Xuedong Shen

A new score system for predicting response to cardiac resynchronization therapy

BACKGROUND The aim of this study was to establish a score system derived from clinical, echocardiographic and electrocardiographic indexes and evaluate its clinical value for cardiac resynchronization therapy (CRT) patient selection. METHODS Ninety-three patients receiving CRT were enrolled. A patient selection score system was generated by the clinical, echocardiographic and electrocardiographic parameters achieving a significant level by univariate and multivariate Cox regression model. The positive response to CRT was a left ventricular end systolic volume decrease of ≥ 15% and not reaching primary clinical endpoint (death or re-hospitalization for heart failure) at the end of follow-up. RESULTS Thirty-nine patients were CRT non-responders (41.94%) and 54 were responders (58.06%). A 4-point score system was generated based on tricuspid annular plane systolic excursion (TAPSE), longitudinal strain (LS), and complete left bundle branch block (CLBBB) combined with a wide QRS duration (QRSd). The sensitivity and specificity for prediction of a positive response to CRT at a score > 2 were 0.823 and 0.850, respectively (AUC: 0.92295% CI 0.691-0.916, p< 0.001). CONCLUSIONS A patient selection score system based on the integration of TAPSE, LS and CLBBB combined with a wide QRSd can help to predict positive response to CRT effectively and reliably.

Clinical consideration of cardiac pacemaker implantation through a persistent left superior vena cava with an absent right superior vena cava

Persistent left superior vena cava (PLSVC) with an absent right superior vena cava (RSVC) is a rare anatomic variation (0.07-0.13%) (1) that is typically asymptomatic and discovered incidentally during device implantation. Serious complications, including PLSVC-like shock, cardiac arrest or angina, can occur during catheterisation, which is likely due to the manipulation of the catheter in the coronary sinus or the perforation of the brachiocephalic vein, which can occur in the absence of the RSVC (2). This report presents a patient with PLSVC and an absent RSVC with no other cardiac abnormalities, who was diagnosed incidentally during pacemaker implantation (PMI). A 65-year-old male patient with hypertension was referred to our clinic for pacemaker implantation. The patient had suffered from vertigo with several presyncopal episodes. A 24-hour Holter revealed a 2:1 second-degree atrioventricular block with an intermittent third-degree atrioventricular block. These results prompted pacemaker implantation. The guidewire did not advance to the RSVC after routine puncture of the left axillary vein. Instead, an acute downward angula- tion was performed on the left side, parallel to the right-sided vena cava. A venogram was performed, and the diagnosis of PLSVC with an RSVC that descended into the coronary sinus (CS) was confirmed (Fig. 1A-D). Two 60-cm leads (Setrox S 60-B active fixation, Biotronik GmbH & Co., Berlin, Germany) were advanced separately in the right

Assessment of Subclinical Doxorubicin-induced Cardiotoxicity in a Rat Model by Speckle-Tracking Imaging

Backgrounds Despite their clear therapeutic benefits, anthracycline-induced cardiotoxicity is a major concern limiting the ability to reduce morbidity and mortality associated with cancers. The early identification of anthracycline-induced cardiotoxicity is of vital importance to assess the cardiac risk against the potential cancer treatment. Objective To investigate whether speckle-tracking analysis can provide a sensitive and accurate measurement when detecting doxorubicin-induced left ventricular injury. Methods Wistar rats were divided into 4 groups with 8 rats each, given doxorubicin intraperitoneally at weekly intervals for up to 4 weeks. Group 1: 2.5 mg/kg/week; group 2: 3 mg/kg/week; group 3: 3.5mg/kg/week; group 4: 4mg/kg/week. An additional 5 rats were used as controls. Echocardiographic images were obtained at baseline and 1 week after the last dose of treatment. Radial (Srad) and circumferential (Scirc) strains, radial (SRrad) and circumferential (SRcirc) strain rates were analyzed. After the experiment, cardiac troponin I (cTnI) was analyzed and the heart samples were histologically evaluated. Results After doxorubicin exposure, LVEF was significantly reduced in group 4 (p = 0.006), but remained stable in the other groups. However, after treatment, Srads were reduced in groups 2, 3 and 4 (p all < 0.05). The decrease in Srads was correlated with cTnI (rho = -0.736, p = 0.000) and cardiomyopathy scores (rho = -0.797, p = 0.000). Conclusion Radial strain could provide a sensitive and noninvasive index in early detection of doxorubicin-induced myocardial injury. The changes in radial strain had a significant correlation with myocardial lesions and serum cardiac troponin I levels, indicating that this parameter could accurately evaluate cardiotoxicity severity.

