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PubMed2002

Prognostic role of myocardial blood flow impairment in idiopathic left ventricular dysfunction.

BACKGROUND: Depressed myocardial blood flow (MBF) has been reported in dilated cardiomyopathy. The aim of this study was to investigate whether MBF impairment is an independent predictor of prognosis in patients with idiopathic left ventricular (LV) dysfunction. METHODS AND RESULTS: Sixty-seven patients (52 male, mean age 52+/-12 years) with different degrees of idiopathic LV systolic dysfunction (average LV ejection fraction, 0.34+/-0.10; range, 0.07 to 0.49) were prospectively enrolled. Thirty-four subjects (51%) had no history of heart failure symptoms at enrollment (NYHA class I). All patients underwent clinical and functional evaluation and a PET study to measure absolute MBF at rest and after intravenous dipyridamole. During a mean follow-up of 45+/-37 months, 24 patients had major cardiac events, including cardiac death in 8 and development or progression of heart failure in 16 patients. Multivariate regression analysis (Cox proportional hazards model) revealed heart rate (chi(2) 11.06, P<0.001), LV end-diastolic dimension (chi(2) 11.73, P<0.001), and dipyridamole MBF (chi(2) 11.04, P<0.001) as independent predictors of subsequent cardiac events. Dipyridamole MBF < or = 1.36 mL. min(-1). g(-1) was associated with an increase in the relative risk of death, development, or progression of heart failure of 3.5 times over other more common clinical and functional variables. CONCLUSIONS: The present study demonstrates that severely depressed MBF is a predictor of poor prognosis in patients with idiopathic LV dysfunction independently of the degree of LV functional impairment and of the presence of overt heart failure.

Coronary Circulation↗
PubMed1994

Left ventricular remodeling and function in adult aortic stenosis.

The aim of this study was to analyze the left ventricular (LV) geometric changes occurring in chronic pressure overload due to valvular aortic stenosis (AS). Fifty-six adult patients (30 women, 26 men, mean age seventy-two +/- nine years, range forty-five to eighty-five years) with isolated AS (mean valve area by Doppler = 0.6 +/- 0.2 cm2) underwent a complete Doppler echocardiographic examination. According to the value of relative wall thickness (RWT = 2 x posterior wall thickness/LV end-diastolic diameter) and LV mass index (LVMI) in normal subjects (RWT < or = 0.44, LVMI < or = 125 gr/m2) AS patients were subdivided into four groups: Normal: no patients; Concentric Remodeling RWT > 0.44, LVMI < or = 125 gr/m2): 4 patients (7%); Concentric Hypertrophy (RWT > 0.44, LVMI > 125 gr/m2): 39 patients (70%); and Eccentric Hypertrophy (RWT < or = 0.44, LVMI > 125 gr/m2): 13 patients [23%]. Eccentric hypertrophy patients had, as compared with those with concentric hypertrophy, a larger left ventricle (61 +/- 6.5 mm vs 47.6 +/- 6 mm, P < or = 0.001), a smaller mean wall thickness (11.3 +/- 1.2 vs 14.7 +/- 1.7 mm, P < 0.001) and reduced LV fractional shortening (FS% = 22.9 +/- 11 vs 42.6 +/- 8.7%, P < 0.001). Furthermore, most patients (11/13) of the former group had heart failure due to LV systolic dysfunction, while only 16 of 39 patients of the latter group had heart failure and all but 2 had normal LV systolic function.(ABSTRACT TRUNCATED AT 250 WORDS)

Aged↗
PubMed2003

[Calcified aortic stenosis with left ventricular dysfunction and low transvalvular gradients. Must one reject surgery in certain cases?].

