Angiotensin-converting enzyme inhibition facilitates alveolar-capillary gas transfer and improves ventilation-perfusion coupling in patients with left ventricular dysfunction

OBJECTIVE

The backward effects of left ventricular dysfunction include alterations in alveolar-capillary gas transfer and ventilation-perfusion coupling. Because the angiotensin-converting enzyme (ACE) is highly concentrated in the vascular endothelium of the lungs, we examined whether ACE inhibitors may influence the pulmonary function in patients with congestive heart failure.

METHODS

In 20 patients with idiopathic cardiomyopathy, pulmonary function and exercise capacity were evaluated at baseline and 6 and 12 months after treatment with enalapril (10 mg twice a day) was started. The study also included 19 age- and sex-matched control subjects with mild primary hypertension and normal left ventricular function who were given enalapril as a standard treatment of high blood pressure.

RESULTS

In congestive heart failure, forced expiratory volume in 1 second, vital capacity, and total lung capacity did not vary significantly with enalapril; alveolar-capillary diffusion of carbon monoxide (DL(CO)) increased toward normal; exercise tolerance time, peak exercise oxygen uptake (peak VO2), minute ventilation and tidal volume (peak VT) also increased; and the ratio of volume of dead space (VD) to VT (peak VD/VT) at peak exercise reduced. Changes in peak VO2 showed a direct correlation with those in DL(CO) and an inverse correlation with those in peak VD/VT. Results at 6 and 12 months were comparable. Enalapril did not affect these variables in the control population.

CONCLUSIONS

In patients with idiopathic cardiomyopathy heart failure, but not in control subjects, gas transfer and ventilation-perfusion improved with ACE inhibition. These pulmonary changes may contribute to the associated increase in exercise tolerance.

Results after partial left ventriculectomy in a European heart failure population

BACKGROUND

Forty-nine consecutive patients undergoing partial left ventriculectomy (Batista) surgery between January 1995 and June 1998 were studied.

METHODS

Patient ages ranged from 12 to 85 years, and all patients were in New York Heart Association functional Class III or IV. Thirty-three patients had ischemic cardiomyopathy, and 16 had idiopathic myopathy. Inclusion criteria were left ventricular end diastolic volume index of > 150 mL/m2, left ventricular ejection fraction of < 20%, or left ventricular end-diastolic diameter of > 70 mm. Sixteen patients were transplant candidates. Partial left ventriculectomy and mitral valve repair by means of a Cosgrove annuloplasty ring plus the Alfieri repair constituted only part of the complex cardiac reconstruction in 38 patients.

RESULTS

Five patients died early and five patients died late between 3 and 30 months postoperatively. The actuarial 1-year survival rate was 81%. Twenty-seven patients with coronary artery disease underwent one to five bypass grafts when appropriate. In addition, three patients received aortic valve replacement, four received tricuspid valve repair, two received mitral valve replacement, and two underwent dynamic cardiomyoplasty. Left ventricular (LV) diameter could be reduced from a preoperative mean of 71 to 56 mm postoperatively. LV ejection fraction increased to 36% postoperatively. Ninety percent of patients are in New York Heart Association functional Class I or II.

CONCLUSIONS

Patients with end-stage idiopathic or ischemic cardiomyopathies can be improved considerably with partial left ventriculectomy. Any cardiac comorbidity should be repaired simultaneously.

Myocardial imaging with 123I-BMIPP in patients with congestive heart failure

First, we studied the diagnostic utility of myocardial imaging with 123I-BMIPP (BMIPP), a 3-methyl-branched fatty acid analog, in patients with various types of cardiomyopathy and left ventricular dysfunction (ejection fraction below 40%) by comparing with myocardial flow tracer imaging. The incidence of a dissociation between myocardial BMIPP and 201Tl distributions (BMIPP < 201Tl) as a marker of metabolic abnormality in viable tissue varied considerably among various heart diseases. Patients with ischemic cardiomyopathy and the dilated form of hypertrophic cardiomyopathy had a higher incidence while those with idiopathic dilated, alcoholic and hypertensive cardiomyopathy had a lower incidence. These results suggest that the marked difference between ischemic and idiopathic dilated cardiomyopathies may contribute to the differential diagnosis between these two diseases which are main basic abnormalities in congestive heart failure. Second, we investigated the relationship between myocardial BMIPP uptake and ventricular stress in patients with right ventricular pressure overload due to pulmonary hypertension. Myocardial BMIPP uptake in the right ventricle estimated by referring to uptake in the left ventricle showed a significant correlation with mean pulmonary artery pressure (mPAP) and no significant difference with myocardial 99mTc-sestamibi uptake in the 15-81 mmHg mPAP range. These results suggest that myocardial utilization of free fatty acid may be preserved in the presence of higher ventricular wall stress.

