Miokardo gyvybingumas – svarbus požymis numatant chirurginį išeminio širdies nepakankamumo gydymą

Elvyra Voluckienė1, Loreta Ivaškevičienė2, Virginija Grabauskienė3, Jurgita Židanavičiūtė4, Giedrius Uždavinys2 1 Vilniaus universiteto ligoninės Santariškių klinikų Širdies chirurgijos centras, Santariškių g. 2, LT-08661 Vilnius 2 Vilniaus universiteto Širdies chirurgijos centras, Santariškių g. 2, LT-08661 Vilnius 3 Vilniaus universiteto Kardiologijos ir angiologijos centras 4 Vilniaus Gedimino technikos universitetas El paštas: [email protected] Tikslas Nustatyti priešoperacinės kairiojo skilvelio (KS) funkcijos prognostinę reikšmę pacientams, sergantiems sunkiu išeminiu širdies nepakankamumu (IŠN), po chirurginės kairiojo skilvelio rekonstrukcijos (KSR) ir aortos bei vainikinių jungčių (AVJ) suformavimo operacijos. Ligoniai ir metodai Retrospektyvinei analizei tikslingai atrinkti 37 pacientai (32 vyrai, vidutinis amžius 59 ± 10,5 m.), sergantys IŠN ir KS išvarymo frakcija (IF) < 30%, kuriems buvo atlikta KSR ir AVJ suformavimo operacija. Po persirgto Q bangos priekinio miokardo infarkto buvo praėję vidutiniškai 5,8 ± 3,3 mėnesio. Vidutinė NYHA klasė buvo 3,4 ± 1,3. KS funkcijos rodikliai buvo apskaičiuoti dobutamino echokardiografijos tyrimo ramybės (r) ir mažos dobutamino dozės (mdd) metu: diastolinio skersmens indeksas – DDI cm/m² (r), IF (%) (r), sienos judėjimo indeksas – SJIr ir SJImdd, asinergijos plotas (Aproc.) (mdd). Hospitalinis mirštamumas buvo 13,5%; mirštamumas per vienus metus buvo 6,25%. Vidutinė NYHA klasė po vienų metų buvo 2,2 ± 1,1. Rezultatai Logistinės regresijos analizė ir „Proportional Odds“ modelis parodė, kad priešoperacinis KS Aproc. (mdd) buvo statistiškai reikšmingas prognostinis pooperacinės vienų metų NYHA klasės požymis (OR 0,86, p = 0,0086). Išvada Priešoperacinis kairiojo skilvelio asinergijos dydis, nustatytas dobutamino echokardiografijos tyrimo metu, yra svarbus požymis, numatant pooperacinę vienų metų NYHA klasę pacientams, sergantiems sunkiu išeminiu širdies nepakankamumu po chirurginės kairiojo skilvelio rekonstrukcijos ir aortos bei vainikinių jungčių suformavimo operacijos. Pagrindiniai žodžiai: išeminis širdies nepakankamumas, kairiojo skilvelio rekonstrukcija Myocardial viability predicts improvement in patients after surgical treatment of ischemic heart failure Elvyra Voluckienė1, Loreta Ivaškevičienė2, Virginija Grabauskienė3, Jurgita Židanavičiūtė4, Giedrius Uždavinys2 1 Vilnius University Hospital Santariškių Clinics, Cardial Surgery Centre, Santariškių str. 2, LT-08661 Vilnius, Lithuania 2 Vilnius University, Cardiac Surgery Centre, Santariškių str. 2, LT-08661 Vilnius, Lithuania 3 Vilnius University, Centre of Cardiology and Angiology 4 Vilnius Gediminas Technical University E-mail: [email protected] Objective This study sought to define the prognostic value of myocardial viability in patients with severe ischemic heart failure, who underwent surgical ventricular reconstruction with associated coronary grafting. Patients and methods This retrospective study selected 37 consecutive patients (32 men, mean age 59 ± 10.5 years) who underwent surgical ventricular reconstruction with associated coronary grafting, and preoperative left ventricular (LV) ejection fraction < 30% (mean, 25 ± 4.6%). The mean New York Heart Association (NYHA) class before operation was 3.4 ± 1.3. The time-frame of the large anterior myocardial infarction was 5.8 ± 3.3 months. LV systolic function was assessed by echo-dobutamine: the wall motion score index at rest (WMSIr), WMSI and the extent of LV asynergy (A%) during low-dose dobutamine (ldd). In-hospital mortality was 13.5%. After one-year, the mean functional NYHA class was 2.2 ± 1.1, and at one-year the mortality was 6.25%. Results Logistic regression analysis and the Proportional Odds model showed that LV A% during ldd (OR 0.86, p = 0.0086) was an independent predictor for the one-year postoperative functional NYHA class. Conclusions The preoperative extent of left ventricular asynergy during echo-dobutamine can predict the expectation of functional NYHA class improvement in patients with a severe ischemic heart failure one-year following surgical ventricular reconstruction with associated coronary grafting. Key words: ischemic heart failure, surgical ventricular reconstructio

