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1.  Effect of prostaglandin E1 inhalation on pulmonary hypertension following corrective surgery for congenital heart disease 
BACKGROUND:
Intravenous infusion of prostaglandin E1 (PGE1) has been used to treat pulmonary arterial hypertension (PAH); however, the efficacy and safety of inhaled PGE1 is unclear.
OBJECTIVES:
To investigate the effect of inhaled PGE1 on PAH following corrective surgery for congenital heart disease.
METHODS:
Sixty patients with postoperative residual PAH following corrective surgery for congenital heart disease were randomly assigned to a control group, a PGE1 infusion group (intravenous PGE1 infusion; 30 ng/kg/min daily for 10 days) or a PGE1 inhalation group (100 μg nebulized PGE1 every 8 h for 10 days). Systolic blood pressure, mean pulmonary arterial pressure, arterial oxygen pressure, oxygen saturation and serum endothelin-1 level were measured before and after the treatment.
RESULTS:
At the end of the study, the mean pulmonary arterial pressure in the two PGE1 groups were lower than in the control group (P<0.01), whereas the mean arterial oxygen pressure was higher (P<0.01). Compared with the PGE1 infusion group, the mean pulmonary arterial pressure in the PGE1 inhalation group was lower (P<0.01) whereas the arterial oxygen pressure was higher (P<0.01). The mean endothelin-1 levels in the two PGE1 groups were lower than in the control group (P<0.01), but there was no statistically significant difference in endothelin-1 levels between the PGE1 inhalation and infusion groups (P>0.05).
CONCLUSIONS:
In pediatric patients with PAH, PGE1 inhalation was associated with a reduction in pulmonary arterial pressure and improvement in arterial blood oxygen levels.
PMCID: PMC3716482  PMID: 24294030
Congenital heart disease; Postoperative; Prostaglandin E1; Pulmonary hypertension
2.  Mitral valve repair versus replacement in simultaneous aortic and mitral valve surgery 
BACKGROUND:
Double valve replacement for concomitant aortic and mitral valve disease is associated with substantial morbidity and mortality. Excellent results with valve repair in isolated mitral valve lesions have been reported; therefore, whether its potential benefits would translate into better outcomes in patients with combined mitral-aortic disease was investigated.
METHODS:
A retrospective observational study was performed involving 341 patients who underwent aortic valve replacement with either mitral valve repair (n=42) or double valve replacement (n=299). Data were analyzed for early mortality, late valve-related complications and survival.
RESULTS:
The early mortality rate was 11.9% for valve repair and 11.0% for replacement (P=0.797). Survival (± SD) was 67±11% in mitral valve repair with aortic valve replacement and 81±3% in double valve replacement at five years of follow-up (P=0.187). The percentage of patients who did not experience major adverse valve-related events at five years of follow-up was 83±9% in those who underwent mitral valve repair with aortic valve replacement and 89±2% in patients who underwent double valve replacement (P=0.412). Age >70 years (HR 2.4 [95% CI 1.1 to 4.9]; P=0.023) and renal dysfunction (HR 1.9 [95% CI 1.2 to 3.7]; P=0.01) were independent predictors of decreased survival.
CONCLUSIONS:
In patients with double valve disease, both mitral valve repair and replacement provided comparable early outcomes. There were no significant differences in valve-related reoperations, anticoagulation-related complications or prosthetic valve endocarditis. Patient-related factors appear to be the major determinant of late survival, irrespective of the type of operation.
PMCID: PMC3716483  PMID: 24294032
Aortic valve replacement; Double valve surgery; Mitral valve repair; Mitral valve replacement
3.  Right ventricular myocardial infarction: From pathophysiology to prognosis 
Right ventricle myocardial infarctions (RVMIs) accompany inferior wall ischemia in up to one-half of cases. The clinical sequelae of RVMIs vary from no hemodynamic compromise to severe hypotension and cardiogenic shock. Diagnosis is based on physical examination, electrocardiography, echocardiography and coronary angiography. Because the standard 12-lead electrocardiogram is insufficient for the assessment of RV involvement, right-sided precordial leads should always be included. Adequate fluid administration in combination with positive inotropic agents and early coronary reperfusion are crucial components of treatment, while diuretics and nitrates should be avoided. Intra-aortic balloon counterpulsation and right ventricle assist devices may be used with success in RVMIs associated with medically refractory heart failure. Right ventricular involvement appears to be an independent prognostic factor that dramatically increases in-hospital mortality, due, in part, to a significantly higher risk of hemodynamically compromising arrhythmias. Thus, using right-sided precordial leads and early RVMI identification to trigger an appropriately aggressive treatment protocol may improve patients’ prognosis.
