Effect of immunosuppressive therapy in inflammatory cardiomyopathy: data from The Czech Inflammatory Cardiomyopathy Immunosuppressive Trial.

INTRODUCTION: The indications for specific treatment in the cases of inflammatory cardiomyopathy are based on limited data from several small clinical trials. AIM: A comparison of the effect of two dose regimens of combined immunosuppressive therapy by adding them to conventional heart failure therapy and comparing them with conventional heart failure therapy alone in patients with inflammatory cardiomyopathy. METHODS AND STUDY POPULATION: We enrolled 20 patients; mean age 46.10±7.33 years, duration of symptoms <6 months, LVEF ≤40 %, NYHA class II-IV, with biopsy­proven myocarditis. Patients were randomly separated into groups treated with immunosuppressive therapy in addition to conventional heart failure therapy or to a group treated with conventional heart failure therapy alone. Clinical and echocardiographic parameters were evaluated. RESULTS: The baseline values of LVEF in the group of immunosuppressive therapy (LVEF 22.3±4.7 %) were similar to those in the group treated with conventional heart failure therapy (LVEF 21.7±4.7 %; p=0.757). After twelve months there was no statistically significant difference in LVEF between the two studied groups (LVEF 33.7±9.5 % for the immunosuppressive therapy group and 41.3±13.0 % for the conventional therapy group; p=0.175). CONCLUSION: In our study population, we proved no positive effect of combined immunosuppressive therapy on the left ventricular function over 12 months. The main limitation of the study is the small number of enrolled patients (Tab. 4, Fig. 1, Ref. 35).

[Farmacotherapy of hypertension after heart transplantation]. / Farmakoterapie hypertenze po transplantaci srdce.

Heart transplantation is now used for the treatment of severe heart failure. In a long-term patient follow-up, hypertension has been identified as a complication. Incidence of hypertension in patients treated with cyclosporine and prednisone is between 70-90%. Besides the traditional mechanisms (renin-angiotensin system, fluid volume and peripheral resistance), aetiology of hypertension includes negative effect of cardiac denervation, cyclosporine immunosuppression, administration of corticosteroids and nephropathy. There is no night drop in the blood pressure and heart rate. Treatment aims to maintain cyclosporine level as low as possible and, if feasible, to discontinue steroids during the first year. Hypertension is usually treated with a combination therapy. Our own observations suggest that the majority of post-transplantation patients have a dual therapy. Calcium channel blockers should be the treatment of choice as they also have an effect on graft vasculopathy. Angiotenzin-converting enzyme (ACE) inhibitors or angiotensin II receptor blockers (ARB), beta-blockers and diuretics are also recommended. Long-acting products should be preferred.

[Heart transplantation]. / Transplantace srdce.

The first heart transplantation (SHT) was performed by Professor Ch. Barnard in 1967 but it was not until 1980s that this method became an established approach to treatment of patients with end-stage heart failure. Considering the limited number of donor organs and the number of potential post-transplantation complications, the decision to perform heart transplantation at the right time in an indicated patient is difficult and complex. Subsequent pharmacological management with immunosuppressive agents and other medication becomes everyday life reality. Knowledge of drug interactions and collaboration with cardiologists are necessary in order to maintain long-term treatment success. Despite the current developments in surgical methods, examination methods and immunosuppressant therapy, a range of complications has to be dealt with. The future of care for patients with transplants will rely on the development of new immunosuppressive drugs with a minimum of adverse effects and discovery of a non-invasive technique for graft rejection diagnosis.

Contribution to the V-V interval optimization in patients with cardiac resynchronization therapy.