Prevalence and prognostic relevance of myocardial inflammation and cardiotropic viruses in non-ischemic dilated cardiomyopathy

Background: Non-ischemic dilated cardiomyopathy (DCM) is a heterogeneous disease with a spectrum of etiological factors. However, subsets of the disease are not well-characterized with respect to these factors. The aim of this study was to evaluate the prevalence of myocardial inflammation and cardiotropic viruses in DCM patients and their impact on clinical outcome. Methods: Fifty-seven patients with DCM underwent endomyocardial biopsy between 2010 and 2013. Biopsies were analyzed by polymerase chain reaction (PCR) for the presence of cardiotropic viruses, and inflammatory cell infiltration was assessed by immunohistochemistry. During a 5-year follow-up, 27 (47%) patients reached the primary composite outcome measure: heart transplantation, left ventricle assist device implantation or cardiovascular-related death. Results: rvovirus B19 and human herpesvirus type-6. Four specific sub-groups were distinguished by PCR and immunohistochemistry: virus-positive (chronic) myocarditis, autoreactive inflammatory DCM, viral DCM, non-inflammatory DCM. The presence of a viral genome in myocardium or diagnosis of inflammatory DCM did not predict the outcome of composite outcome measures (p &gt; 0.05). However, univariate Cox regression and survival function estimation revealed an association between inflammation by a high number of T-cells and poor prognosis. Conclusions: This study has shown that two markers — cardiotropic viruses and myocardial inflammation — are prevalent among DCM patients. They are also helpful in identifying sub-groups of DCM. An increased number of T-lymphocytes in the myocardium is a predictor of poor mid-term and long‐term prognosis

Uždegiminė diliatacinė kardiomiopatija: naUji diagnostikos ir gydymo būdai inflammatory dilated cardiomyopathy: new perspective in diagnostics and treatment