PMCID: PMC3716484  PMID: 24294033
Arrhythmias; Revascularization; Right ventricular myocardial infarction; Treatment
4.  Cardioverter-defibrillator implantation in myeloma-associated cardiac amyloidosis 
A 62-year-old woman with multiple myeloma and light-chain amyloidosis with significant heart involvement developed an in-hospital cardiac arrest. After cardiopulmonary resuscitation, a stable sinus rhythm without any cerebral damage was restored, and the patient was admitted to the coronary care unit. A cardioverter-defibrillator was implanted, and it successfully intervened in two sustained ventricular tachycardia episodes and one ventricular fibrillation episode, which were recorded during hospitalization. After achieving discrete cardiac compensation, the patient was transferred to the emergency medicine department where she underwent chemotherapy for multiple myeloma. The patient died 40 days after admission from refractory heart failure. In the literature, there are studies that describe the use of cardioverter-defibrillator implantation in cardiac amyloidosis; however, at present, there is no evidence of a beneficial effect on survival with the use of this intervention. A high index of suspicion for amyloid heart disease and early diagnosis are critical to improving outcomes.
PMCID: PMC3716485  PMID: 24294034
Amyloid heart disease; Cardioverter-defibrillator; Restrictive cardiomyopathy
5.  Pacemaker-mediated angina 
Angina is a clinical syndrome characterized by discomfort in the chest, jaw, shoulder, back or arm. It is typically aggravated by exertion or emotional stress and relieved by nitroglycerin. Atherosclerotic coronary artery disease is the most common cause of angina. Dual-chamber pacemakers track the atrial electrical activity by pacing the ventricle. The present article reports the first case in the literature involving pacemaker-mediated angina. A 78-year-old man complained of chest pain shortly after the placement of a permanent dual-chamber pacemaker and experienced immediate relief of his pain after the pacemaker mode was switched from tracking the atrium and pacing the ventricle to sensing and pacing the ventricle. The pain was identified as angina pectoris. The comprehensive history-taking performed before pacemaker placement helped to quickly identify the cause of the patient’s pain.
PMCID: PMC3716486  PMID: 24294035
Angina; Pacemaker; Pacemaker-mediated
6.  Effect of the stellate ganglion on atrial fibrillation and atrial electrophysiological properties and its left-right asymmetry in a canine model 
OBJECTIVE:
To investigate the effect of the stellate ganglion (SG) and its left-right asymmetry on atrial fibrillation (AF) inducibility, AF duration and atrial electrophysiological properties.
METHODS:
Sixteen adult mongrel dogs were randomly assigned to three groups. The control group (n=4) underwent 6 h rapid atrial pacing (RAP) only; the right SG (RSG) group (n=6) underwent 6 h RSG stimulation plus RAP; and the left SG (LSG) group (n=6) underwent 6 h LSG stimulation plus RAP. AF induction rate, AF duration, effective refractory period (ERP) and dispersion of ERP (dERP) were measured.
RESULTS:
In the RSG group, the induction rate of AF was significantly increased in sites in the right atrium (RA) compared with baseline (P<0.05). In the LSG group, the induction rate of AF was significantly increased (P<0.05) compared with baseline in the left atrium (LA), left superior pulmonary vein and left inferior pulmonary vein, respectively. Compared with RSG stimulation, right stellate ganglionectomy markedly decreased the AF induction rate of the RA (P<0.05). Compared with LSG stimulation, left stellate ganglionectomy markedly decreased the AF induction rate of the LA, the left superior pulmonary vein and the left inferior pulmonary vein (P<0.05). In the RSG group, the ERP was significantly shortened (P<0.05) and the dERP was significantly increased (P<0.05) in RA sites (P<0.05). The ERP was significantly shortened in the LSG group (P<0.05). The dERP was significantly increased (P<0.05) in LA and pulmonary vein sites (P<0.05).
CONCLUSIONS:
Unilateral electrical stimulation of the SG in combination with RAP can successfully establish a canine model of acute AF mediated by excessive sympathetic activity. SG stimulation facilitates AF induction and aggravates electrical remodelling in sites in the atrium and pulmonary vein. Inhibiting sympathetic nerve activation through unilateral stellate ganglionectomy can reduce AF initiation.
PMCID: PMC3716487  PMID: 24294036
Atrial fibrillation; Stellate ganglion; Sympathetic nerve
7.  Validation of the vitronectin knockout mouse as a model for studying myocardial infarction: Vitronectin appears to influence left ventricular remodelling following myocardial infarction 
BACKGROUND:
Vitronectin (VN) is an abundant acute-phase plasma protein that regulates cell adhesion and migration as well as interactions with components of the plasminogen activator/plasmin system, specifically plasminogen activator inhibitor type 1. This system plays a major role in tissue remodelling regulating wound healing after myocardial infarction.
OBJECTIVES:
To investigate the feasibility of using VN knockout mice (VN−/−) to study the role of VN on ventricular remodelling following myocardial infarction.
METHODS:
Specifically bred VN−/− mice and normal wild-type (VN+/+) mice underwent coronary artery ligation and were assessed 28 days postligation using echocardiography and morphometric histology.
RESULTS:
No difference was observed between VN−/− mice and VN+/+ mice with respect to gross phenotype, weight, coronary anatomy or echocardiographically measured ejection fraction (56%). Following myocardial infarction, VN−/− mice exhibited less ventricular dilation and less impairment in echocardiographic ejection fraction compared with VN+/+ mice (48% versus 41%; P=0.01). VN−/− mice also exhibited smaller infarcts on morphometric analysis.