The present study proposed procedure for predicting an optimal left and right ventricular pacing interval delay (V-V interval). In 16 patients (heart failure, left bundle branch block, biventricular pacing) two methods (A and B) identifying optimal V-V interval were tested. Method A: predicted optimal V-V interval A (POVV-A) = electromechanical delay of the segment paced by left ventricle lead minus electromechanical delay of the segment paced by right ventricle lead. Method B: predicted optimal V-V interval B (POVV-B) = difference in the onset of aortic and pulmonary flows. Both methods were validated using echocardiography and right-sided heart catheterization. Cardiac output during POVV-A (4.6 l.min(-1)) was significantly better than that during POVV-A minus 20 ms (4.3 l.min(-1), p<0.01) and POVV-A plus 20 ms (4.3 l.min(-1), p<0.01), and than that during POVV-B (4.4 l.min(-1), p<0.05). LV dP/dt during POVV-A (818 mm Hg.s(-1), exceeded that during POVV-A plus 20 ms (717 mm Hg.s(-1),, p<0.05) and POVV-A minus 20 ms (681 mm Hg.s(-1), p<0.05), and that during POVV-B (727 mm Hg.s(-1), p<0.01). The time difference in onsets of myocardial deformation of left ventricle segment paced by the left ventricle and right ventricle lead allows identifying the optimal V-V interval and improves left ventricle performance.

Cardiac resynchronization therapy. Midterm follow-up of 128 patients.

OBJECTIVE: Cardiac resynchronization therapy has been used in the treatment of advanced heart failure with inter- and intraventricular dyssynchrony for more than ten years. AIM OF THE STUDY: A retrospective study was conducted to assess midterm results of biventricular (BiV) pacing in cardiac resynchronization therapy. METHODS: 128 consecutive patients (age 61.0+/-9.6, 98 males), with heart failure NYHA class 2.9+/-0.4 (2.5-3.5), with LBBB, QRS> or =130 ms, with dilated cardiomyopathy--DCM (86), with coronary artery disease--CAD (36), with both these etiologies (4) and with valvular disease (2) had a BiV PM (82) or BiV ICD (46) implanted in 2000-2007. AV delay was optimized individually, using echocardiography. Before and 3 months after implantation, the following was established: NYHA class, LVEF (echocardiographically), maximum oxygen uptake (spiroergometrically), left ventricle diastolic diameter and mitral regurgitation. The average follow-up time was 25.8+/-20.8 months. Complications and 2-year survival (n=68) were also assessed. RESULTS: 1) After 3 months of BiV pacing, NYHA class improved from 2.9+/-0.4 to 2.4+/-0.6 (n=99, p<0.001), LVEF increased from 20.2+/-4.9 to 23.9+/-6.6 % (n=92, p<0.001). Left ventricle diastolic diameter decreased from 69.8+/-8 to 67.5+/-10.0 mm (n=88, p=0.001) and mitral regurgitation was reduced from 2.2+/-0.9 to 1.9+/-0.9 (n=87, p=0.001) and maximum oxygen uptake during spiroergometry increased from 14.5+/-2.7 to 15.5+/-2.6 ml/min/kg (n=52, p=0.005). 2) Coronary sinus lead reposition was done in 2.3 %, epicardial lead implantation in 4.7 %, atrial lead reposition in 2.3 %, and right ventricular lead reposition in 2.3 % of patients. Contralateral reimplantation due to inflammatory complications in 1.6 % of patients. 3) Heart transplantation was performed on 9 patients. 4) Two-year survival was recorded in 77.9 % of 68 followed patients (72.2 % in CAD, 79.6 % in DCM). CONCLUSION: In the retrospective study of patients with BiV pacing a decline in heart failure, an increase in cardiac pump efficiency, reverse remodelling of left ventricle and acceptable occurrence of complications were confirmed (Tab. 4, Fig. 7, Ref. 18). Full Text (Free, PDF) www.bmj.sk

WITHDRAWN: Prognostic Importance of the Right Ventricular Function Assessed by Doppler Tissue Imaging.

The publisher regrets that this was an accidental duplication of an article that has already been published in Eur. J. Echocardiogr., 4 (2003) 262-271, . The duplicate article has therefore been withdrawn.

