Harriette F. Verwey

Relationship between QRS duration and left ventricular dyssynchrony in patients with end-stage heart failure.

Introduction: Patients with end‐stage heart failure and a wide QRS complex are considered candidates for cardiac resynchronization therapy (CRT). However, 20% to 30% of patients do not respond to CRT. Lack of left ventricular dyssynchrony may explain the nonresponse. Accordingly, we evaluated the presence of left ventricular dyssynchrony using tissue Doppler imaging (TDI) in 90 consecutive patients with heart failure.

Hemodynamic Effects of Long-Term Cardiac Resynchronization Therapy Analysis by Pressure-Volume Loops

Background— Acute hemodynamic effects of cardiac resynchronization therapy (CRT) were reported previously, but detailed invasive studies showing hemodynamic consequences of long-term CRT are not available. Methods and Results— We studied 22 patients scheduled for implantation of a CRT device based on conventional criteria (New York Heart Association class III or IV, left ventricular [LV] ejection fraction <35%, left bundle-branch block, and QRS duration >120 ms). During diagnostic catheterization before CRT, we acquired pressure-volume loops using conductance catheters during atrial pacing at 80, 100, 120, and 140 bpm. Studies were repeated during biventricular pacing at the same heart rates after 6 months of CRT. Our data show a significant clinical benefit of CRT (New York Heart Association class change from 3.1±0.5 to 2.1±0.8; quality-of-life score change from 44±12 to 31±16; and 6-minute hall-walk distance increased from 260±149 to 396±129 m; all P<0.001), improved LV ejection fraction (from 29±10% to 40±13%, P<0.01), decreased end-diastolic pressure (from 18±8 to 13±6 mm Hg, P<0.05), and reverse remodeling (end-diastolic volume decreased from 257±67 to 205±54 mL, P<0.01). Previously reported acute improvements in LV function remained present at 6 months: dP/dtmax increased 18%, −dP/dtmin increased 13%, and stroke work increased 34% (all P<0.01). Effects of increased heart rate were improved toward more physiological responses for LV ejection fraction, cardiac output, and dP/dtmax. Moreover, our study showed improved ventricular-arterial coupling (69% increase, P<0.01) and improved mechanical efficiency (44% increase, P<0.01). Conclusions— Hemodynamic improvements with CRT, previously shown in acute invasive studies, are maintained chronically. In addition, ventricular-arterial coupling, mechanical efficiency, and chronotropic responses are improved after 6 months of CRT. These findings may help to explain the improved functional status and exercise tolerance in patients treated with CRT.

Exercise training increases oxygen uptake efficiency slope in chronic heart failure.

Background and aim The oxygen uptake efficiency slope (OUES) is a novel measure of cardiopulmonary reserve. OUES is measured during an exercise test, but it is independent of the maximally achieved exercise intensity. It has a higher prognostic value in chronic heart failure (CHF) than other exercise test-derived variables such as V . O 2 peak or V . E / V . CO 2 slope. Exercise training improves V . O 2 peak and V . E / V . CO 2 in CHF patients. We hypothesized that exercise training also improves OUES. Methods and results We studied 34 New York Heart Association (NYHA) class II–III CHF patients who constituted an exercise training group T (N = 20; 19 men/1 woman; age 60 ± 9 years; left ventricular ejection fraction 34 ± 5%) and a control group C (N = 14; 13 men/one woman; age 63 ± 10 years; left ventricular ejection fraction 34 ± 7%). A symptom-limited exercise test was performed at baseline and repeated after 4 weeks (C) or after completion of the training program (T). Exercise training increased NYHA class from 2.6 to 2.0 (P [ 0.05), V . O 2 peak by 14% [P(TvsC)[0.01], and OUES by 19% [P(TvsC) [ 0.01]. Exercise training decreased V . E / V . CO 2 by 14% [P(TvsC) [ 0.05]. Conclusion Exercise training improved NYHA class, V . O 2 peak , V . E / V . CO 2 and also OUES. This finding is of great potential interest as OUES is insensitive for peak load. Follow-up studies are needed to demonstrate whether OUES improvements induced by exercise training are associated with improved prognosis.