CONCLUSIONS:
The results of the present study confirmed the feasibility of using coronary artery ligation in VN knockout mice to investigate the role of VN in post-myocardial infarction remodelling. The absence of VN appears to result in favourable effects on wound healing. These data suggest that this model may offer novel insights into the role of VN in the regulation of myocardial remodelling.
PMCID: PMC3716488  PMID: 24294037
Myocardial infarction; Remodelling; Vitronectin
8.  A novel measurement technique for the design of fenestrated stent grafts: Comparison with three-dimensional aorta models 
BACKGROUND:
Stent graft placement is an acceptable treatment option for aortic disease, particularly for abdominal aortic aneurysm. At present, the use of stent grafts is expanding beyond current indications for use. Fenestrated stent grafts are used in patients with abdominal aortic aneurysms whose aortic anatomy is unsuitable for repair using standard devices. The success of fenestrated stent graft placement is largely dependent on planning, including obtaining measurements and designing the stent.
OBJECTIVE:
To demonstrate a measurement technique that may be used for the design of fenestrated stent grafts to repair endovascular aneurysms, and to compare these measurements, obtained using archived two-dimensional patient data, with measurements obtained using a three-dimensional (3-D) computer-assisted design model.
METHODS:
Fenestrated stent grafts were designed and fabricated based on computed tomographic angiography images. 3-D models were constructed using modelling software and rapid prototyping technology incorporated with fused deposition modelling. The stent grafts were trunk-type, with four holes for the visceral branches (celiac axis, superior mesenteric artery, right renal artery and left renal artery). Computed tomography scans of 10 patients with abdominal aortic aneurysms were reviewed. Axial, multiplanar reconstruction and curved multiplanar reconstruction images were used to measure 11 parameters. Sizing of the fenestrated aortic stent grafts was performed independently by an experienced interventional radiologist, and the results were compared with the same measurements calculated using the 3-D aorta model (generated using Materialise Interactive Medical Image Control System software [Materialise NV, Belgium]). Data were reported as the mean of the measurements. Measurements were evaluated using Bland-Altman analysis and concordance correlation coefficients (CCCs).
RESULTS:
A total of 10 fenestrated stent grafts were fabricated. The proximal landing section above the celiac axis (one point of the wall being defined as the standard point) was 3 cm, and the distal flared section was 3 cm below the lowest renal artery. Ten computer-assisted design aorta models were successfully constructed. Measurements of the aortic diameter showed high agreement between those obtained using the archived patient computer system stent graft and those obtained using the 3-D aorta model. The CCC for variability was 0.9974. The distance from the standard point to the branch vessels also demonstrated good agreement. The CCC for variability was 0.9999.
DISCUSSION:
A direct measurement technique using a standard point was simple to perform and was easily applied to the fabrication process. Preparation time will likely be shortened and the versatility of stent grafts will be improved using this method. It will be possible to produce standardized fenestrated stent grafts once patients’ measurements are recorded and analyzed.
CONCLUSION:
A fenestrated stent graft design technique using measurements of distance from a standard point generally showed a high level of agreement with a 3-D aorta model.
PMCID: PMC3716489  PMID: 24294038
Abdominal aortic aneurysm; Fenestration; Stent graft
9.  Left ventricular systolic and diastolic function in subjects with a bicuspid aortic valve without significant valvular dysfunction 
BACKGROUND:
The bicuspid aortic valve (BAV) represents the most common cardiac congenital malformation in adults. It is frequently associated with dilation, aneurysm and dissection of the ascending aorta.
OBJECTIVE:
To evaluate left ventricular systolic and diastolic function in subjects with BAVs.
METHODS:
Thirty-five subjects with BAV (mean [± SD] age 25.9±5.7 years [range 17 to 36 years]; 18 male, 17 female) with either no valvular impairment or mild valvular impairment were recruited along with 30 control subjects (24.5±4.4 years of age [range 15 to 35 years]; 15 male, 15 female) who were matched for age, sex and body surface area. Left ventricular systolic and diastolic function were evaluated using conventional and tissue Doppler echocardiography. Left ventricular systolic and diastolic parameters were compared between the two groups.
RESULTS:
In subjects with BAVs, the ratio of mitral early diastolic velocity to late diastolic velocity was lower (0.95±0.4 versus 1.27±0.9; P=0.001), the ratio of mitral early diastolic velocity to myocardial early diastolic velocity was higher (10.1±3.2 versus 6.5±2.4; P=0.001) and the myocardial early diastolic velocity was lower (8.4±2.1 versus 15.3±3.6; P<0.001) compared with control subjects. In addition, the myocardial performance index was higher in subjects with BAVs than in control subjects (P=0.03). The left ventricular ejection fraction was also lower (53±11% versus 64±13%; P<0.001). No other statistically significant differences were observed between the two groups with regard to left ventricular systolic and diastolic parameters. In addition, the number of mitral valve prolapses and atrial septal aneurysms was higher in subjects with BAVs.
CONCLUSION:
BAVs may be associated with left ventricular systolic and diastolic dysfunction.
