Heart failure as presenting manifestation of cardiac involvement in systemic lupus erythematosus.

BACKGROUND: Heart failure in systemic lupus erythematosus (SLE ) is rare, and its long-term outcome is unknown. The aim of this study was to analyse the long-term outcome of six SLE patients with heart failure as first manifestation of cardiac involvement and to review previously reported cases. METHODS: We conducted a retrospective chart review of SLE patients from two tertiary referral centres who presented between 1999 and 2004 with clinical and echocardiographic signs of heart failure as their first manifestation of cardiac involvement. Details of the clinical presentation and follow-up and serial findings at echocardiography were collected. A retrospective review of the literature was performed using the PubMed database. RESULTS: Six cases were identified who presented with heart failure, as confirmed by echocardiography (left ventricular ejection fraction (LVEF) ranging from 23 to 37%). Treatment with high-dose glucocorticoids, cytotoxic treatment (azathioprine in one patient, cyclophosphamide in five patients), intravenous immunoglobulins (in one patient) and temporary inotropic support (two patients) resulted in complete resolution of symptoms and improvement of LVEF , with a mean follow-up of 77 months (range 43 to 113). Twenty-one additional cases of heart failure as manifestation of cardiac involvement in SLE have been reported, most with favourable short-term outcome following institution of immunosuppressive therapy. CONCLUSIONS: Heart failure is a rare but life-threatening manifestation of cardiac involvement in SLE. Long-term outcome can be excellent when aggressive treatment is instituted promptly.

Prognostic value of echocardiography after acute myocardial infarction.

Echocardiography is useful for risk stratification and assessment of prognosis after myocardial infarction, which is the focus of this review. Various traditional echocardiographic parameters have been shown to provide prognostic information, such as left ventricular volumes and ejection fraction, wall motion score index, mitral regurgitation and left atrial volume. The introduction of tissue Doppler imaging and speckle-tracking strain imaging has resulted in additional prognostic parameters, such as left ventricular strain (rate) and dyssynchrony. Also, (myocardial) contrast echocardiography provides valuable information, particularly about myocardial perfusion (as a marker of myocardial viability), which is strongly related to prognosis after myocardial infarction. Stress echocardiography provides information on ischaemia and viability, coronary flow reserve can be obtained by Doppler imaging of the coronary arteries, and finally, three-dimensional echocardiography provides optimal information on left ventricular volumes, function and sphericity, which are also important for long-term outcome.

Effect of intramyocardial bone marrow cell injection on left ventricular dyssynchrony and global strain.

OBJECTIVE: To evaluate the effect of bone marrow cell injection on global strain and left ventricular (LV) dyssynchrony. METHODS: In 14 patients with severe postinfarction heart failure, 93 (14) x 10(6) autologous bone marrow cells were percutaneously injected in the infarction border zone. LV ejection fraction (LVEF), LV dyssynchrony and echocardiographic global strain were assessed at baseline and 3 months in patients and in a non-randomised control group of 10 patients with a history of infarction who developed heart failure and were treated medically. RESULTS: No periprocedural complications occurred during bone marrow cell injection. At 3 months mean (SD) LVEF increased from 23 (8)% to 27 (9)% (p = 0.02) and global strain improved from -7.7 (4.7)% to -8.5 (4.9)% (p = 0.04). In patients with > or =5% improvement in LVEF after bone marrow cell injection, global strain improved from -8.7 (4.6)% to -10.6 (4.5)% (p<0.01). Global strain remained unchanged in patients with <5% improvement in LVEF (-6.6 (4.9)% vs -6.4 (4.5)%, p = NS). The relation between the increase in LVEF and improvement in global strain was significant (r = 0.84, p<0.01). In patients with > or =5% improvement in LVEF, LV dyssynchrony decreased from 173 (64) ms to 116 (64) ms (p = 0.01). In patients with <5% improvement in LVEF, LV dyssynchrony remained unchanged (155 (67) ms vs 177 (81) ms, p = NS). The correlation between improvement in LVEF and reduction in LV dyssynchrony was good (r = -0.77, p<0.01). In the control group, LVEF, global strain and LV dyssynchrony did not improve. CONCLUSIONS: Bone marrow cell injection improves LVEF in patients with severe postinfarction heart failure. The improvement in LVEF was related to reduced LV dyssynchrony and increased global strain.