The natural history of severe aortic stenosis (aortic valve area < 1 cm2 or < 0.6 cm2/m2) with left ventricular systolic dysfunction and low transvalvular gradients (mean gradient < 40 mmHg) is mediocre in the short term and the operative risk is high. Dobutamine echocardiography provides a reliable evaluation of the aortic obstacle by diagnosing the rare cases of relative aortic stenosis in which the valve surface area has been underestimated because of a low cardiac output (aortic surface area > 1.2 cm2 with a mean gradient < 30 mmHg with dobutamine): in this case, the limited available data suggests that medical therapy with strict follow-up of its efficacy is the best management. The other use of dobutamine echocardiography is to assess left ventricular contractile reserve, defined as a increase > or = 20% in stroke volume under dobutamine. Cases with a contractile reserve have an operative risk of 5 to 10% and the medium-term benefits of valve replacement have been demonstrated. In the absence of contractile reserve, the operative risk is much grater, 30 to 60%, and also depends on other parameters such as the mean basal transaortic pressure gradient (risk five times greater in cases with a mean gradient < 20 mmHg), the need for coronary bypass surgery and associated co-morbid conditions. The surgical contraindications are in fact relatively few and concern patients with several risk factors: absence of contractile reserve itself is not a definitive surgical contraindication.

Aortic Valve Stenosis↗
PubMed2004

[Diabetes mellitus, left ventricular dysfunction and congestive heart failure].

Diabetes is a well known risk factor for the development of congestive heart failure. Epidemiological evidence in the community underscores the prevalence of left ventricular systolic dysfunction in diabetic patients as 2-fold with respect to non-diabetic ones, with half of them completely asymptomatic. Diastolic dysfunction in diabetic hearts, in comparison with non-diabetic, is even more frequent. The high prevalence has been explained by the frequent coexistence of an underlying diabetic cardiomyopathy, hypertension and ischemic heart disease. In these patients, the diabetic metabolic derangement, together with the early activation of sympathetic nervous system, induce a decrease of myocardial function. The activation of renin-angiotensin system results in an unfavorable cardiac remodeling. The progression from myocardial damage to overt dysfunction and heart failure is often asymptomatic for a long time and frequently undiagnosed and untreated. Currently, the widespread availability of echocardiography and possibly the use of cardiac natriuretic peptides, may allow for an earlier recognition of most of such patients. In heart failure, diabetic patients have a worse prognosis than non-diabetics. The available pharmacological treatments, such as ACE-inhibitors, beta-blockers and possibly angiotensin receptor blockers, togheter with a tight glycemic control, may be effective to reverse the remodeling process and prevent cardiovascular events. In order to identify most of the diabetic patients at risk of development of left ventricular dysfunction and to prevent its progression to overt heart failure, it seems important to elaborate a screening strategy in order to diagnose and treat most of diabetic patients with myocardial damage.

Diabetes Complications↗
PubMed1991

Angiographic prediction of cardiac events after first acute transmural myocardial infarction. A prospective study of 108 patients.

108 patients with acute myocardial infarction (MI), aged 70 years or younger, underwent left ventriculography and coronary arteriography (mean one month) after infarction and were followed up for an average period of 22 months (range 5-47 months). The contribution of angiographic variables to a first cardiac event (death, recurrent infarction, coronary artery bypass grafting or congestive heart failure) was evaluated with Kaplan-Meier survival curve analysis and long-rank test. Patients with cardiac events had left ventricular dilation, systolic dysfunction, multivessel coronary disease and lack of residual flow to the infarct region. Multivariate analysis showed that left ventricular end-systolic volume (P less than 0.001), end-diastolic volume (P less than 0.01) and the number of the diseased coronary vessels (P less than 0.05) were of significance in predicting the outcome. This prospective study indicates that in survivors of first acute transmural MI, cardiac catheterization performed one month after infarction can provide additive prognostic information that can be used to stratify risk.

Adult↗
PubMedDate not supplied

The relative effects of left ventricular hypertrophy, coronary artery disease, and ventricular dysfunction on survival among black adults.