[Pericarditis secondary to the rupture of a hydatid cyst]

Cardiac hydatic cysts are rare and represent 0.5 to 2% of all hydatic cysts in humans, but usually associated with fatal complications. We report a case of a male 27 years old with a hydatid cyst located in left ventricle asymptomatic until rupture. It was diagnosed by two-dimensional echocardiogram in a control.

Autoimmune rheumatic diseases and the heart

Involvement of the heart is a common finding in autoimmune rheumatic diseases. Although clinically silent changes are common, potentially life-threatening manifestations are well known but early recognition is important if appropriate therapy is to be instituted.

The investigation of sudden cardiac death

Pathologists are faced with an increasing complexity in the cardiac diseases that cause sudden natural death in the absence of coronary artery disease. A significant proportion of such natural sudden deaths are due to familial heart muscle disease (cardiomyopathy). The phenotypic characteristics of both hypertrophic cardiomyopathy and arrythmogenic right ventricular dysplasia are wider than previously thought and the hearts may be very close to normal on naked eye examination. Detailed histology of the myocardium is needed to identify such cases. Up to 200 sudden deaths a year in England occur in young, apparently fit individuals in whom toxicology and detailed examination of the heart for structural abnormalities is negative. Genetic defects in ion channels (long QT interval) are now known to be one cause of this phenomenon. In investigating a case of sudden death without cause, a study of the family -- if they wish it -- may be helpful in arriving at a cause.

[Systemic Buschke's scleredema with cardiomyopathy, monoclonal IgG kappa gammopathy and amyloidosis. Case report with autopsy]

A 73 year old retired truck driver and blacksmith was studied in June 1996 for thoracic pain and was diagnosed as acute pericarditis which responded well to steroid treatment. In January 1997, he noted swelling of the abdominal skin, genitalia and limbs, sparing the feet. He was euthyroid, did not have evidence of diabetes or a Raynaud's phenomenon. His proteinogram showed an IgG-Kappa monoclonal paraprotein M component, 1.31 g/oo. TSH and tetraiodotironine were normal; ESR 16 mm in the first hour. As he did not respond to treatment he was referred to our hospital in March 1997. On physical examination the most relevant findings were a non-pitting edema of the abdomen and lower limbs, sparing the feet. An echocardiogram was consistent with an infiltrative cardiomyopathy. Soon after his hospitalization his condition worsened suddenly with severe bradicardia (28/minute) due to a junctional rhythm and righ bundle branch block. He suffered a cardiac arrest and died. The autopsy findings favoured the diagnosis of systemic scleredema adultorum of Buschke. Amyloid deposits were also found although not abundant, with a similar distribution except in the skin. In this article the clinical and autopsy findings are presented in a patient showing coexistence of systemic Buschke's scleredema with an infiltrative cardiomyopathy, IgG Kappa gammopathy and amyloidosis.

[The role of myocardial apoptosis in the development of heart failure]

Heart failure can result from a variety of causes, including volume or pressure overload and contractile disturbances of the myocardium. Loss of myocytes is an important mechanism in the development of cardiac failure. In general, myocyte death resulting in progressive deterioration of myocardial function is attributed to necrosis, but recently the involvement of programmed cell death (mainly apoptosis) has been suggested. The authors review the possible role of myocardial apoptosis in developing of heart failure. Subcellular genetic regulatory processes as well as the pharmacological susceptibility of programmed cell death are also discussed. In heart failure, significant amount of cardiac myocytes undergoes apoptosis, that unlike necrosis can be prevented. Specific inhibition of this process could mean a considerable part of cardioprotection after thorough understanding of the underlying cellular mechanisms.