Enhanced susceptibility of low-density lipoproteins to oxidation in coronary bypass patients with progression of atherosclerosis

Oxidation of low-density lipoprotein (LDL) may play a causal role in atherosclerosis. In this study we analyzed whether the severity of progression of coronary atherosclerosis is related to the susceptibility of LDL to oxidative modification. On the basis of repeated coronary angiography, 28 coronary bypass patients were divided into two groups: group A, 12 patients with, and group B, 16 patients without progression of coronary atherosclerosis. The lag time, reflecting the resistance of LDL to oxidative modification, was significantly smaller in group A as compared with group B (81 +/- 10 and 93 +/- 15 min, respectively). Besides differences in cholesterol and apolipoprotein B concentrations, the difference in susceptibility of LDL to oxidation significantly contributes to the differences between the progression and the non-progression group (P = 0.02). In the combined groups of patients, the lag phase of LDL for oxidation was positively correlated with LDL cholesterol ester to protein ratio (r = 0.53, P = 0.01). It is concluded that LDL samples obtained from coronary bypass patients differ with respect to their oxidizability depending on progression of atherosclerosis following coronary bypass surgery.

Single‐beat estimation of the left ventricular end‐systolic pressure–volume relationship in patients with heart failure

Aim:  The end‐systolic pressure–volume relationship (ESPVR) constructed from multiple pressure–volume (PV) loops acquired during load intervention is an established method to asses left ventricular (LV) contractility. We tested the accuracy of simplified single‐beat (SB) ESPVR estimation in patients with severe heart failure.

Clinical and Functional Effects of Restrictive Mitral Annuloplasty at Midterm Follow-Up in Heart Failure Patients

BACKGROUND Restrictive mitral annuloplasty (RMA) is increasingly applied to treat functional mitral regurgitation in heart failure patients. Previous studies indicated beneficial clinical effects with low recurrence rates. However, the underlying pathophysiology is complex and outcome in terms of left ventricular function is not well known. We investigated chronic effects of RMA on ventricular function in relation to clinical outcome. METHODS Heart failure patients (n = 11) with severe mitral regurgitation scheduled for RMA were analyzed at baseline (presurgery) and midterm follow-up by invasive pressure-volume loops, using conductance catheters. Clinical performance was evaluated by New York Heart Association class, quality-of-life-score, and 6-minute hall-walk-test. RESULTS All patients were alive without recurrence of mitral regurgitation at follow-up (9.4 ± 4.1 months). Clinical parameters improved significantly (all p < 0.05). Global cardiac function, assessed by cardiac output, stroke volume, and stroke work did not change after RMA. Reverse remodeling was demonstrated by decreased end-systolic and end-diastolic volumes (16% and 11%, both p < 0.001). Systolic function improved, evidenced by increased ejection fraction (0.32 ± 0.05 to 0.36 ± 0.07, p = 0.001) and leftward shift of the end-systolic pressure-volume relation (ESV(100): 116 ± 43 to 74 ± 26 mL, p < 0.001). Diastolic function, however, demonstrated impairment by increased tau (69 ± 13 to 80 ± 14 ms, p < 0.001) and stiffness constant (0.022 ± 0.022 to 0.031 ± 0.028 mL(-1), p = 0.001). CONCLUSIONS Restrictive mitral annuloplasty significantly improved clinical status without recurrence of mitral regurgitation at midterm follow-up in patients with heart failure. Hemodynamic analyses demonstrated significant reverse remodeling with unchanged global function and improved systolic function, but some signs of diastolic impairment. Overall, RMA appears an appropriate therapy for patients with dilated cardiomyopathy and functional mitral regurgitation.

Wall motion score index predicts mortality and functional result after surgical ventricular restoration for advanced ischemic heart failure

OBJECTIVE Advanced ischemic heart failure can be treated with surgical ventricular restoration (SVR). While numerous risk factors for mortality and recurrent heart failure have been identified, no plain predictor for identifying SVR patients with left ventricular damage beyond recovery is yet available. We tested echocardiographic wall motion score index (WMSI) as a predictor for mortality or poor functional result. METHODS One hundred and one patients electively operated between April 2002 and April 2007 were included for analysis. All patients had advanced ischemic heart failure (NYHA-class>or=III and LVEF<or=35%). Mean logistic EuroSCORE was 10+/-8. All patients were evaluated at 1-year follow-up. Risk factors for poor outcome, defined as mortality or poor functional result (NYHA class>or=III) at 1-year follow-up were identified by univariable logistic regression analysis. Preoperatively, a 16-segment echocardiographic WMSI was calculated and receiver operating characteristic curve analysis was used to identify cut-off values for WMSI in predicting poor outcome. RESULTS Early mortality was 9.9%, late mortality 6.6%. NYHA class improved from 3.2+/-0.4 to 1.5+/-0.7. At 1-year follow-up, 10 patients (12%) were in NYHA class III and the remaining patients were in NYHA class I or II (75 patients, 88%). WMSI was found to be the only statistically significant predictor for poor outcome (odds ratio 139, 95% confidence interval (CI) 17-1116, p<0.0001). The optimal cut-off value for WMSI in predicting mortality or poor functional result was 2.19 with a sensitivity and specificity of 82% (95% CI 81.5-82.5% and 81.4-82.6%). The area under the curve was 0.94 (95% CI 0.90-0.99). Positive and negative predictive values were 67% and 92% respectively (95% CI 66.4-67.6% and 91.4-92.6%). CONCLUSIONS Sufficient residual remote myocardium is necessary to recover from a SVR procedure and to translate the surgically induced morphological changes into a functional improvement. Preoperative WMSI is a surrogate measure of residual remote myocardial function and is a promising tool for better patient selection to improve results after SVR procedures for advanced ischemic heart failure.