OBJECTIVE: To evaluate the effect of echocardiographically determined left ventricular hypertrophy (LVH) on survival in comparison with number of stenosed vessels and left ventricular systolic dysfunction. DESIGN: Cohort study based on a consecutive sample from a hospital registry, with a mean follow-up of 5 years. SETTING: An inner-city public hospital in Chicago, Ill. PATIENTS: The study included 1089 consecutive black patients who underwent both coronary angiography and M-mode echocardiography as part of a diagnostic evaluation. RESULTS: Nonstenosed coronary arteries, single-vessel disease, and multivessel disease were found in 48%, 16%, and 36% of patients, respectively; LVH (left ventricular mass index > 131 g/m2 in men and > 100 g/m2 in women) was detected in 50% of patients. Hypertrophy without coexistent obstructive coronary disease was associated with a lower survival rate than that observed for single-vessel disease and was similar to multivessel disease. When LVH, number of diseases vessels, and left ventricular dysfunction were subjected to multivariate analysis, hypertrophy conferred a relative risk (RR) of 2.4 (95% confidence interval [CI], 1.7 to 3.2). By comparison, the presence of a single stenosed vessel did not increase the risk of death. Multivessel disease and ejection fraction less than 45% were associated with an RR of 1.6 (95% CI, 1.1 to 2.2) and 2.0 (95% CI, 1.4 to 2.7), respectively. Calculation of the attributable risk fraction demonstrated that for every 100 deaths in this cohort, LVH independently accounted for 37. The corresponding attributable risk fractions were 1%, 22%, and 9% for single-vessel disease, multivessel disease, and ventricular dysfunction, respectively. CONCLUSIONS: Left ventricular hypertrophy was associated with a greater RR and attributable risk than the traditional measures of coronary disease severity. The high prevalence and powerful risk of LVH make an important contribution to the adverse survival rates among black patients with heart disease and may account for much of the black-white differential.

Aged↗
PubMed1986

Alpha-adrenergic mechanisms in the pathophysiology of left ventricular heart failure--an analysis of their role in systolic and diastolic dysfunction.

Alpha-adrenoceptor (alpha-AR) mechanisms may contribute to systolic and diastolic dysfunction of the left ventricle. Centrally acting alpha 2-AR agonist drugs, including methyldopa, clonidine, and guanabenz, activate brainstem alpha 2-AR and this activation results in a decrease in overall sympathetic tone and an increase in parasympathetic tone. Peripherally acting alpha 1-AR antagonists, such as prazosin, inhibit the actions of catecholamines at post-synaptic receptor sites. Heart failure is characterized by hyperactivity of sympathetic pathways and parasympathetic withdrawal. In this situation, alpha 2-agonists reduce sympathetic activity and improve hemodynamic parameters of cardiac function; both acute and chronic administration of alpha 2-AR have been demonstrated to reduce serum catecholamine levels, heart rate, and arterial blood pressure, and to improve exercise performance. Diastolic dysfunction of the left ventricle is characterized by a marked decrease in ventricular compliance, often a result of hypertension and left ventricular hypertrophy; the end result is an increase in left ventricular filling pressure and pulmonary venous pressure. Treatment with alpha 2-AR, by decreasing sympathetic tone and blood pressure, and alpha 1-AR antagonists, by reducing blood pressure and by directly inhibiting the actions of catecholamines at alpha 1-AR, may produce a reduction in the degree of ventricular hypertrophy and improve diastolic performance of the left ventricle. Thus, therapeutic intervention in heart failure with either alpha 2-AR agonists or alpha 1-AR antagonists may favorably modulate these alterations in sympathetic tone and improve ventricular function.

Adrenergic alpha-Antagonists↗
PubMed1998

Effects of moderate exercise training on thallium uptake and contractile response to low-dose dobutamine of dysfunctional myocardium in patients with ischemic cardiomyopathy.