1 Vilniaus universiteto Medicinos fakulteto Patologijos, teismo medicinos ir farmakologijos katedra 2 Vilniaus universiteto Medicinos fakulteto Širdies ir kraujagyslių ligų klinika santraUka Reikšminiai žodžiai: uždegiminė diliatacinė kardiomiopatija, širdies nepakankamumas, etiologija, gydymas. Neišeminės kilmės, uždegiminė diliatacinė kardiomiopatija (uDKMP) yra viena svarbiausių širdies nepakankamumo ir šir-dies transplantacijų priežasčių. Širdies raumuo gali būti organas -taikinys virusinei, bakterinei, pirmuonių ar parazitinei infekcijai, tačiau taip pat gali nukentėti ir netiesiogiai, dėl infekcinių organizmų ir kryžminio antikūnų poveikio. Kliniškai miokarditas ir uždegiminė kardiomiopatija gali pasireikšti daugybe simptomų -nuo asimptominės eigos iki miokardo infarkto ar net sunkaus kardiogeninio šoko. Tokie pacientai gali spontaniškai pasveikti, tačiau dažniausiai jiems pamažu progresuoja širdies nepakankamumas ir tenka transplantuoti širdį. Pastarojo meto diliatacinės kardiomiopatijos etiologijos tyrimai parodė, kad pagrindinės šios ligos priežastys yra virusinė infekcija, genetiniai sutrikimai ir autoimuniniai mechanizmai. Nors buvo pasiekta didelė pažanga gydant širdies nepakankamumą kaip kardiomiopatijos pasekmę, vis dar nemažėja pacientų su gydymui atspariu širdies nepakankamumu, o jų būklė negerėja nepaisant viso prieinamo gydymo. Siekdami pademonstruoti šiuolaikines uDKMP diagnostines ir etiopatogenetinio gydymo galimybes, pateikiame du klinikinius atvejus ir trumpą literatūros apžvalgą. abstract Key words: Myocarditis; Inflammatory cardiomyopathy; Heart Failure; Endomyocardial Biopsy, Virus genome; Aetiologydirected treatment. Non-ischemic, inflammatory dilated cardiomyopathy (iCMP) is an important cause of heart failure and heart transplantation. The heart can be the primary target of a viral, bacterial, protozoic or parasitic infection or it could be involved in the &quot;collateral damage&quot; of infective organisms and cross-reactive antibodies. Clinical manifestation of myocarditis or inflammatory cardiomyopathy varies, with a broad spectrum of symptoms ranging from asymptomatic courses over presentations with signs of myocardial infarction to devastating illness with cardiogenic shock. The affected patients may recover or develop dilated cardiomyopathy with heart failure and the need for heart transplantation. The recent progress in study on etiology of dilative cardiomyopathy has shown that viral infection, genetic abnormalities and autoimmune mechanisms are major causes of this disease. Although significant progress has been achieved in the treatment of heart failure as a result of cardiomyopathy, it is a still matter of fact that there are many patients with refractory heart failure who do not respond despite every available treatment. Presently, feasible clinical pathways are available, which can lead to a correct diagnosis and specific treatment. Two cases are presented to illustrate the possibilities of the diagnosis of distinct iCMP subentities and aetiology-directed treatment strategies. Dainius Daunoravičiu

Delayed diagnosis of an isolated partial anomalous pulmonary venous connection

In this case report we describe the delayed diagnosis of a very rare congenital anomaly — isolated partial anomalous pulmonary venous connection. This congenital anomaly should be suspected at any age in the clinical setting of right heart volume overload, especially in the absence of a large atrial septal defect. Tomographic imaging modalities (computed tomography or cardiovascular magnetic resonance) not only allow the comprehensive structural and functional assessment of this anomaly, but also help assess the patient’s suitability for surgical treatment. Surgery is the definitive treatment of a patient with a significant left-to-right shunt due to partial anomalous pulmonary venous connection

The role of cardiac T-cadherin in the indicating heart failure severity of patients with non-ischemic dilated cardiomyopathy

Background and objectives: T-cadherin (T-cad) is one of the adiponectin receptors abundantly expressed in the heart and blood vessels. Experimental studies show that T-cad sequesters adiponectin in cardiovascular tissues and is critical for adiponectin-mediated cardio-protection. However, there are no data connecting cardiac T-cad levels with human chronic heart failure (HF). The aim of this study was to assess whether myocardial T-cad concentration is associated with chronic HF severity and whether the T-cad levels in human heart tissue might predict outcomes in patients with non-ischemic dilated cardiomyopathy (NI-DCM). Materials and Methods: 29 patients with chronic NI-DCM and advanced HF were enrolled. Patients underwent regular laboratory investigations, echocardiography, coronary angiography, and right heart catheterization. TNF- and IL6 in serum were detected by enzyme-linked immunosorbent assay (ELISA). Additionally, endomyocardial biopsies were obtained, and the levels of T-cad were assessed by ELISA and CD3, CD45Ro, CD68, and CD4- immunohistochemically. Mean pulmonary capillary wedge pressure (PCWP) was used as a marker of HF severity, subdividing patients into two groups: mean PCWP > 19 mmHg vs. mean PCWP 19 mmHg compared to those with mean PCWP 19 mmHg (p = 0.058). Cardiac T-cad levels correlate negatively with myocardial CD3 cell count (rho = 0.423, p = 0.028). Conclusions: Univariate Cox regression analysis did not prove T-cad to be an outcome predictor (HR = 1, p = 0.349). However, decreased T-cad levels in human myocardium can be an additional indicator of HF severity. T-cad in human myocardium has an anti-inflammatory role. More studies are needed to extend the role of T-cad in the outcome prediction of patients with NI-DCM