PMCID: PMC3716490  PMID: 24294040
Atrial septal aneurysm; Bicuspid aortic valve; Cardiomyopathy; Diastolic dysfunction; Systolic dysfunction
10.  Mitral annulus calcification is independently associated with all-cause mortality 
BACKGROUND:
Mitral annulus calcification (MAC) is an important echocardiographic finding that is significantly associated with valvular abnormalities. However, the effect of documented MAC on all-cause mortality is not known. Using a large database, associations between MAC and long-term all-cause mortality were evaluated.
METHODS:
A retrospective analysis of 3169 echocardiograms, which were performed for clinical reasons in southern California between 1983 and 1998 in patients between 16 and 99 years of age, was performed. Mortality data were extracted from the national mortality database at the end of 2007. Using uni- and multivariate analysis, associations between total mortality and the echocardiographic presence of MAC documented in the final report by the interpreting cardiologist were evaluated.
RESULTS:
MAC was significantly associated with all-cause mortality (174 of 334 [52.1%] patients with MAC died versus 709 of 2835 [25.0%] patients without MAC; OR 3.26 [95% CI 2.58 to 4.10]; P<0.001). Using multivariate analysis adjusting for age, left ventricular hypertrophy, sex, abnormal left ventricular systolic function and significant valvular abnormalities, MAC remained independently associated with all-cause mortality (OR 2.50 [95% CI 1.81 to 3.45]; P<0.001).
CONCLUSION:
Using a large echocardiographic database, MAC was found to be independently associated with all-cause mortality. This finding confirms the importance of an abnormal mitral annulus as an important prognostic marker.
PMCID: PMC3716491  PMID: 24294050
Cardiovascular mortality; Coronary artery disease; Echocardiography; Mitral annulus calcification; Mitral valve disease; Mortality
11.  Detection of left ventricular asynchrony and its relationship with the Tei index in patients with coronary artery ectasia 
OBJECTIVE:
To evaluate left ventricular (LV) systolic asynchrony and its relationship with the Tei index using tissue Doppler imaging (TDI); and to evaluate the relationship of thrombolysis in myocardial infarction frame count (TFC) and Tei index with LV asynchrony in patients with coronary artery ectasia (CAE).
METHODS:
A total of 50 CAE patients and 40 control subjects were evaluated. Diagnosis of CAE was made angiographically and TFC was calculated. LV systolic and diastolic function was assessed by conventional echocardiography and TDI. Evaluation of intra-LV systolic asynchrony was performed using tissue synchronization imaging (TSI).
RESULTS:
In patients with CAE, the Tei index was significantly higher than in controls (0.63±0.12 versus 0.52±0.12; P<0.001). LV systolic asynchrony parameters of TSI including SD of the peak tissue velocity (Ts) of the 12 LV segments (Ts-SD-12), maximal difference in Ts between any two of the 12 LV segments (Ts-12), SD of the Ts of the six basal LV segments (Ts-SD-6), maximal difference in Ts between any of the six basal LV segments (Ts-6) were significantly lengthened in patients with subclinical hypothyroidism compared with controls (P<0.001, P<0.001, P<0.001 and P<0.001, respectively). In addition, a positive correlation was found between Ts-SD-12 and the Tei index in patients with CAE (r=0.841; P<0.001) and mean TFC was positively correlated with Ts-SD-12 and the Tei index (r=0.345; P=0.013 and r=0.291; P=0.021, respectively).
CONCLUSION:
Patients with CAE exhibit evidence of LV systolic asynchrony according to TSI. LV systolic asynchrony is related to the Tei index and mean TFC. Furthermore, the Tei index is an independent risk factor for LV systolic asynchrony.
PMCID: PMC3716492  PMID: 24294056
Coronary artery ectasia; Left ventricular asynchrony; Tei index
12.  Depression increases the risk for uncontrolled hypertension 
BACKGROUND:
Because hypertension and depression share common pathways, it is possible that each disease has an impact on the natural history of the other.
OBJECTIVE:
To determinate whether depression influences blood pressure control in hypertensive patients.
METHODS:
Forty hypertensive patients undergoing antihypertensive treatment, excluding beta-blockers and central-acting agents, self-measured their blood pressure several times a day for three days using a validated, commercially available device. All patients also completed the Zung Self-rating Depression Scale survey for depression. Associations between the results of the blood pressure and depression tests were determined using the Spearman correlation coefficient; RR was also measured.
RESULTS:
Of the 40 patients, 23 were depressed, and 21 of these 23 had poor control of their blood pressure. The RR for uncontrolled hypertension in depressed patients was 15.5. A significant correlation between systolic (r=0.713) and diastolic (r=0.52) blood pressure values and depression was found.
CONCLUSION:
Depression is common in patients with uncontrolled hypertension and may interfere with blood pressure control. Screening for depression in hypertensive patients is a simple and cost-effective tool that may improve outcomes.
PMCID: PMC3716493  PMID: 24294029
Blood pressure control; Depression; Hypertension
13.  Hematological parameters and coronary collateral circulation in patients with stable coronary artery disease 
BACKGROUND:
Although hematological parameters have been associated with prognosis in patients with various cardiovascular diseases, their relationship with coronary collateral (CC) circulation in patients with stable coronary artery disease (CAD) is unknown.