BACKGROUND: There is evidence that exercise training can induce myocardial and coronary adaptations in both animals and humans. However, the significance of these potentially important changes remains to be determined in patients with ischemic heart disease and left ventricular (LV) systolic dysfunction. METHODS AND RESULTS: To investigate whether exercise training can improve thallium uptake and the contractile response to low-dose dobutamine of dysfunctional myocardium, 46 patients (42 men, 4 women; mean age, 57+/-9 years) with chronic coronary artery disease and impaired LV systolic function (ejection fraction < 40%) were randomly assigned to two groups. The exercise group (n = 26) underwent exercise training at 60% of peak oxygen uptake for 8 weeks. The control group (n = 20) was not exercised. At baseline and after 8 weeks all patients underwent an exercise test with gas exchange analysis and stress echocardiography using low-dose dobutamine (5 to 10 microg/kg per minute) followed by thallium myocardial scintigraphy. Coronary angiography was performed in 23 patients at baseline and after 8 weeks. After 8 weeks, peak oxygen uptake increased significantly only in trained patients (24%). Significant improvements in the contractile response to dobutamine and thallium activity were observed in trained patients (28% and 31%, respectively; trained versus control: P<.001 for both). In a subgroup of trained patients, both improvements were correlated with an increase in the coronary collateral score (P<.005 and P<.001, respectively). CONCLUSIONS: Moderate exercise training improves both thallium activity and the contractile response of dysfunctional myocardium to low doses of dobutamine in patients with ischemic cardiomyopathy. The implication of this study is that even a short-term exercise training may improve quality of life by improvement of LV systolic function during mild-to-moderate physical activity in patients with ischemic cardiomyopathy.

Adaptation, Physiological↗
PubMedDate not supplied

[Underestimated--diastolic heart failure in elderly patients].

Age-related changes of diastolic left ventricular (LV) function consist of increased diastolic wall stiffness (reduced compliance) and diminished velocity and extent of relaxation. There is a shift of ventricular filling from early to late diastole. Atrial contribution to LV filling increases, which helps maintain stroke volume. In normal cardiovascular aging this diastolic dysfunction is compensated. However, the aging heart is sensitized against influences aggravating diastolic dysfunction such as arterial hypertension, LV hypertrophy, myocardial ischemia (coronary heart disease), tachycardias/ tachyarrhythmias. In diastolic heart failure LV is unable to fill adequately at normal diastolic pressures, resulting in symptoms of pulmonary congestion and, less often, low output despite normal LV size and contraction. Diastolic heart failure may be misinterpreted as systolic dysfunction and, eventually, treated in an unsuitable manner. In order to obtain data on the incidence of diastolic heart failure among inpatients of a department of geriatrics of a municipal hospital, the results of 253 patients undergoing echocardiography in the course of 1 year were analyzed. The investigations comprised 70 males and 183 females, aged 81.3 (61-98) years on average. In 164 cases, symptoms of heart failure were present. Only in 48 of them (29%) LV proved to be dilated. In the majority, LV size was normal (116 patients; 71%): systolic function was compromised in 53 cases, whereas 63 patients (38% of all cases with heart failure) had a normal systolic function. Most of the latter (48 patients) had diastolic dysfunction, whereas an adequate echocardiographic evaluation was not possible for technical reasons in the remaining 15 cases. It is highly probable, however, that they had diastolic LV dysfunction as well. Thus, the results show a high frequency of LV dysfunction in elderly inpatients, which underlines the importance of diastolic heart failure in this age group.

Aged↗
PubMed2005

[Transient ventricular dysfunction (Takotsubo cardiomyopathy)].

The patient was a male with myasthenia gravis, hospitalized with acute respiratory failure due to decompensation of the underlying disease. He evolved with findings suggestive of acute myocardial infarction, with electrocardiographic and enzymatic alterations compatible with that diagnosis. The patient underwent emergency coronary angiography, which showed no severe coronary obstruction, although his left ventricle had significant systolic dysfunction with characteristic alterations, on ventriculography, of the syndrome described as transient ventricular dysfunction or Takotsubo syndrome. On evolution, complete recovery of the electrocardiographic alterations and systolic ventricular function assessed on echocardiography occurred, confirming the syndrome.

Cardiomyopathies↗
PubMed2006

Impaired left ventricular systolic function early after heart transplantation is associated with cardiac allograft vasculopathy.