Severe cardiomyopathy in mice lacking dystrophin and MyoD

The mdx mouse, a mouse model of Duchenne muscular dystrophy, carries a loss-of-function mutation in dystrophin, a component of the membrane-associated dystrophin-glycoprotein complex. Unlike humans, mdx mice rarely display cardiac abnormalities and exhibit dystrophic changes only in a small number of heavily used skeletal muscle groups. By contrast, mdx:MyoD-/- mice lacking dystrophin and the skeletal muscle-specific bHLH transcription factor MyoD display a severe skeletal myopathy leading to widespread dystrophic changes in skeletal muscle and premature death around 1 year of age. The severely increased phenotype of mdx:MyoD-/- muscle is a consequence of impaired muscle regeneration caused by enhanced satellite cell self-renewal. Here we report that mdx:MyoD-/- mice developed a severe cardiac myopathy with areas of necrosis associated with hypertrophied myocytes. Moreover, heart tissue from mdx:MyoD-/- mice exhibited constitutive activation of stress-activated signaling components, similar to in vitro models of cardiac myocyte adaptation. Taken together, these results support the hypothesis that the progression of skeletal muscle damage is a significant contributing factor leading to development of cardiomyopathy.

[Intracardiac ectopic thyroid: a report of a clinical case with a long-term follow-up]

We describe the prolonged follow-up of a 64-year-old female patient, with an ectopic intracardiac thyroid gland. The mass was first detected 14 years ago, during a routine echocardiographic examination. The patient suffered from episodes of palpitation and cardiac auscultation revealed a systolic murmur. At cardiac surgery a right ventricular mass penetrating most of the interventricular septum was found. The mass was also prolapsing into the pulmonary infundibulum and could not be removed. On histopathology examination, the presence of a normal tissue was demonstrated. Two main clinical events characterized the prolonged follow-up: the gradual development of a massive tricuspid insufficiency, probably due to the strict anatomic relationship between the septal tricuspid papillary muscle and the mass itself; frequent supraventricular arrhythmias, partially refractory to different pharmacologic regimens, which could be ascribed to the chronic overload of the right atrium. The mass size has been stable over the years, and no thyroid hormone derangement was ever found.

[The relation between ischemic cerebral stroke and heart diseases]

The aim of the study was to evaluate the relation between heart diseases and ischemic cerebral stroke. In addition to routine tests, echocardiographic examinations were performed in 70 patients with ischemic cerebral stroke and in 30 persons constituting the control group. It was found that heart diseases occurred in 70% of the patients in the group studied i.e. three times more frequently than in the control group. Heart disease confirmed by echocardiography and electrocardiography occurred more frequently in patients with cerebral infarct than in those with RIND. In the majority of cases cardiac valve diseases and/or atrial fibrillation were noted. It was found that in 14.3% of the patients studied, the results of the echocardiography indicated the need for modification of the treatment applied.

Evidence of cell-mediated cardiac myocyte injury involved in the heart failure of a patient with progressive systemic sclerosis

A 54-year-old woman with progressive systemic sclerosis (PSS) was admitted to hospital because of dyspnea and chest pain. Echocardiogram revealed diffuse hypokinesis of the left ventricle (ejection fraction 24%). Methylprednisolone, heparin, and diuretics were administered, without benefit. Anemia, thrombocytopenia, and renal dysfunction rapidly progressed, and she died of heart failure on the 14th hospital day. Immunohistochemical study of the myocardial tissue showed mild to moderate cell infiltration, mainly consisting of natural killer (NK) cells, macrophages, cytotoxic T lymphocytes (CTLs), and T helper cells. Perforin, a cytolytic factor, was expressed in the infiltrating CTLs and NK cells, indicating that these cells were activated killer cells. Furthermore, human leukocyte antigen classes I and II, intercellular adhesion molecule-1, as well as costimulatory molecules B7-1, B7-2, and CD40, all of which are known not to be expressed in cardiac myocytes under normal conditions, were moderately to strongly expressed in cardiac myocytes. There was no detectable level of enterovirus genomes in the polymerase chain reaction products from the myocardial tissue of this patient. These findings strongly suggest that the infiltrating killer cells recognized cardiac myocytes as target cells and directly damaged them by releasing perforin. Enhanced expression of these antigens may have played an important role in the activation and cytotoxicity of the infiltrating killer cells. Absence of enterovirus genomes in the myocardial tissue may suggest that this autoimmune process is primarily induced by PSS.