OBJECTIVE:
To investigate the relationship between hematological parameters and CC vessel development in patients with stable CAD.
METHODS:
A total of 96 patients who underwent coronary angiography were retrospectively enrolled. All study participants had at least one occluded major coronary artery. Development of CCs was classified using the method of Rentrop. Rentrop grades of 0 and 1 indicate poor CCs, whereas grades 2 and 3 indicate good CCs. Hematological parameters, including mean platelet volume (MPV) and neutrophil/lymphocyte (N/L) ratio, were measured. Multivariate logistic regression analysis was performed to identify independent variables.
RESULTS:
The MPV and N/L ratio were significantly higher in the poor CC group compared with the good CC group. Negative correlations were found in the analyses comparing Rentrop score with MPV and N/L ratio (r=−0.274; P=0.012 and r=−0.339; P=0.001, respectively). In multivariate analysis, the N/L ratio was independently related to CC circulation (OR 0.762 [95% CI 0.587 to 0.988]; P=0.04).
CONCLUSION:
The results suggest that N/L ratio and MPV are associated with poor CCs, and a high N/L ratio is a significant predictor of poor CC development in patients with stable CAD.
PMCID: PMC3716494  PMID: 24294041
Coronary collateral circulation; Hematological parameters; Mean platelet volume; Neutrophil/lymphocyte ratio
14.  High prevalence of subclinical thyroid dysfunction and the relationship between thyrotropin levels and cardiovascular risk factors in residents of the coastal area of China 
OBJECTIVES:
To investigate the prevalence of subclinical thyroid dysfunction and the relationship between thyrotropin levels and cardiovascular risk factors in residents of the coastal area of China.
METHODS:
Atotalof4256individuals(mean[±SD]age50.51±14.24years; 2079 males, 2177 females,) were enrolled in the present study. Sex, blood pressure, body mass index, waist-to-hip ratio, serum levels of fasting glucose, total cholesterol, high-density lipoprotein cholesterol, low-density lipoprotein cholesterol, triglycerides, uric acid and smoking status were measured. The relationship between thyrotropin levels and cardiovascular risk factors was analyzed.
RESULTS:
The overall prevalence of thyroid dysfunction was 11.07%. The prevalence of subclinical hypothyroidism (6.32%) was higher than that of hyperthyroidism (1.53%). The prevalence of thyroid dysfunction among female subjects was higher than that among male subjects (16.54% versus 5.34%, respectively; P<0.001). Significant differences were detected with respect to body mass index (P=0.026), waist-to-hip ratio (P<0.001), fasting glucose levels (P=0.001), total cholesterol levels (P=0.013), triglyceride levels (P=0.003) and smoking status according to different thyrotropin levels.
CONCLUSION:
The prevalence of thyroid dysfunction was high in residents of China’s coastal area. Significant differences were detected with regard to body mass index, waist-to-hip ratio, fasting glucose levels, total cholesterol levels, triglyceride levels and smoking status according to different thyrotropin levels.
PMCID: PMC3716495  PMID: 24294042
Cardiovascular risk factors; Coronary heart disease; Thyroid dysfunction
15.  Percutaneous coronary intervention delays pacemaker implantation in coronary artery disease patients with established bradyarrhythmias 
BACKGROUND:
Pacemakers have long been used to assist the heart under pathological conditions, and they are the first choice in the treatment of systematic bradyarrhythmias. However, the effect of percutaneous coronary intervention (PCI) in patients with coronary artery disease as well as bradyarrhythmias remains unknown.
METHODS:
In the present study, 42 patients with chest pain and/or abnormal stress test results were surveyed. Before coronary angiography, patients underwent complete examination, including a 24 h dynamic electrocardiogram, which was used to diagnose bradyarrhythmias that were not suitable for pacemaker implantation due to a lack of arrhythmia-related symptoms. All patients underwent PCI but did not undergo pacemaker implantation. Forty-one patients with chest pain and/or abnormal stress test results, as well as symptom-free bradyarrhythmias, were selected as the control group. All of the patients in the control group were committed to treatments without PCI.
RESULTS:
During a mean (±SD) of 3.3±0.5 years of follow-up (range 2.5 to 4.5 years), 24 of 42 patients who received PCI underwent pacemaker implantation for arrhythmia-related symptoms, eight were shown by Holter monitoring to have worsened but still exhibited no symptoms, and the remainder did not show any changes according to the examinations performed. In the control group, 31 patients underwent pacemaker implantation for arrhythmia-related symptoms, eight were shown by Holter monitoring to have worsened but still exhibited no symptoms, and two did not show any changes according to the examinations performed. Nevertheless, the rates of pacemaker implantation each year (from the first to the third year) between the two groups were 7.1% versus 39.0% (P=0.001); 33.3% versus 63.4% (P=0.006); and 57.1% versus 75.6%, (P=0.075), respectively.
CONCLUSIONS:
The present study found that PCI delayed the demand for pacemaker implantation among coronary artery disease patients.