Cardiac allograft vasculopathy (CAV) is a major cause of death more than 1 year after heart transplantation. We evaluated the role and possible predictive value of different etiological factors on development of CAV as diagnosed by quantitative coronary angiography (QCA). A total of 121 patients were studied with baseline QCA and 117 had a follow-up study at 1 year to assess the relationship of mean lumen diameter loss (MLDL) in main coronary arteries to immunological and non-immunological factors potentially affecting long-term survival. Out of them, 103 patients were males (85%), 114 (94%) patients were Caucasians and mean age was 48.5 +/- 10 years. Univariate analysis showed that MLDL at 1 year was inversely related to echocardiographic fractional shortening (FS) measured within the first week after transplantation (p = 0.0098) and to intracranial hemorrhage as cause of donor death (p = 0.04) and was directly related to male donors (p = 0.0008), domino transplants (p = 0.037) and donor negative cytomegalovirus (CMV) status (p = 0.022). Multivariate analysis showed that initial FS (p = 0.006) and donor intracranial hemorrhage as a cause of death (p = 0.042) were inversely related to MLDL whereas donor male sex (p = 0.003) and prednisolone treatment throughout the first year (p = 0.012) were directly related. Thus, left ventricular systolic dysfunction early after heart transplantation was associated with subsequent development of CAV.

Coronary Angiography↗
PubMed2006

N-terminal proBNP levels in patients with Chagas disease: a marker of systolic and diastolic dysfunction of the left ventricle.

AIMS: NT-proBNP levels are known to be elevated in systolic and diastolic dysfunction. Doppler indices of diastolic dysfunction (DD) have been shown to have prognostic value in patients with Chagas' cardiomyopathy (CC). However, the additional value of NT-proBNP levels in further stratifying these patients according to DD has not been established. This study analyzed the correlation of N-terminal proBNP (NT-proBNP) levels with systolic and diastolic function in patients with CC. METHODS AND RESULTS: NT-proBNP levels were measured in 59 patients with dilated cardiomyopathy due to Chagas disease without other systemic illness that were studied by Doppler echocardiography, including left atrial volume (LAV) calculation and tissue Doppler evaluation of LV longitudinal function. Univariate analysis showed a strong correlation of NT-proBNP values with LVEF (r=-0.733, p<0.001) and a weak correlation with most Doppler echocardiographic parameters of diastolic function. On a multivariate analysis, LVEF and LAV volume emerged as correlating with elevated levels of the NT-proBNP. Patients with restrictive filling pattern (n=10), when compared to other patterns of DD, (n=49), showed a lower LVEF (25.4+/-6.4% vs. 39.8+/-9.4, p<0.001), a larger LAV (50.1+/-17.2 vs. 37.7+/-15.6 ml/m(2), p=0.004) and higher NT-proBNP levels (median+/-IQR: 3488+/-3056 vs. 492+/-700 pg/dl, p<0.001). A marked elevated concentration of NT-proBNP (> or =800 pg/ml) had a sensitivity of 90.0%, specificity of 70.5%, positive predictive value of 40.9% and negative predictive value of 96.9% for detecting a restrictive filling pattern. CONCLUSION: In patients with CC, NT-proBNP augmentation is a marker of LV dysfunction, with higher levels correlating with the more severe forms of both systolic and diastolic dysfunction.

Adult↗
PubMed2006

Cost-effectiveness of eplerenone in patients with left ventricular dysfunction after myocardial infarction--an analysis of the EPHESUS study from a Swiss perspective.