Left ventricular global longitudinal strain predicts elevated cardiac pressures and poor clinical outcomes in patients with non-ischemic dilated cardiomyopathy

BACKGROUND: Risk stratification in patients with non-ischemic dilated cardiomyopathy (NI-DCM) is essential to treatment planning. Global longitudinal strain (GLS) predicts poor prognosis in various cardiac diseases, but it has not been evaluated in a cohort of exclusively NI-DCM. Although deformation parameters have been shown to reflect diastolic function, their association with other hemodynamic parameters needs further elucidation. We aimed to evaluate the association between GLS and E/GLS and invasive hemodynamic parameters and assess the prognostic value of GLS and E/GLS in a prospective well-defined pure NI-DCM cohort. METHODS AND RESULTS: Forty-one patients with NI-DCM were enrolled in the study. They underwent a standard diagnostic workup, including transthoracic echocardiography and right heart catheterization. During a five-year follow-up, 20 (49%) patients reached the composite outcome measure: LV assist device implantation, heart transplantation, or cardiovascular death. Pulmonary capillary wedge pressure (PCWP), mean pulmonary artery pressure, pulmonary vascular resistance (PVR) correlated with GLS and E/GLS (p  3 Wood units). Survival analysis showed GLS and E/GLS to be associated with short- and long-term adverse cardiac events (p < 0.05). GLS values above thresholds of -5.34% and -5.96% indicated 18- and 12-fold higher risk of poor clinical outcomes at one and five years, respectively. Multivariate Cox regression analysis revealed that GLS is an independent long-term outcome predictor. CONCLUSION: GLS and E/GLS correlate with invasive hemodynamics parameters and identify patients with elevated PCWP and high PVR. GLS and E/GLS predict short- and long-term adverse cardiac events in patients with NI-DCM. Worsening GLS is associated with incremental risk of long-term adverse cardiac events and might be used to identify high-risk patients

Inflammation-Related Biomarkers Are Associated with Heart Failure Severity and Poor Clinical Outcomes in Patients with Non-Ischemic Dilated Cardiomyopathy

Inflammation-related biomarkers are associated with clinical outcomes in mixed-etiology chronic heart failure populations. Inflammation-related markers tend to be higher in ischemic than in non-ischemic dilated cardiomyopathy (NI-DCM) patients, which might impact their prognostic performance in NI-DCM patients. Therefore, we aimed to assess the association of inflammation-related biomarkers with heart failure severity parameters and adverse cardiac events in a pure NI-DCM patient cohort. Fifty-seven patients with NI-DCM underwent endomyocardial biopsy. Biopsies were evaluated by immunohistochemistry for CD3+, CD45ro+, CD68+, CD4+, CD54+, and HLA-DR+ cells. Blood samples were tested for high-sensitivity C-reactive protein (hs-CRP), interleukin-6, tumor necrosis factor-α (TNF-α), soluble urokinase-type plasminogen activator receptor and adiponectin. During a five-year follow-up, twenty-seven patients experienced at least one composite adverse cardiac event: left ventricle assist device implantation, heart transplantation or death. Interleukin-6, TNF-α and adiponectin correlated with heart failure severity parameters. Patients with higher levels of interleukin-6, TNF-α, adiponectin or hs-CRP, or a higher number of CD3+ or CD45ro+ cells, had lower survival rates. Interleukin-6, adiponectin, and CD45ro+ cells were independently associated with poor clinical outcomes. All patients who had interleukin-6, TNF-α and adiponectin concentrations above the threshold experienced an adverse cardiac event. Therefore, a combination of these cytokines can identify high-risk NI-DCM patients