Early resolution of ST-segment elevation after reperfusion therapy for acute myocardial infarction: Its relation to echocardiography-determined left ventricular global and regional function and deformation

AIMS To evaluate the relationships between ST-segment resolution (STR) and echocardiography-determined left ventricular (LV) global and regional function and deformation in the sub-acute phase of STEMI. METHODS AND RESULTS STR, defined as either complete (≥70%) or incomplete (<70%), was evaluated 60minutes after primary percutaneous coronary intervention (PCI) of 84 STEMI patients. Conventional two-dimensional (2D) echocardiography and 2D speckle-tracking echocardiography (STE) were performed at 3-7days after reperfusion. LV deformation [including the infarction-related regional longitudinal (RLS), circumferential (RCS), and radial (RRS) strains, and global longitudinal (GLS), circumferential (GCS), and radial (GRS) strains] was measured by 2D STE. LV segmental function was assessed by wall motion score index (WMSI). Patients in incomplete vs. complete STR groups had higher WMSI (p<0.001); decreased peak amplitude of RLS (p<0.001), RCS (p=0.008), RRS (p=0.002); and decreased peak amplitude of GLS (p<0.001), GCS (p<0.001), GRS (p=0.003). RLS (r=0.27, p=0.015) and GLS (r=0.33, p=0.003) were best correlates of STR at the regional and global level, respectively. CONCLUSIONS STR correlated with global and regional LV function and deformation in patients with sub-acute phase of STEMI after PCI. RLS and GLS were the strongest correlates of STR at the regional and global levels, respectively.

Combined use of external therapeutic ultrasound and tirofiban has synergistic therapeutic effects on no-reflow after myocardial reperfusion

This study aimed to evaluate the effects of the combined use of external therapeutic ultrasound (ETUS) and the specific glycoprotein IIb/IIIa inhibitor tirofiban on myocardial no‐reflow in a canine model of acute myocardial infarction after reperfusion.

Prevalence and Prognosis of Portopulmonary Hypertension in 223 Liver Transplant Recipients

Objective To investigate the prevalence and prognosis of portopulmonary hypertension (PoPH) in liver transplant recipients. Methods Patients with advanced liver disease who underwent orthotopic liver transplantation (OLT) were included in this retrospective study from January 2012 to June 2015. According to the 2015 European Society of Cardiology (ESC)/European Respiratory Society (ERS) guidelines for the diagnosis of pulmonary hypertension (PH), patients with tricuspid regurgitation velocity (TRV) >3.4 m/s or 2.9 m/s ≤ TRV ≤ 3.4 m/s coexisting with other echocardiographic PH signs were judged as PH. PH patients with portal hypertension and without other known causes of PH were diagnosed as PoPH. Results A total of 223 (170 males and 53 females) middle-aged (50.9 ± 9 years old) liver transplant recipients were included in this study. Fourteen patients (6.3%) were diagnosed with PoPH, and none of the patients were treated with vasodilators before or after OLT. After OLT, patients were followed up for 26 ± 13.5 months. In total, 8 of 14 (57%) PoPH patients died, and the main cause of death was pulmonary infection. Kaplan–Meier survival curves revealed a significant difference in survival between PoPH and non-PoPH patients (p < 0.001), and the median survival time after OLT of PoPH was 11.4 months. Conclusions The prevalence of PoPH was 6.3% in OLT recipients. The survival of untreated PoPH patients was dismal after OLT.

Subclinical Anthracycline-Induced Cardiotoxicity in the Long - Term Follow-Up of Lymphoma Survivors: A Multi-Layer Speckle Tracking Analysis