OBJECTIVE: The EPHESUS study demonstrated that aldosterone blockade with eplerenone decreased mortality in patients with left ventricular systolic dysfunction (LVSD) and heart failure after acute myocardial infarction (AMI). The EPHESUS pharmacoeconomic analysis was performed to evaluate the cost-effectiveness of eplerenone in the Swiss setting. MATERIALS AND METHODS: A total of 6,632 patients with LVSD and heart failure after AMI were randomized to eplerenone or placebo and followed for a mean of 16 months. The co-primary endpoints were all-cause death and the composite of cardiovascular death/cardiovascular hospitalization. The evaluation of resource use included hospitalizations, outpatient services, and medications. Survival beyond the trial period was estimated using data from the Framingham Heart Study, the Saskatchewan Health database, and the Worcester Heart Attack Registry. The incremental cost-effectiveness of eplerenone in cost per life-year and quality-adjusted life-year gained was estimated. The perspective of the Swiss third party payers was used. Daily treatment costs of eplerenone were set at CHF 3.88. All other resources were valued on the basis of official tariffs. Discounting of the results was performed at a rate of 3%. RESULTS: The number of life-years gained with eplerenone was 0.1083 based on Framingham, 0.0661 with Saskatchewan and 0.1518 with Worcester survival estimates. Total costs were CHF 1,028 higher over the trial period in the eplerenone arm, due to drug cost. The incremental cost-effectiveness ratio was CHF 10,145 per life-year gained with Framingham, CHF 16,178 with Saskatchewan, and CHF 7,693 with Worcester survival estimates. The corresponding costs per QALY were CHF 15,219, CHF 23,965 and CHF 11,337, respectively. CONCLUSION: Eplerenone is effective in reducing mortality and, in Switzerland, is also cost-effective in increasing years of life for patients with LVSD after AMI.

Adult↗
PubMed2006

Effects of nebivolol in elderly heart failure patients with or without systolic left ventricular dysfunction: results of the SENIORS echocardiographic substudy.

AIMS: The SENIORS trial recently demonstrated that nebivolol reduces the composite risk of all-cause mortality and cardiovascular hospital admission in elderly patients with chronic heart failure and, importantly, that ejection fraction does not influence the clinical effects of nebivolol. An echocardiographic substudy was designed to evaluate the effects of nebivolol on systolic and diastolic left ventricular (LV) function in patients stratified according to the presence or absence of systolic LV dysfunction. METHODS AND RESULTS: The substudy randomized 112 patients in 29 European centres, of whom 104 were evaluable for the study; 43 had an ejection fraction (EF) 35%. LV end-systolic volume (ESV), EF, mitral valve E/A ratio, and E-wave deceleration time were assessed at baseline and after 12 months. Echocardiograms were submitted to a core laboratory to perform quantitative analysis in blinded condition. In the group with EF</=35%, nebivolol reduced ESV (adjusted difference between treatments 25.8 mL, 95%CI: -46.6; -5.0, P=0.016) and improved EF (adjusted difference between treatments 4.6%, 95%CI: 1.3;7.9, P=0.008); no changes were observed in the E/A ratio or E-wave deceleration time. In EF>35% group, no significant changes in either systolic or diastolic parameters were observed. CONCLUSION: In patients with heart failure and advanced systolic LV dysfunction, nebivolol reduces ventricular size and improves EF. The absence of detectable changes with standard echocardiography in patients with predominant diastolic heart failure questions the mechanism of benefit on morbidity/mortality in such patients.

Adrenergic beta-Antagonists↗
PubMed2000

Diastolic heart failure in the community.

Although it is now widely recognized that isolated diastolic dysfunction can lead to the classic signs and symptoms of congestive heart failure (CHF), this disease process is poorly understood and remains of great interest and concern to cardiovascular disease specialists, as well as to primary care physicians. Recent epidemiologic data have suggested that diastolic heart failure is predominantly a disease of the elderly, the fastest growing segment of our population. Diagnosis is often difficult in this subgroup of patients due to the presence of confounding comorbidities. However, early identification in community-based practices and timely intervention is important due to the significant disability and death that results from this progressive disease process. The poor prognosis of CHF patients with systolic dysfunction is shared by those with isolated diastolic heart failure and preserved systolic function. Further studies of the prevalence, clinical characteristics, and natural history of patients with diastolic dysfunction are needed. This review focuses on the emerging data regarding the prevalence and natural history of diastolic heart failure in the community.

Diastole↗
PubMed1990

Neuroendocrine activation after acute myocardial infarction.