[Does G8002A polymorphism in endothelin gene have a meaning for other risks at the patients with heart failure?]. / Má polymorfizmus G8002A v genu pro endotelin význam pro dalsí rizika u pacientu se srdecním selháním?

UNLABELLED: Objective of the work is to determine the relation of G8002 polymorhism in endothelin 1 gene to the incidence of diabetes mellitus (DM), ischemic disease of lower limbs (ID LL) and myocardial infarction (MI) at the patients with heart failure. METHODICS: There were observed 224 patients, 176 males, 48 females, average age 55 +/- 12 years, NYHA II/III/IV 82/131/11, average EF LK 25 +/- 7 %, diagnosis ischemic heart disease (IHD) 133, dilatation cardiomyopathy (DCMP) 91. RESULTS: Patients with IHD had higher incidence of hypertension (p < 0.0007), diabetes mellitus (p < 0.00007) and hyperlipoproteinemy (p < 0.0006) than patients with DCMP. Patients with IHD who experienced MI had a difference in the distribution of G8002A genotypes for endothelin 1 gene: G 0.718 and A 0.282 alleles vs ischemic patients without MI G 0.882 and A 0.118 (p < 0.05) alleles. Ischemic patients with DM had G allele in 0.67 and A 0.33 unlike ischemic patients without DM G allele 0.791 and A 0.209 (p < 0.03). Ischemic patients with synchronous ID LL had G allele in 0.718 and A 0.282 vs ischemic patients without ID LL G allele 0.882 and A 0.118 (p < 0.0004). At the patients with DCMP there was not found a difference in G8002A genotype and the presence of DM or ID LL. RESULTS: At the patients with heart failure on the basis of ischemic heart disease there was found a difference in endothelin G8002A genotype distribution depending on other accessory diseases. There was more frequently present an A allele and less present G allele in the ischemic patients with DM, who had experienced MI or ID LL than in the ischemic patients without these diseases. Genotype with A allele is connected with higher risk of all accessory diseases.

[Transplantation of the heart--indications, complications, therapy--our experience from investigations of 100 patients after cardiac transplantation]. / Transplantace srdce--indikace, komplikace, terapie--nase zkusenosti ze sledování 100 pacientu po srdecní transplantaci.

Transplantation of the heart has become an accepted method for the treatment of terminal cardiac failure. Despite obvious advances in the care of patients after trasplantation a number of problems exist. The authors summarize their experience with the long-term follow-up of 100 adult patients with transplantations made in the Brno Centre of Cardiovascular and Transplantation Surgery. One-year survival in the group of patients is 80%, three-year survival 69%. The authors discuss indications and contraindications of cardiac transplantations, necessary preoperative and postoperative examinations, they follow-up the most serious complications during the posttransplantation period. They mention therapeutic possibilities and outline briefly the perspectives of care of patients after cardiac transplantation. Despite the number of problems encountered transplantation of the heart is for indicated patients with cardiac failure a unique chance to improve the prognosis of survival and the quality of life.

[Disorders of laminins in diseases of myocardial and skeletal muscles]. / Poruchy laminu u postizení srdce a kosterního svalstva.