Atrial septal aneurysm in a patient with pseudoxanthoma elasticum

Pseudoxanthoma elasticum (PXE) is a rare heritable disorder of the connective tissue characterized by marked clinical heterogeneity. Common cardiovascular complications of PXE include renovascular hypertension, premature coronary artery disease and calcification of peripheral arteries frequently leading to claudicatio intermittens; fibrous thickening of the endocardium and atrioventricular valves, leading to restrictive cardiomyopathy and/or mitral valve prolapse have been also described. We herein report on a PXE patient who developed an atrial septal aneurysm as a previously undescribed cardiologic manifestation of her disease.

[Lung cancer accompanying sarcoidosis with diffuse myocardial involvement]

We describe an interesting case of adenocarcinoma of the lung accompanying sarcoidosis with diffuse myocardial involvement. A 69-year-old man had a tumor shadow on chest X-ray films of the right upper lung field. Bronchofiberscopy was performed in Jan. 1997. Because transbronchial biopsy specimens disclosed granuloma, the patient was treated with isoniazid, rifampicin, and streptomycin sulfate for tuberculosis, but did not show any improvement. In March 1997, the patient was examined by an ophthalmologist for blurred vision. He was given a diagnosis of uveitis and referred to us for evaluation because his serum ACE and lysozyme levels were elevated. Bronchofiberscopy was performed again, and a diagnosis of lung cancer accompanying sarcoidosis was made based on the findings of transbronchial biopsy and bronchoalveolar lavage. The disease progressed rapidly, and the patient died 47 days after admission. Autopsy disclosed sarcoid granulomas in cardiac muscle tissue and lung tissue. There have been very few reports on the co-existence of sarcoidosis and lung cancer, and the relationship between the two diseases is unclear.

Echocardiographically diagnosed cardiac echinococcus complicated by embolic intraventricular thrombus

A young woman had cerebral embolism caused by an unusual complication of an asymptomatic cardiac hydatid cyst. The diagnosis of the cyst by means of echocardiography was confirmed by surgery as well as nuclear magnetic resonance, computed tomography, and serologic tests. Transesophageal echocardiography revealed a thrombus in the left ventricle that was situated aside the cyst. It was thought to be the source of an embolus. Surgical removal of the cyst was successful. Cerebral damage was reduced by administration of heparin.

Clinical characteristics of sudden death victims in heritable (chromosome 1p1-1q1) conduction and myocardial disease

OBJECTIVES

The purpose of this study was to identify the clinical characteristics of family members at risk of sudden death.

BACKGROUND

The significance of sudden death in heritable cardiac disorders with delayed expression is incompletely understood. Additional insights come from a four-decade experience of seven generations of a family of German origin with autosomal dominant (chromosome 1p1-1q1) cardiac conduction and myocardial disease.

METHODS AND RESULTS

A total of 38 family members (20 males; 18 females) were identified with sudden death. Twenty-eight family members (mean age 48+/-8 years) from earlier generations had no pacemaker at the time of sudden death. In this group, 15 subjects were asymptomatic prior to sudden death. Ten family members with sudden death, from later generations, had chronically implanted pacemakers for high grade atrioventricular block. This group was older (mean age 57+/-2 years), with decreased functional status (New York Heart Association class II to IV), enlarged left atria, dilated left ventricles with reduced systolic function and documented ventricular fibrillation in three members. Twenty-eight family members with sudden death were descendants of sib lineages 2 or 6; 21 family members with sudden death were offspring of a parent who also suffered sudden death.

CONCLUSION

Sudden death is an important late outcome in heritable (chromosome 1p1-1q1) cardiac conduction and myocardial disease. Pacemaker therapy is important for the treatment of symptomatic bradycardia, but it does not prevent sudden death. Family members who are beyond the third decade of life with reduced functional capacity, left ventricular dysfunction, pacemakers and who are the offspring of a parent with sudden death appear to be at greatest risk

Mitral valve repair in cardiomyopathy

BACKGROUND

Volume overload secondary to mitral regurgitation (MR) in cardiomyopathy is considered critical in the pathogenesis of subsequent ventricular dysfunction. Open mitral valve repair (OMVP) is hypothesized to improve symptomatology and ventricular function by reducing the volume overload of the left ventricle.