Treatment options in end-stage heart failure: where to go from here?

Chronic heart failure is a major healthcare problem associated with high morbidity and mortality. Despite significant progress in treatment strategies, the prognosis of heart failure patients remains poor. The golden standard treatment for heart failure is heart transplantation after failure of medical therapy, surgery and/or cardiac resynchronisation therapy. In order to improve patients’ outcome and quality of life, new emerging treatment modalities are currently being investigated, including mechanical cardiac support devices, of which the left ventricular assist device is the most promising treatment option. Structured care for heart failure patients according to the most recent international heart failure guidelines may further contribute to optimal decision-making. This article will review the conventional and novel treatment modalities of heart failure.

Pain symptoms accompanying chronic poststernotomy pain: a pilot study.

OBJECTIVE Despite the technical developments in surgical procedures, chronic poststernotomy pain (CPSP) is still very common. Many theories for its cause have been proposed in the literature, but the etiology is still not clear. Pain along the sternal scar and in the upper extremities (sometimes accompanied with paresthesia) persists in about 30% of cases. These symptoms have been regarded as two separate complications. This study investigated all pain symptoms in patients following sternotomy. DESIGN Retrospective pilot study. SETTING Outpatient clinic at the Leiden University Medical Center. PATIENTS A cohort of patients who underwent open heart surgery by median sternotomy between January 1, 2004 and January 1, 2006. INTERVENTIONS A questionnaire was completed by 631 patients, and a selected sample of 277 patients was examined for pain of the head, neck, back, and chest and upper extremities. OUTCOME MEASURES All pain locations were compared in two groups: 189 patients with sternal pain and 88 patients without sternal pain. RESULTS We found that pain and muscular tenderness in the investigated areas unrelated to the chest wall incision were significantly more common in patients with sternal pain compared to the nonsternal pain group. No surgical or demographic factors with the exception of female gender were consistent predictors of sternal pain. CONCLUSION CPSP is an extensive pain syndrome. Sternal pain is frequently accompanied by pain of the head, neck, back, and upper extremities. Further research on the possible etiology is warranted.

Standardised pre-hospital care of acute myocardial infarction patients: MISSION! guidelines applied in practice

Background. To improve acute myocardial infarction (AMI) care in the region ‘Hollands-Midden’ (the Netherlands), a standardised guideline-based care program was developed (MISSION!). This study aimed to evaluate the outcome of the pre-hospital part of the MISSION! program and to study potential differences in pre-hospital care between four areas of residency.Methods. Time-to-treatment delays, AMI risk profile, cardiac enzymes, hospital stay, in-hospital mortality, and pre-AMI medication was evaluated in consecutive AMI patients (n=863, 61±13years, 75% male) transferred to the Leiden University Medical Center for primary percutaneous coronary intervention (PCI).Results. Median time interval between onset of symptoms and arrival at the catheterisation laboratory was 150 (interquartile range [IQR] 101-280) minutes. The alert of emergency services to arrival at the hospital time was 48 (IQR 40-60) minutes and the door-to-catheterisation laboratory time was 23 (IQR 13-42) minutes. Despite significant regional differences in ambulance transportation times no difference in total time from onset of symptoms to arrival at the catheterisation room was found. Peak troponin T was 3.33 (IQR 1.23-7.04) µg/l, hospital stay was 2 (IQR 2-3) days and in-hospital mortality was 2.3%. Twelve percent had 0 known risk factors, 30% had one risk factor, 45% two to three risk factors and 13% had four or more risk factors. No significant differences were observed for AMI risk profiles and medication pre-AMI. Conclusions. This study shows that a standardised regional AMI treatment protocol achieved optimal and uniformly distributed pre-hospital performance in the region ‘Hollands-Midden’, resulting in minimal time delays regardless of area of residence. Hospital stay was short and in-hospital mortality low. Of the patients, 88% had ≥1 modifiable risk factor. (Neth Heart J 2010;18:408-15.)