UNLABELLED: The Emery-Dreifuss muscular dystrophy is caused by muscular lesions and disorders of cardial rhythm and/or by cardiomyopathy. An autosomal dominant form is related to mutations of genes, which are coding for lamins A/C. GROUP AND METHODS: In the group A the authors examined 37 patients with the diagnosis of dilatation cardiomyopathy (DKMP) and the mean ejection fraction 28.4; 8.8%. In the group B of 13 patients a cardiac stimulator was implanted for a rhythm disorder. Both groups were subjected to cardiological, neurological, clinical and electromyographic (EMG) examinations. A muscle biopsy from m. vastus lateralis was made and the sample was evaluated by histology, histochemistry and immunohistochemistry. The coding sequences of genes for lamins were amplified by polymerase chain reaction and the products were analyzed by the DHPLC method (denaturing higher performance liquid chromatography). RESULTS: In the group A there was a clinically myopathic picture in three patients, while EMG examination revealed a myogenic finding in 12 patients and a marginally myogenic one in five patients. The histological finding in 12 patients was evaluated as myogenic and marginally myogenic in six. In one patient the mutation analysis revealed mutation in the gene for lamin A/C. A myogenic finding in this patient was determined by EMG as well as by histological examination and the autosomal dominant form of the Emery-Dreifuss muscular dystrophy was therefore diagnosed. In the group B one patient displayed a myopathic neurological finding and a myogenic finding during EMG. A subsequent mutation analysis revealed a mutation in the gene for lamin A/C. The case was therefore the autosomal dominant form of the Emery-Dreifuss muscular dystrophy. In the other patients the clinically marginal myopathic finding was observed once, a marginally myogenic finding during EMG was seen five times, histology and immunochemistry revealed a myogenic finding once and a marginally myogenic finding also once. The other findings were within normal range. CONCLUSIONS: A careful neurological examination including EMG determined symptoms of skeletal muscle myopathies in a surprisingly high percentage of our cardiological patients. This observation draws attention to the need of neurological examination in patients with DKMP in order to discovered disorder in this area in time. In two patients mutations in genes coding lamins A/C were detected. It would be useful to analyze also genes coding for other cytoskeletal proteins in the future.

[Does insufflation of the abdomen in laparoscopic surgery affect acid-base and ventilatory parameters?]. / Ovlivnuje insuflace bricha pri laparoskopické operaci acidobazické a ventilacní parametry?

The cardiopulmonary and metabolic changes experienced by patients undergoing laparoscopic cholecystectomy with CO2 pneumoperitoneum are not well understood. The purpose of this study is to determine changes of basal parameters during laparoscopy and evaluate their prognostic value. One hundred patients (26 obese, 39 older than 60 years, 7 obese and older than 60) undergoing laparoscopic cholecystectomy for uncomplicated cholecystolithiasis were included in the study. Arterial blood gases, respiratory and ventilatory parameters, heart rate, blood pressure were determined before the induction of pneumoperitoneum, at the peak of operation and after exsufflation. The obtained variables were statistically evaluated. Pneumoperitoneum caused significant hypercapnia and a decrease of pH accompanied with increase of expiratory CO2 concentration, which continued after exsufflation (p < 0.001). The changes were more expressed in older and obese patients and were solely of a respiratory type. No significant changes were observed in the heart rate, blood pressure, minute ventilation, PaO2, SaO2, base excess. Although changes were highly significant, there was no impact on clinical status--all patients survived without problems. The authors conclude that observed increase of carbon dioxide levels and decrease of pH had no impact on survival of patients. Changes were caused mostly by CO2 absorption from the abdominal cavity. Laparoscopic cholecystectomy is a safe and effective procedure even in older and obese patients, especially when insufflation is as low as possible.

Intracisternal administration of Mycobacterium tuberculosis potentiates the delayed type hypersensitivity in guinea-pigs.

The delayed type hypersensitivity (DTH) was studied in guinea-pigs using the skin test. The mycobacterium tuberculosis (M. tbc)--was applied by various routes. The control group received ovalbumin in Freund's incomplete adjuvant (FIA) into the footpad. The first experimental group received ovalbumin in Freund's complete adjuvant (FCA) into the footpad. The other experimental groups always received, in addition to ovalbumin plus FIA into the footpad, the M. tbc. 1. intracisternally, 2. intramuscularly, 3. intraperitoneally, 4. orally. On the day of administration of the sensibilizing substance, the body temperature was monitored. The skin test was measured after 14 and 21 days. It was established that, for the study of the DTH, the 21-day interval was more significant than the 14-day interval. A 100 times smaller dose of M. tbc. given intracisternally had the same immunostimulating effect as the injection of ovalbumin with M. tbc into the footpad (p less than 0.01). The size of the skin reaction was not only significantly influenced by the intramuscular and oral administration of M. tbc. On the other hand, the intraperitoneal administration inhibited the DTH (p less than 0.01). The increase of body temperature after the administration of M. tbc. correlated with the influence on the DTH except for the intraperitoneal administration. The route of the M. tbc. administration was crucial for the development of the DTH.