PMCID: PMC3716496  PMID: 24294031
Pacemaker; Percutaneous coronary intervention; Sinus node diseases
16.  How do cardiorespiratory fitness improvements vary with physical training modality in heart failure patients? A quantitative guide 
BACKGROUND:
Peak oxygen consumption (VO2) is the gold standard measure of cardiorespiratory fitness and a reliable predictor of survival in chronic heart failure patients. Furthermore, any form of physical training usually improves cardiorespiratory fitness, although the magnitude of improvement in peak VO2 may vary across different training prescriptions.
OBJECTIVE:
To quantify, and subsequently rank, the magnitude of improvement in peak VO2 for different physical training prescriptions using data from published meta-analyses and randomized controlled trials.
METHODS:
Prospective randomized controlled parallel trials and meta-analyses of exercise training in chronic heart failure patients that provided data on change in peak VO2 for nine a priori comparative analyses were examined.
RESULTS:
All forms of physical training were beneficial, although the improvement in peak VO2 varied with modality. High-intensity interval exercise yielded the largest increase in peak VO2, followed in descending order by moderate-intensity aerobic exercise, functional electrical stimulation, inspiratory muscle training, combined aerobic and resistance training, and isolated resistance training. With regard to setting, the present study was unable to determine whether outpatient or unsupervised home exercise provided greater benefits in terms of peak VO2 improvment.
CONCLUSIONS:
Interval exercise is not suitable for all patients, especially the high-intensity variety; however, when indicated, this form of exercise should be adopted to optimize peak VO2 adaptations. Other forms of activity, such as functional electrical stimulation, may be more appropriate for patients who are not capable of high-intensity interval training, especially for severely deconditioned patients who are initially unable to exercise.
PMCID: PMC3716497  PMID: 24294043
Exercise training; Left ventricular dysfunction; Peak VO2; Quality of life
17.  Combined circumferential and longitudinal left ventricular systolic dysfunction in patients with type 2 diabetes mellitus without myocardial ischemia 
BACKGROUND/OBJECTIVE:
Left ventricular (LV) circumferential or longitudinal shortening may be impaired in patients with type 2 diabetes mellitus (DM). In the present study, patients with type 2 DM without myocardial ischemia and combined impairment of circumferential and longitudinal (C+L) shortening were studied to assess the prevalence and factors associated with this condition.
METHODS:
Data from 386 patients with type 2 DM enrolled in the SHORTening of midWall and longitudinAl left Ventricular fibers in diabEtes study were analyzed. One hundred twenty healthy subjects were used to define C+L dysfunction. Stress-corrected midwall shortening and mitral annular peak systolic velocity were considered as indexes of C+L shortening and classified as low if <89% and <8.5 cm/s, respectively (10th percentiles of controls).
RESULTS:
Combined C+L dysfunction was detected in 66 patients (17%). The variables associated with this condition were lower glomerular filtration rate (OR 0.98 [95% CI 0.96 to 0.99], greater LV mass (OR 1.05 [95% CI 1.02 to 1.08]), high pulmonary artery wedge pressure (OR 1.23 [95% CI 1.04 to 1.44]) and mitral annular calcifications (OR 3.35 [95% CI 1.71 to 6.55]). Considering the entire population, the relationship between stress-corrected midwall shortening and peak systolic velocity was poor (r=0.20), and the model was linear. The relationship was considerably closer and nonlinear in patients with combined C+L dysfunction (r=0.61; P<0.001), having the best fit by cubic function.
CONCLUSIONS:
Combined C+L dysfunction was present in one-sixth of patients with type 2 DM without myocardial ischemia. This condition was associated with reduced renal function, worse hemodynamic status and structural LV abnormalities, and may be considered a preclinical risk factor for heart failure.
PMCID: PMC3716498  PMID: 24294044
Diabetes; Left ventricular systolic dysfunction; Longitudinal function; Midwall shortening; Mitral calcification
18.  Prevalence of mixed dyslipidemia among Australian patients undergoing lipid-modifying therapy 
BACKGROUND:
Few studies have assessed the prevalence of mixed dyslipidemia (MD) and the effectiveness of lipid-modifying therapy (LMT) for the treatment of abnormal levels of low-density lipoprotein cholesterol (LDL-C), triglycerides (TG) and high-density lipoprotein cholesterol (HDL-C) in Australian clinical practice.
OBJECTIVE:
To estimate the prevalence of MD in Australian patients undergoing LMT.
METHODS:
Patients 35 years of age and older undergoing LMT for ≥1 year were enrolled from nine general practice and cardiologist/endocrinologist outpatient clinics in Australia between April 2007 and May 2008. Lipid levels, including LDL-C, HDL-C and TG levels, were prospectively collected at the enrollment date and from patient records one year before LMT was initiated. Normal lipid levels were assessed according to Australian guidelines. Multivariate logistic regression was used to evaluate predictors of normal lipid level attainment.
RESULTS:
Of 297 patients (mean age 60.1 years; 43% male), the prevalence of MD before LMT was 61%; 93% of patients had elevated LDL-C levels, 17% had low HDL-C levels and 62% had elevated TG levels. Following LMT (98.3% statins), 31% of patients had MD. The prevalence of elevated LDL-C levels, low HDL-C levels and elevated TG levels were 44%, 21% and 42%, respectively. Baseline lipid levels were significant predictors of attainment of normal LDL-C levels (OR 0.42 [95% CI 0.27 to 0.63]) and TG levels (OR 0.26 [95% CI 0.16 to 0.45]).
