Zhe Zhen

A detailed evaluation of cardiac function in cirrhotic patients and its alteration with or without liver transplantation

BACKGROUND Cirrhosis has been shown to be associated with left ventricular (LV) myocardial dysfunction, but studies of right ventricular (RV) function in cirrhotic patients compared with controls are scarce. Limited studies have prospectively evaluated the progression of myocardial function in patients with cirrhosis and assessed changes in cardiac function following liver transplantation (LTx). So the aim of the study was to evaluate biventricular myocardial function in cirrhotic patients and its alteration with or without liver transplantation. METHODS A total of 103 patients with cirrhosis (age 55±7 years, male 75%) were recruited. Conventional and 2-dimensional speckle tracking echocardiography was performed to determine the presence of LV and RV (biventricular) dysfunction. For comparison, 48 matched control subjects were included. Follow-up echocardiography was performed in 41 patients following LTx and in 26 patients who did not undergo LTx. RESULTS Patients with cirrhosis had biventricular dilatation, increased LV mass, impaired LV diastolic function, and biventricular systolic strain compared with controls. Following LTx, cirrhotic patients had reduced biventricular dilatation, a smaller LV mass, and improved biventricular systolic strain after a mean duration of 18.2±6.6 months. Patients who did not undergo LTx had a further increase in LV mass but no significant change in biventricular dimensions or systolic strain (mean duration of 20.4±8.3 months). CONCLUSIONS The present study demonstrates that patients with cirrhosis had biventricular dilatation and impaired biventricular systolic strain compared with controls. Following LTx, biventricular dilatation reduced and biventricular systolic strain improved. In contrast, patients who did not undergo LTx experienced a further increase in LV mass.

Association of myocardial dysfunction with vitamin D deficiency in patients with type 2 diabetes mellitus.

AIMS The underlying mechanism of myocardial dysfunction in patients with type 2 diabetes mellitus (T2DM) is unclear. Nonetheless recent studies have revealed that vitamin D (vit-D) deficiency, which is prevalent in such patients, is associated with adverse cardiovascular events. We hypothesized that vit-D deficiency in patients with T2DM may contribute to left ventricular (LV) dysfunction. METHODS We studied 95 patients (62±9years, 58% female) with T2DM. None had any history of coronary artery disease and all underwent detailed transthoracic echocardiography, including speckle tracking derived strains. Plasma level of 25-hydoxyvitamin D (25-OHD) was also measured. RESULTS Vitamin D deficiency was evident in 60 (63%) patients. The LV dimension, LVEF and diastolic grade were similar between those with and without deficiency although an impaired global longitudinal strain was present in the former. Importantly, 25-OHD was negatively associated with global longitudinal strain (R = -0.21, P=0.046) and positively with body-mass index (BMI; R=0.26, P=0.01). Both vit-D deficiency and BMI were associated with impaired global LV longitudinal strain, independent of T2DM disease characteristics. CONCLUSIONS In patients with T2DM and no history of coronary artery disease, vit-D deficiency is independently associated with impaired global longitudinal strain. This suggests that vit-D deficiency may contribute to the development of myocardial dysfunction in these patients.

Prevalence, Predictors and Clinical Outcome of Residual Pulmonary Hypertension Following Tricuspid Annuloplasty.

Background Tricuspid annuloplasty is increasingly performed during left heart valve surgery, but the long‐term clinical outcome postoperatively is not satisfactory. The aim of this study was to determine whether residual pulmonary hypertension (PHT) contributes to the adverse outcome. Methods and Results One‐hundred thirty‐seven patients (age 61±11 years; men, 30%) who underwent tricuspid annuloplasty during left‐side valve surgery were enrolled. The mean pulmonary artery systolic pressure before surgery was 49±13 mm Hg and 32±15 mm Hg following surgery. Patients were divided into 3 groups according to postoperative pulmonary artery systolic pressure: no residual PHT (n=78, 57%), mild residual PHT (n=43, 31%), or significant residual PHT (n=16, 12%). A preoperative larger right ventricular (RV) geometry and tricuspid valve tethering area were associated with mild or significant residual PHT. A total of 24 adverse events (20 heart failures and 4 cardiovascular deaths) occurred during a median follow‐up of 25 months. Kaplan–Meier survival curve demonstrated that patients with significant residual PHT had the highest percentage of adverse events followed by those with mild residual PHT. Patients with no residual PHT had a very low risk of adverse events. Multivariable Cox regression analysis revealed that both mild (hazard ratio=4.94; 95% CI =1.34–18.16; P=0.02) and significant residual PHT (hazard ratio=8.67; 95% CI =2.43–30.98; P<0.01) were independent factors associated with adverse events. Conclusions The present study demonstrated that 43% of patients who underwent tricuspid annuloplasty had residual PHT. The presence of mild or significant residual PHT was associated with adverse events in these patients.