Prognostic importance of the right ventricular function assessed by Doppler tissue imaging.

AIMS: We sought to assess whether the peak systolic and diastolic tricuspid annular velocities as indicators of the right ventricular systolic and diastolic function are of prognostic importance in patients with symptomatic heart failure. METHODS AND RESULTS: The study included 139 consecutive patients with symptomatic heart failure. Their mean left ventricular ejection fraction was 24% (range, 10-39%); 107 patients (77%) were in functional class III according to the New York Heart Association. All patients underwent clinical and laboratory examination, standard echocardiography completed by the Doppler tissue imaging of the tricuspid annular motion, and the right-sided heart catheterization. They were followed up for cardiac-related death and non-fatal cardiac events including the need for implantation of a cardioverter-defibrillator and hospitalization for heart failure. The median follow-up was 11 months (range, 1-48 months). There were 17 cardiac-related deaths and 23 non-fatal cardiac events. The multivariate stepwise Cox regression modelling revealed three effective predictors for both survival and event-free survival: aetiology of heart failure, left ventricular end-diastolic diameter, and the peak systolic tricuspid annular velocity (Sa). Patients with Sa<10.8cms(-1) exhibited worse survival (P=0.048) and event-free survival (P<0.001) compared with those having Sa>/=10.8cms(-1). Risk values of Sa (<10.8cms(-1)) and the left ventricular end-diastolic diameter (>70mm) were found to be of additive simultaneous influence leading to a very poor prognosis, mainly if aetiology of heart failure was idiopathic dilated cardiomyopathy (P<0.001). CONCLUSION: The Sa represents a significant independent predictor of survival and event-free survival in patients with symptomatic heart failure. Its combination with the left ventricular end-diastolic diameter provides a very powerful tool for patient risk stratification.

Pulsed Doppler tissue imaging of the velocity of tricuspid annular systolic motion; a new, rapid, and non-invasive method of evaluating right ventricular systolic function.

AIMS: Rapid, accurate, and widely available non-invasive evaluation of right ventricular function still presents a problem. The purpose of the study was to determine whether the parameters derived from Doppler tissue imaging of tricuspid annular motion could be used as indexes of right ventricular function in patients with heart failure. METHODS: Standard and pulsed Doppler tissue echocardiography were obtained in 44 patients with heart failure (mean left ventricular ejection fraction 24 +/- 7%) and in 30 age- and sex-matched healthy volunteers. The tricuspid annular systolic and diastolic velocities were acquired in apical four-chamber views at the junction of the right ventricular free wall and the anterior leaflet of the tricuspid valve using Doppler tissue imaging. Within 2 h of Doppler tissue imaging, the first-pass radionuclide ventriculogram, determining right ventricular ejection fraction and equilibrium gated radionuclide ventriculography single photon emission computed tomography, were performed in all patients. RESULTS: In patients with heart failure, the peak systolic annular velocity was significantly lower and the time from the onset of the electrocardiographic QRS complex to the peak of systolic annular velocity was significantly greater than the corresponding values in healthy subjects (10.3 +/- 2.6 cm. s(-1) vs 15.5 +/- 2.6 cm.s(-1), P < 0.001, and 198 +/- 34ms vs 171 +/- 29 ms, P < 0.01, respectively). There was a good correlation between systolic annular velocity and right ventricular ejection fraction (r = 0.648, P <0.001). A systolic annular velocity < 11.5 cm.s(-1)predicted right ventricular dysfunction (ejection fraction < 45%) with a sensitivity of 90% and a specificity of 85%. CONCLUSION: We conclude that the evaluation of peak systolic tricuspid annular velocity using Doppler tissue imaging provides a simple, rapid, and non-invasive tool for assessing right ventricular systolic function in patients with heart failure.