CONCLUSION:
Among Australian patients primarily treated with statins, nearly one-third had MD despite LMT. LMT considerably improved LDL-C goal attainment; however, a large proportion of patients did not achieve normal HDL-C and TG levels. Patients may benefit from a more comprehensive approach to lipid management that treats all three lipid risk factors, as suggested in clinical guidelines.
PMCID: PMC3716499  PMID: 24294045
Australia; Dyslipidemia; High-density lipoprotein cholesterol; Lipid modifying therapy; Low-density lipoprotein cholesterol; Triglycerides
19.  Relationship between serum uric acid levels and ventricular function in patients with idiopathic pulmonary hypertension 
OBJECTIVE:
To investigate the relationship between serum uric acid levels and pulmonary hypertension in patients with idiopathic pulmonary artery hypertension (IPAH).
METHODS:
Serum uric acid levels were measured in 86 patients (mean [± SD] age 35.2±12.3 years; 36 men) with IPAH. Pulmonary arterial pressure and ventricular function were assessed using echocardiography. Serum uric acid levels were also measured in 40 healthy subjects (35.9±11.6 years of age; 15 men).
RESULTS:
Serum uric acid levels in IPAH patients were higher compared with control subjects (405±130 μmol/L versus 344±96 μmol/L; P<0.05). Fifty-two (60.4%) of the 86 patients with IPAH had elevated serum uric acid levels. The pulmonary systolic pressure and mean pulmonary pressure in the high uric acid group were higher than in the normal uric acid group (P<0.05). The left and right ventricular ejection fractions were lower in the high uric acid group compared with the normal uric acid group (P<0.05). Serum uric acid levels were correlated with the mean pulmonary arterial pressure (r=0.387; P<0.01) and New York Heart Association class (r=0.41; P<0.01). There was also an inverse correlation between uric acid levels and the left (r=−0.550; P<0.01) and right ventricular ejection fractions (r=−0.481; P<0.05).
CONCLUSION:
Serum uric acid levels are associated with IPAH severity and the severity of ventricular dysfunction.
PMCID: PMC3716500  PMID: 24294046
Idiopathic pulmonary artery hypertension; Uric acid; Ventricular function
20.  Atorvastatin improves endothelial progenitor cell function and reduces pulmonary hypertension in patients with chronic pulmonary heart disease 
OBJECTIVE:
To explore the effects of atorvastatin on the migration and adhesion of endothelial progenitor cells (EPCs) and on pulmonary artery pressure (PAP) in patients with chronic pulmonary heart disease.
METHODS:
A total of 68 patients with chronic pulmonary heart disease were randomly assigned to either a control group (n=35) or a treatment group (n=33). In addition, 30 healthy volunteers (17 male, 13 female) were enrolled as healthy controls. Atorvastatin (20 mg per day) was administered to the treatment group. The migration and adhesion activities of EPCs in peripheral blood were assessed before and six months after the treatment. PAP was measured using echocardiography before and after the treatment.
RESULTS:
EPC number, migration ability and adhesion activity in the peripheral blood of patients in the control and treatment groups were lower than in patients in the healthy control group at baseline (all P<0.05). After six months of atorvastatin therapy, the number of EPCs in the treatment group was greater than in the control group (P<0.05). Migration and adhesion functions of EPCs in the treatment group were greater than in the control group (all P<0.05). The reduction in PAP in the treatment group was greater than in the untreated control group following six months of therapy (P<0.05).
CONCLUSION:
Atorvastatin therapy increased the migration and adhesion activities of EPCs in patients with chronic pulmonary heart disease. Atorvastatin treatment was also associated with a reduction in PAP in these patients.
PMCID: PMC3716501  PMID: 24294047
Atorvastatin; Chronic pulmonary heart disease; Endothelial progenitor cells; Pulmonary hypertension
21.  Abnormal myocardial perfusion and risk of heart failure in patients with type 2 diabetes mellitus 
BACKGROUND:
Diabetes is a major risk factor for heart failure (HF), although the pathophysiological processes have not been clarified.
OBJECTIVE:
To determine the prevalence of HF and of abnormal myocardial perfusion in diabetic patients evaluated using technetium (99m) sestamibi single-photon emission computed tomography.
METHODS:
An observational cross-sectional study was conducted that included patients with type 2 diabetes mellitus who underwent echocardiography to diagnose HF and a pharmacological stress test with intravenous dipyridamole to examine cardiac scintigraphic perfusion abnormalities. Clinical and biochemical data were also collected.
RESULTS:
Of the 160 diabetic patients included, 92 (57.6%) were in HF and 68 (42.5%) were not. When patients were stratified according to the presence of abnormal myocardial perfusion, those with abnormal perfusion had a higher prevalence of HF (93%) than those with normal perfusion (44.4%) (P<0.0001). Patients with HF weighed more (P=0.03), used insulin less frequently (P=0.01), had lower total cholesterol (P=0.05) and high-density lipoprotein cholesterol concentrations (P=0.002), and a greater number of their myocardial segments showed abnormal perfusion (P≤0.001). More HF patients had a history of myocardial infarction (P<0.001) compared with those without HF. In a logistic regression analysis, the number of segments exhibiting abnormal myocardial perfusion was an independent risk factor for HF.