Relation between endothelial progenitor cells and arterial stiffness in patients with psoriasis.

Patients with psoriasis are prone to premature atherosclerosis. We hypothesize that depletion of circulating endothelial progenitor cells (EPC) is related to patients with psoriasis and can contribute to the development of atherosclerosis. Thirty‐five plaque‐type psoriasis patients (41.9 ± 5.5 years, 30 men) and 20 age‐ and sex‐matched controls were studied. Four subpopulations of EPC, namely, CD34+ EPC, CD133+ EPC, CD34+/kinase insert domain‐containing receptor (KDR)+ EPC and CD133+/KDR+ EPC were measured by flow cytometry. Arterial stiffness in psoriasis patients was assessed by heart to ankle pulse wave velocity (haPWV), augmentation index (AI) and carotid intima media thickness (IMT). Patients with psoriasis had a lower level of CD34+ EPC (7.85 ± 2.49% vs 6.26 ± 2.13%, P = 0.02) compared with healthy controls. In patients with psoriasis, level of CD34+ EPC was negatively related with haPWV (r = −0.43 P = 0.01) and Psoriasis Area and Severity Index (r = −0.39 P = 0.02). Multivariate regression analysis further demonstrated that haPWV was independently associated with level of CD34+ EPC. Each percentage decrease in CD34+ EPC accounted for an increase in haPWV of +0.02 m/s. The result demonstrated that patients with psoriasis had reduced CD34+ EPC compared with controls. Importantly, CD34+ EPC was independently related with haPWV in these patients. This finding suggests that EPC reduction is associated with the development of arterial stiffness in patients with psoriasis.

Relation of Tricuspid Regurgitation to Liver Stiffness Measured by Transient Elastography in Patients With Left-Sided Cardiac Valve Disease

The aim of the study was to evaluate the relation between tricuspid regurgitation (TR) severity and liver stiffness (LS) in patients with TR. A total of 131 patients with various degrees of TR secondary to left-sided heart valve disease were enrolled. Severity of TR was quantitatively assessed by proximal isovelocity surface area-derived effective regurgitant orifice (ERO). Patients were divided into 2 groups: 48 with mild-moderate TR (ERO <0.4 cm(2)) and 83 with severe TR (ERO ≥0.4 cm(2)). Transient elastography was used to measure the level of LS, an established marker of liver fibrosis, with the threshold of significant LS set at ≥12.5 kPa. Patients with severe TR had a higher LS and prevalence of significant LS than those with mild-moderate TR. Furthermore, LS and significant LS independently correlated with TR-ERO, right atrial pressure and inferior vena cava (IVC) diameter. The presence of a large TR-ERO (≥0.4 cm(2)) and IVC diameter (>2.15 cm(2)) provided a high specificity of 78% for significant LS. In conclusion, the present study demonstrates that TR-ERO, right atrial pressure, and IVC diameter are important parameters associated with LS in patients with TR.

The effects of hyperuricaemia on flow-mediated and nitroglycerin-mediated dilatation in high-risk patients

BACKGROUND AND AIMS Uric acid is emerging as one of the newer risk markers to consider in the cardiovascular risk assessment because it is demonstrated to be associated with adverse cardiovascular outcomes, particularly in high cardiovascular risk patients. One of the proposed mechanisms involving hyperuricaemia is the development of vascular damage. The aim of this study is to examine the role of hyperuricaemia on vascular function in patients with high cardiovascular risk. METHODS AND RESULTS We examined the clinical significance of hyperuricaemia in relation to vasomotor response of the brachial artery by using high-resolution ultrasound in 304 subjects with coronary artery disease and/or diabetes. Nitroglycerin-mediated dilatation (NMD) was significantly lower in the hyperuricaemic group compared with the normouricaemic group (12.8 ± 6.9% vs. 16.2 ± 7.7%, p < 0.001), but no significant difference was observed in flow-mediated dilatation (FMD) between the two groups [3.78 (95% CR: 1.5-9.9) vs. 3.88 (95% CR: -2.6 to 9.9), p = 0.78]. Multivariate analysis demonstrated that smoking was the strongest predictor of FMD (b = -0.81, p = 0.02); and that smoking (b = -2.62, p = 0.003), SBP (b = -0.11, p = 0.001), hyperuricaemia (b = -2.11, p = 0.02) and use of nitrates (b = -3.30, p = 0.001) were independent predictors of NMD. CONCLUSION High cardiovascular risk patients with hyperuricaemia had a lower NMD than those with normouricaemia. Importantly, hyperuricaemia was independently associated with NMD after multivariable adjustments. To further understand the pathophysiological mechanisms involving hyperuricaemia, particularly in the context of impaired NMD, further experimental and clinical studies are needed.

Increased T-wave alternans is associated with subclinical myocardial structural and functional abnormalities in patients with type 2 diabetes.