METHODS AND RESULTS

All patients who underwent OMVP with a left ventricular ejection fraction (EF) of < 0.30 (n = 81) from 1984 through 1997 were reviewed (1 patient was lost to follow-up). Fifteen operations (18.5%) were repeat operations after previous coronary artery bypass graft surgery. Preoperative and postoperative EFs and NYHA class were compared. Survival probabilities were calculated, and multivariate analysis was performed. The average age of all patients was 67.1 years (range, 41 to 83 years). Mean follow-up was 1.7 years (range, 2 months to 8.5 years). The most common mitral repair was ring annuloplasty. Sixty-two patients (77%) had concomitant coronary artery bypass graft surgery. The surgery mortality rate was 11% (9 of 81); 6 of these 9 patients were > 70 years old. The overall Kaplan-Meier survival probability rate at 1, 2, 3, 4, and 5 years was 0.73, 0.68, 0.58, 0.50, and 0.38, respectively. EF improved significantly (0.24 to 0.32; P < 0.0001), as did the NYHA class (3.2 to 1.6; P < 0.0001), at follow-up. There was no difference in late survival between patients with an EF of < 0.20 (21 patients) and those with an EF between 0.20 and 0.30 (P = NS). Risk factors for death included heart failure and old age.

CONCLUSIONS

OMVP for MR in the setting of ischemic cardiomyopathy and low EF appear to improve ventricular function, medium-term patient symptomatology, and survival.

Determination of olanzapine in a postmortem case

Olanzapine, a new antipsychotic agent, was approved by the U.S. Food and Drug Administration in 1996 for use in the treatment of schizophrenia. It is structurally similar to clozapine, has a low incidence of extrapyramidal effects, and is effective in treating both the positive and negative symptoms of schizophrenia. This paper describes the determination of olanzapine in biological specimens obtained from the autopsy of a 35-year-old white male found dead in bed at a psychiatric facility. In the months prior to his death, the deceased was prescribed multiple medications, including olanzapine. Olanzapine was identified qualitatively by full scan gas chromatography-mass spectrometry, with quantitative analysis performed by liquid-liquid extraction followed by dual-column gas chromatography. The following concentrations were determined in the specimens analyzed: heart blood, 550 ng/mL; bile, 6346 ng/mL; and gastric contents, 157 ng/mL. Vitreous humor, cerebrospinal fluid, and urine specimens were negative. Although steady-state plasma concentrations of 10-25 ng/mL olanzapine have been reported, effective levels are known to be highly variable and a plasma concentration of 300 ng/mL has been tolerated without adverse effects. Based upon the autopsy, toxicological findings, and case investigation, the cause of death was determined to be intramyocardial arteriosclerosis with severe stenosis of the nodal artery due to hypertensive cardiovascular disease, and the manner was natural.

Necrotizing myocardial vasculitis in Churg-Strauss syndrome: clinicohistologic evaluation of steroids and immunosuppressive therapy

Treatment of cardiac dysfunction associated with Churg-Strauss syndrome (CSS) is empiric since the histologic findings provided by endomyocardial biopsy are rare and often nondiagnostic. Myocardial necrotizing vasculitis presenting as restrictive cardiomyopathy has not been reported before. A case of CSS, presenting with fever and progressive heart failure due to pericarditis, eosinophilic endomyocarditis, and myocardial necrotizing vasculitis, is reported. Cardiac involvement assessed by noninvasive (cardiac two-dimensional echocardiogram and nuclear magnetic resonance [NMR] imaging) and invasive (cardiac catheterization, angiography, and biopsy) studies showed a moderate degree of pericardial effusion and left ventricular (LV) dysfunction (ejection fraction 0.40), severe diastolic dysfunction (increased right and LV filling pressure with a dip and plateau pattern) and a severe reduction of cardiac index (1.6 L/min/m2). Histologic characteristics showed marked eosinophilic infiltration of the endocardium and myocardium with myocitolysis and fibrinoid necrosis of arterioles, venules, and capillaries. Combination therapy of steroids and cyclophosphamide resulted in both a clinical (regression of pericardial effusion, normalization of systolic and diastolic dysfunction, and increase of cardiac index to 2.8 L/min/m2) and histologic (sequential endomyocardial biopsies at 1, 3, and 6 months of follow-up) resolution of cardiac involvement. No recurrences were registered at 12-month follow-up with the patient receiving a maintenance drug regimen.