Neuroendocrine response after acute myocardial infarction (MI) results in activation of the sympathetic nervous system, the renin-angiotensin system, and vasopressin and atrial natriuretic peptide release. The net effect of this response is vasoconstriction, cardiac stimulation and regional flow redistribution that may have a favorable effect in some situations and a deleterious effect in others. The possible adverse effects of vasoconstriction were studied in a Veterans Administration Cooperative Study that evaluated a 48-hour infusion of sodium nitroprusside in the setting of acute MI. In the presence of mild, probably primarily diastolic left ventricular dysfunction, nitroprusside appeared to have an adverse effect on long-term survival. However, in the presence of more severe, probably predominantly systolic dysfunction, nitroprusside had a favorable effect on the prognosis. Therefore, the decision of whether to accept or inhibit neuroendocrine activation in acute MI probably depends on the severity of the disease and the timing of the therapeutic intervals.

Atrial Natriuretic Factor↗
PubMed2005

Late outcome of Senning and Mustard procedures for correction of transposition of the great arteries.

OBJECTIVES: To evaluate late mortality and morbidity after an atrial switch procedure for correction of transposition of the great arteries (TGA) and to assess predictive factors for adverse outcome. SETTING: Tertiary referral centre. DESIGN AND PATIENTS: Retrospective follow up study of 137 patients surviving hospitalisation for TGA atrial switch procedure (Mustard or Senning) in a single institution and divided into two groups (simple and complex) depending on presurgical anatomy. Several surgical and follow up factors were evaluated during 16.7 (5.6) years' follow up. RESULTS: Late mortality was 5.1% (95% confidence interval 1.37% to 8.84%) with sudden death as the most common cause. No significant difference was found between Mustard and Senning procedures and between the complex and simple groups in terms of mortality. Independent predictive factors for late mortality were a history of supraventricular tachyarrhythmias and advanced New York Heart Association (NYHA) functional class during follow up. A very common finding was development of sinus node dysfunction (47.6%), which had no influence on mortality. There was little need for reintervention (5.1%) and relatively few cases of right ventricular systolic dysfunction (14.6%). During follow up, most patients (96.2%) were in NYHA functional class I-II. CONCLUSIONS: Overall long term outcomes of patients with atrial repair of TGA in the present era are encouraging in terms of late mortality and quality of life. Nevertheless, better outcomes may be offered through improved diagnostic methods for right ventricular function and better management of supraventricular tachyarrhythmias.

Adolescent↗
PubMed2006

Sepsis-associated myocardial dysfunction: diagnostic and prognostic impact of cardiac troponins and natriuretic peptides.

Myocardial dysfunction, which is characterized by transient biventricular impairment of intrinsic myocardial contractility, is a common complication in patients with sepsis. Left ventricular systolic dysfunction is reflected by a reduced left ventricular stroke work index or, less accurately, by an impaired left ventricular ejection fraction (LVEF). Early recognition of myocardial dysfunction is crucial for the administration of the most appropriate therapy. Cardiac troponins and natriuretic peptides are biomarkers that were previously introduced for diagnosis and risk stratification in patients with acute coronary syndrome and congestive heart failure, respectively. However, their prognostic and diagnostic impact in critically ill patients warrants definition. The elevation of cardiac troponin levels in patients with sepsis, severe sepsis, or septic shock has been shown to indicate left ventricular dysfunction and a poor prognosis. Troponin release in this population occurs in the absence of flow-limiting coronary artery disease, suggesting the presence of mechanisms other than thrombotic coronary artery occlusion, probably a transient loss in membrane integrity with subsequent troponin leakage or microvascular thrombotic injury. In contrast to the rather uniform results of studies dealing with cardiac troponins, the impact of raised B-type natriuretic peptide (BNP) levels in patients with sepsis is less clear. The relationship between BNP and both LVEF and left-sided filling pressures is weak, and data on the prognostic impact of high BNP levels in patients with sepsis are conflicting. Mechanisms other than left ventricular wall stress may contribute to BNP release, including right ventricular overload, catecholamine therapy, renal failure, diseases of the CNS, and cytokine up-regulation. Whereas cardiac troponins may be integrated into the monitoring of myocardial dysfunction in patients with severe sepsis or septic shock to identify those patients requiring early and aggressive supportive therapy, the routine use of BNP and other natriuretic peptides in this setting is discouraged at the moment.

Biomarkers↗