze the efficacy of treatment with intracoronary bone marrow mononuclear cells (BMMC) on left ventricular (LV) function and remodeling and LV diastolic and systolic function in patients with STEMI. MATERIALS AND METHODS: Literature search of PubMed and EMBASE databases between 2004 and 2017 was performed for randomized controlled trials in STEMI patients who underwent successful percutaneous coronary intervention and received intracoronary BMMC therapy. The defined end points were left ventricular ejection fraction (LVEF), left ventricular end-diastolic volume (LVEDV), and left ventricular end-systolic volume (LVESV). Also, sensitivity analysis and several subgroup analyses based on follow-up duration, timing of injection, doses of cells, and imaging modalities were conducted to strengthen the statistic power of the study. RESULTS: A total of 22 trials with 1360 patients were available for the current meta-analysis. The pooled statistics showed a significant improvement in LVEF {2.58 [95% confidence interval (CI), 1.32, 3.84]; p < 0.001}, LVEDV [−3.73, (95% CI, −6.94, −0.52), p=0.02], and LVESV [−4.67, (95% CI, −7.07, −2.28), p < 0.001] in the BMMC group, compared with the control group. However, in sensitivity analysis, a significant reduction in LVEDV disappeared, while the outcomes of LVEF and LVESV remained unchanged. The same results were presented in the subgroup analysis adjusting for imaging modalities and timing of cells injection. CONCLUSION: BMMC transplantation in patients with STEMI was found to lead to improvement in LVEF, LVEDV, and LVESV parameters, indicating that cell therapy has a potential beneficial effect on LV remodeling and function.

Graft Replacement with Partial Extra-corporeal Circulation of Descending Thoracic and Abdominal Aortic Aneurysms in Marfan Syndrome Combined with Severe Left Ventricular Dysfunction and Mitral Regurgitation / 日本心臓血管外科学会雑誌

We report on a rare case of Marfan syndrome with giant dissecting descending thoracic and abdominal aortic aneurysms associated with poor left ventricular function and severe mitral regurgitation. Before the anesthetic induction, a partial extra-corporeal circulation was established to prevent a collapse of the circulation. Descending aortic graft replacement and following abdominal aortic graft replacement were performed safely using the partial extra-corporeal circulation to relief the afterload for the severely deteriorated left ventricle with severe mitral regurgitation. Intra-aortic balloon pumping was also promptly used to assist the poor circulation in the postoperative period. Despite the admission to a specialized institute, he died from irreversible heart failure with a developing renal failure. Even for a difficult patient with Marfan syndrome with severe left ventricular dysfunction and mitral regurgitation, graft replacement was feasible with meticulous perioperative circulatory management using partial extra-corporeal circulation and intra-aortic balloon pumping. However, a prompt registration for heart transplantation and an aortic surgery concomitant with implantation of left ventricular assisted device should have been considered to save the patient.

Improving Asymptomatic Left Ventricular Diastolic Dysfunction in Postmenopausal Hypertensive Women with Metabolic Syndrome: A Prospective, Open-Labeled, Randomized Controlled Trial / 中华医学杂志(英文版)

<p><b>Background</b>Postmenopausal women with metabolic syndrome (MetS) have increased cardiovascular morbidity and left ventricular diastolic dysfunction (LVDD). The various protective effects of astragalus membranaceus (AM) have been described in previous studies. Therefore, this study aimed to evaluate the effects of different doses of AM on diastolic function in postmenopausal hypertensive women with MetS.</p><p><b>Methods</b>This was a prospective, randomized controlled study. The postmenopausal hypertensive patients with MetS were enrolled from Lanzhou University Second Hospital from March 2014 to April 2015. Patients were divided into three groups: control group (received conventional medical treatment), AM Group 1 (received AM capsules at 5 g/d additionally), and AM Group 2 (received AM capsules at 10 g/d additionally). Echocardiographic and clinical characteristics were evaluated before and 12 months after treatment. Quantitative data were analyzed using unpaired t-test, analysis of variance, and multiple linear regression analysis.</p><p><b>Results</b>A total of 154 patients were subjected to final analysis. In the AM Group 2, significant improvements were noted in diastolic function 12 months after treatment than those of the control group, including the early diastolic mitral annular velocity (E'; 0.065 ± 0.007 m/s vs. 0.061 ± 0.008 m/s, P = 0.014), the ratio of the early diastolic mitral peak flow velocity to the late diastolic mitral peak flow velocity (E/A; 0.81 ± 0.05 vs. 0.80 ± 0.06, P = 0.012), the ratio of E' to the late diastolic mitral annular velocity (E'/A'; 0.56 ± 0.12 vs. 0.51 ± 0.13, P = 0.048), and the ratio of the early diastolic mitral peak flow velocity (E) to E' (E/E'; 10.70 ± 1.30 vs. 11.37 ± 1.73, P = 0.031). After treatment, E/E' (10.70 ± 1.30 vs. 11.24 ± 1.56, P = 0.021), deceleration time (DT; 261.49 ± 44.41 ms vs. 268.74 ± 53.87 ms, P = 0.046), and E'/A' (0.56 ± 0.12 vs. 0.52 ± 0.13, P = 0.019) values improved more significantly than those of AM Group 2 before treatment. Besides, waist circumference was positively correlated with E' (r = 0.472; P = 0.003) and E'/A' (r = 0.321; P = 0.047). In addition, the waist-to-hip ratio was a significant predictor of DT (r = 0.276; P = 0.041), E' (r = -0.590; P < 0.001), E/E' (r = 0.454; P = 0.004), and E'/A' (r = -0.377; P = 0.018).</p><p><b>Conclusions</b>Conventional medical plus AM therapy improved diastolic function. Moreover, WC and WHR might be risk factors for LVDD.</p><p><b>Chinese Clinical Trial Register</b>ChiCTR-TRC-11001747. http://www.chictr.org.cn/showprojen.aspx?proj=7798.</p>