CONCLUSIONS:
The prevalence of HF in diabetic patients was high and HF predominantly occured in association with myocardial ischemia.
PMCID: PMC3716502  PMID: 24294048
Diabetes mellitus; Heart failure; Myocardial perfusion
22.  Evaluation of left ventricular function, rotation, twist and untwist in patients with hypertrophic cardiomyopathy 
Hypertrophic cardiomyopathy (HCM) is a disease with an autosomal-dominant pattern of inheritance associated with a variety of disease courses, age of onset, symptom severity, left ventricular outflow obstruction and risk for sudden cardiac death. Left ventricular systolic function is typically normal in most HCM patients using conventional echocardiographic indexes; however, myocardial systolic and diastolic function are reduced, and the mechanism of myocardial dysfunction remains unclear. Echocardiography is an invaluable tool for the diagnosis and assessment of hemodynamic condition, evaluation of therapy and outcome, and follow-up of patients with HCM. The recent advent of speckle tracking imaging provides a novel index for the noninvasive assessment of left ventricular myocardial dysfunction, and has been confirmed by many studies.
A search for original articles focusing on HCM and its associated twist and untwist mechanisms was performed in the MEDLINE and PubMed databases with no date restrictions. All articles identified were English-language, full-text publications. The reference lists of identified articles were also searched for additional articles and reviews.
PMCID: PMC3716503  PMID: 24294049
Hypertrophic cardiomyopathy; Left ventricular rotation; Twist
23.  Patent ductus arteriosus closure using an Amplatzer™ ventricular septal defect closure device 
The ductus arteriosus originates from the persistence of the distal portion of the left sixth aortic arch. It connects the descending aorta (immediately distal to the left subclavian artery) to the roof of the main pulmonary artery, near the origin of the left pulmonary artery. Persistence of the duct beyond 48 h after birth is abnormal and results in patent ductus arteriosus (PDA). PDA is rare in adults because it is usually discovered and treated in childhood. Mechanical closure remains the definitive therapy because the patency of ductus arteriosus may lead to multiple complications, depending on the size and flow through the ductus. PDA closure is indicated in patients with symptoms and evidence of left heart enlargement, and in patients with elevated pulmonary pressures when reversal is possible. Transcatheter closure is the preferred technique in adults because it avoids sternotomy, reduces the length of hospital stay and is associated with fewer complications compared with surgery. First demonstrated in 1967, both the technique and the occluder devices used have since evolved. However, designing an ideal PDA occluder has been a challenge due to the variability in size, shape and orientation of PDAs. The present article describes a case involving a 35-year-old woman who presented to the Center for Advanced Heart Failure (Houston, USA) with congestive heart failure due to a large PDA, which was successfully occluded using an Amplatzer (St Jude Medical, USA) muscular ventricular septal defect closure device. The wider waist and dual-retention discs of these ventricular septal defect closure devices may be important factors to consider in the future development of devices for the occlusion of large PDAs.
PMCID: PMC3716504  PMID: 24294051
Amplatzer™ ventricular septal defect closure device; Patent ductus arteriosus; Transcatheter closure
24.  Role of gamma-glutamyltransferase in cardiovascular diseases 
Cardiovascular diseases are threatening human health with rising morbidity and mortality rates. Gamma-glutamyltransferase (GGT) has been found to be involved in the pathogenesis of cardiovascular diseases, especially coronary artery disease, and the prognosis of cardiovascular disease may be predicted by increasing GGT levels. GGT levels are related to cardiovascular emergencies of chronic heart failure, and an elevated GGT level has been shown to be an independent predictive maker for cardiac death and cardiac transplantation. Investigation of the role of GGT in the mechanism of cardiac diseases will be helpful in developing preventive strategies and treatment methods.
PMCID: PMC3716505  PMID: 24294039
Coronary artery disease; Gamma-glutamyltransferase; Heart failure; Hypertension
25.  What lies beneath: Posterior ST elevation myocardial infarction with underlying right ventricular-paced rhythm 
A 66-year-old man with a history of coronary artery disease, stage V chronic kidney disease, peripheral arterial disease and a dual-chamber pacemaker experienced persistent chest and shoulder discomfort following his daily hemodialysis treatment. Treatment with clopidogrel had been discontinued three days previously due to impending vascular surgery. Electrocardiography revealed a right ventricular-paced rhythm with ST abnormalities indicative of posterior ST elevation myocardial infarction. The patient underwent urgent cardiac catheterization and required percutaneous coronary intervention for an acutely occluded coronary artery. The present case report emphasizes the importance of careful and timely review of the electrocardiogram of any patient with a ventricular-paced rhythm who experiences signs and symptoms consistent with acute coronary syndrome. Certain characteristic electrocardiographic abnormalities have been demonstrated to predict acute myocardial infarction in such patients.
PMCID: PMC3716506  PMID: 24294052
Acute myocardial infarction; Diagnosis of STEMI; Right ventricular pacing

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