BACKGROUND Increased T wave alternans (TWA) represents ventricular depolarization heterogeneity and is a non-invasive marker of sudden cardiac death. This study sought to determine whether myocardial structural alteration and dysfunction in patients with type 2 diabetes mellitus (T2DM) is associated with an increased TWA. METHODS We recruited 108 T2DM patients (59.2±9.7 years and 52% male) without prior history of cardiovascular disease and normal treadmill stress testing. TWA was analyzed during treadmill testing in all standard precordial leads by time-domain method. Transthoracic echocardiography was performed to measure myocardial structural alteration by calibrated integrated backscatter (IBS), left ventricular (LV) systolic function by conventional method, and speckle tracking-derived global longitudinal strain (GLS), and LV diastolic function. RESULTS A total of 29 (26.9%) patients had a high TWA of ≥47mV (defined by ≥75 percentile of the study population). Patients with and without elevated TWA had a similar LV dimension and ejection fraction. Nonetheless, patients with high TWA had a higher calibrated IBS (-15.8±4.0dB vs. -17.9±5.3dB, p=0.04), more impaired GLS (-18.4±2.0% vs. -19.3±1.4%, p=0.02), and a higher prevalence of diastolic dysfunction (60 vs. 33%, p=0.02). Multivariable analysis demonstrated that high TWA was independently associated with calibrated IBS, GLS, and LV diastolic dysfunction grading. CONCLUSIONS Our results demonstrated that calibrated IBS, GLS, and LV diastolic dysfunction are independent predictors for high TWA in T2DM patients. These findings suggest that subclinical myocardial structural and functional abnormalities may contribute to high TWA in T2DM patients.

Improvement of Myocardial Function Following Catheter-Based Renal Denervation in Heart Failure

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Clinical Benefit of Valvular Surgery in Patients with Chronic Kidney Disease

Concomitant chronic kidney disease (CKD) is common in patients with significant valvular heart disease (VHD). This study sought to evaluate the clinical benefit of valvular surgery in patients with concomitant CKD.We evaluated 349 patients with significant VHD who were referred for surgery. Patients were divided into those with CKD stage ≥ 3 (CKD patients; n = 88) and those with CKD stage 1 or 2 (no CKD patients; n = 261). 63 patients did not receive surgery, of which 20 patients had CKD and 43 had no CKD. Mortality and change in eGFR were assessed after a median follow-up of 21 months.In the whole study population, 25% of the patients had CKD and these patients had higher mortality than those with no CKD. The annual mortality rates of patients with CKD who did and did not undergo surgery were 7.9% and 28.0%, respectively. In patients with no CKD, the annual mortality rates of those who did and did not undergo surgery were 1.8% and 2.3%, respectively. Importantly, surgery was associated with significant survival benefit in patients with CKD (log-rank test, P < 0.01), but was neutral in patients with no CKD. Multivariable analysis confirmed the survival benefit of valvular surgery in all patients, which was most significant in patients with CKD. Furthermore, eGFR was preserved in patients who underwent valvular surgery but declined significantly in those who did not.CKD is common in patients with significant VHD and, if left untreated surgically, these patients exhibit a high mortality.

Prevalence, clinical characteristics and echocardiography parameters of non-resistant, resistant and refractory hypertension in Chinese

ABSTRACT Objectives: Refractory and resistant hypertension is defined as hypertension that is uncontrolled despite the use of multiple antihypertensives. The aim of the present study is to evaluate the prevalence, both in young and elderly, and the pattern of left ventricular hypertrophy (LVH) in South-Eastern Chinese patients with refractory, resistant and non-resistant hypertension. Methods: A total of 1455 patients (age 60.3 ± 13.9, male 55.7%) with essential hypertension were recruited. Refractory hypertension was defined as uncontrolled blood pressure (systolic/diastolic, ≥140/90 mm Hg) on ≥5 antihypertensive drug classes. Resistant hypertension was defined as uncontrolled blood pressure (systolic/diastolic, ≥140/90 mm Hg) on 3 or <140/90 mm Hg on ≥4 antihypertensive classes. Results: Among the total population, 1273 (87.4%) patients were considered non-resistant hypertension; 170 (11.7%) with resistant hypertension and 12 (0.8%) with refractory hypertension. The prevalence of the three groups of hypertension were similar between patients age <60 or ≥60. Patients with refractory hypertension had the most dilated LV dimension, greatest left ventricular mass index and highest prevalence of diastolic dysfunction than patients with resistant and non-resistant hypertension. In particular, all patients with refractory hypertension had either concentric or eccentric LVH. Conclusions: In South-Eastern Chinese patients, the prevalence of refractory and resistant hypertension was 0.8% and 11.7%, respectively. Furthermore, no difference was observed in the hypertensive patterns between patients age <60 and ≥60. Importantly, patients with refractory hypertension had the worst LV remodeling with all suffering from either concentric or eccentric hypertrophy.