Background Anthracycline generates progressive left ventricular dysfunction associated with a poor prognosis. Objectives The purpose of this study was to evaluate whether layer-specific strain analysis could assess the subclinical left ventricular dysfunction after exposure to anthracycline. Methods Forty-two anthracycline-treated survivors of large B-cell non-Hodgkin lymphoma, aged 55.83 ± 17.92 years (chemotherapy group) and 27 healthy volunteers, aged 51.39 ± 13.40 years (control group) were enrolled. The cumulative dose of epirubicin in chemotherapy group was 319.67 ± 71.71mg/m2. The time from last dose of epirubicin to the echocardiographic examination was 52.92 ± 22.32 months. Global longitudinal (GLS), circumferential (GCS) and radial strain (GRS), subendocardial, mid and subepicardial layer of longitudinal (LS-ENDO, LS-MID, LS-EPI) and circumferential strain (CS-ENDO, CS-MID, CS-EPI) values were analyzed. Transmural strain gradient was calculated as differences in peak systolic strain between the subendocardial and subepicardial layers. A value of p < 0.05 was considered significant. Results Conventional parameters of systolic and diastolic function showed no significant difference between two groups. Compared with controls, patients had significantly lower GCS and GLS. Multi-layer speckle tracking analysis showed significant reduction of circumferential strain of subendocardial layer, transmural CS gradient and longitudinal strain of all three layers. In contrast, the two groups did not differ in transmural longitudinal strain gradient and radial strains. Conclusions It proved the preferential impairment of subendocardial deformation in long-term survivors after exposure to anthracycline. Multi-layer speckle tracking echocardiography might facilitate the longitudinal follow-up of this at-risk patient cohort.

A Novel Method in the Stratification of Post-Myocardial-Infarction Patients Based on Pathophysiology.

Objectives We proposed that the severity of ST-segment elevation myocardial infarction (STEMI) could be classified based on pathophysiological changes. Methods First-STEMI patients were classified within hospitalization. Grade 0: no detectable myocardial necrosis; Grade 1: myocardial necrosis without functional and morphological abnormalities; Grade 2: myocardial necrosis with reduced LVEF; Grade 3: reduced LVEF on the basis of cardiac remodeling; Grade 4: mitral regurgitation additional to the Grade-3 criteria. Results Of 180 patients, 1.7, 43.9, 26.1, 23.9 and 4.4% patients were classified as Grade 0 to 4, respectively. The classification is an independent predicator of 90-day MACEs (any death, resuscitated cardiac arrest, acute heart failure and stroke): the rate was 0, 5.1, 8.5, 48.8 and 75% from Grade 0 to 4 (p<0.001), respectively. The Grade-2 patients were more likely to have recovered left ventricular ejection fraction than the Grade-3/4 patients did after 90 days (48.9% vs. 19.1%, p<0.001). Avoiding complicated quantification, the classification served as a good reflection of infarction size as measured by cardiac magnetic resonance imaging (0±0, 15.68±8.48, 23.68±9.32, 36.12±11.35 and 40.66±14.33% of the left ventricular mass by Grade 0 to 4, P<0.001), and with a comparable prognostic value (AUC 0.819 vs. 0.813 for infarction size, p = 0.876 by C-statistics) for MACEs. Conclusions The new classification represents an easy and objective method to scale the cardiac detriments for STEMI patients.

THE TYPES OF POSTSYSTOLIC SHORTENING WERE RELATED TO TRANSMURAL NECROSIS AND MICROVASCULAR OBSTRUCTION IN ACUTE PHASE OF MYOCARDIAL INFARCTION: A CONTRAST STUDY WITH CARDIAC MAGNETIC RESONANCE

We hypothesized that the morphology of postsystolic shortening (PSS) from strain curve assessed by myocardial speckle tracking echocardiography (STE) are related to transmural necrosis (TN) and microvascular obstruction (MVO) in acute phase of myocardial infarction (MI). Our study included 30

Subepicardial Aneurysm That Was Diagnosed by Cardiac Imaging and Underwent Successful Surgery.

A 63-year-old man was admitted because of current chest pain with perspiration for 6 hours. Electrocardiography showed complete right bundle-branch block and ST-segment elevation on leads II, III, aVF, and V2 through V6 (Figure 1); we therefore suspected an anterior and inferior wall acute myocardial infarction. Coronary angiography revealed total occlusion of the proximal left anterior descending artery (Figure 2 and Movie I in the online-only Data Supplement); the left circumflex and right coronary arteries showed no abnormalities. The left anterior descending artery was recanalized by percutaneous catheter intervention. The patient complained of chest pain the next afternoon after percutaneous catheter intervention, and the ECG was not changed. A transthoracic echocardiogram was performed, which demonstrated that the apical segments of the left ventricular walls were akinetic with normal thickness in the 4-chamber view (Movie II in the online-only Data Supplement), but the apex myocardium was dyskinetic with a perforation (2 mm in diameter) connected to a small apical aneurysm (10×5 mm) covered by intact epicardium that communicated with the left ventricular cavity as demonstrated by color Doppler (Figure 3A and 3B and Movie III in the online-only Data Supplement) from the apical 2-chamber view. This was consistent with a subepicardial aneurysm (SEA). On the follow-up echocardiography performed 8 days after infarction, …