An unusual case of complete atrioventricular block causing Takotsubo syndrome

Complete atrioventricular (AV) block in association with Takotsubo syndrome (TS) has been well recognized, but the cause and effect relationship has not been elucidated. We describe a 78-year-old female who presented with complete AV block but one week later developed new-onset, diffuse T-wave inversions, QT prolongation, and acceleration of junctional escape rate. Left ventriculogram revealed features typical of TS. One year after permanent pacemaker implantation, complete AV block persisted despite the reversal of wall motion defects implying that conduction abnormality was the trigger of TS rather than its consequence.     

Selective His-bundle pacing in an adult with atrioventricular canal defect via retrograde His localization

Adult congenital heart disease patients may undergo numerous fluoroscopically guided procedures including pacemaker implantation during their lifetime. One alternative to traditional pacemaker setup which may improve long-term pacing outcomes is His bundle pacing. Given the altered His-bundle location, and given increased radiation exposure over a lifetime, we used 3-dimensional mapping to locate the His and to minimize fluoroscopy for placement of a His-bundle pacemaker system in a 31-year old patient with atrioventricular canal defect and complete heart block with 100% RV pacing and epicardial lead fracture.MethodsAn Octapolar Livewire catheter (Abbott, Minneapolis, USA) was used for mapping and location of the His bundle from a right femoral venous access on the EnSite Precision system 3-dimensional mapping system (Abbott Medical, Abbott Park, IL). The same map was used to guide 3830 lead placement into the posterior-inferior His-bundle position.ResultsSuccessful placement of a His-bundle pacing system with thresholds of 1Volt@0.4ms for both the atrial and ventricular leads with selective His-bundle pacing noted. Ten-month follow-up demonstrated His-bundle capture at 0.75V@0.4ms with stable impedance, sensing and with 100% right ventricular pacing a projected longevity of 12 years total.ConclusionsSuccessful placement of selective His-bundle pacing can be achieved in an adult patient with atrioventricular canal defect using 3-dimensional mapping.     

Antithrombotic therapy in patients undergoing TAVI: an overview of Dutch hospitals

Purpose

To assess current antithrombotic treatment strategies in the Netherlands in patients undergoing transcatheter aortic valve implantation (TAVI).

Methods

For every Dutch hospital performing TAVI (n = 14) an interventional cardiologist experienced in performing TAVI was interviewed concerning heparin, aspirin, thienopyridine and oral anticoagulation treatment in patients undergoing TAVI.

Results

The response rate was 100 %. In every centre, a protocol for antithrombotic treatment after TAVI was available. Aspirin was prescribed in all centres, concomitant clopidogrel was prescribed 13 of the 14 centres. Duration of concomitant clopidogrel was 3 months in over two-thirds of cases. In 2 centres, duration of concomitant clopidogrel was based upon type of prosthesis: 6 months versus 3 months for supra-annular and intra-annular prostheses, respectively.

Conclusions

Leaning on a small basis of evidence and recommendations, the antithrombotic policy for patients undergoing TAVI is highly variable in the Netherlands. As a standardised regimen might further reduce haemorrhagic complications, large randomised clinical trials may help to establish the most appropriate approach.

Electronic supplementary material

The online version of this article (doi:10.1007/s12471-013-0496-6) contains supplementary material, which is available to authorized users.     

Isolation of Murine Valve Endothelial Cells

Normal valve structures consist of stratified layers of specialized extracellular matrix (ECM) interspersed with valve interstitial cells (VICs) and surrounded by a monolayer of valve endothelial cells (VECs). VECs play essential roles in establishing the valve structures during embryonic development, and are important for maintaining life-long valve integrity and function. In contrast to a continuous endothelium over the surface of healthy valve leaflets, VEC disruption is commonly observed in malfunctioning valves and is associated with pathological processes that promote valve disease and dysfunction. Despite the clinical relevance, focused studies determining the contribution of VECs to development and disease processes are limited. The isolation of VECs from animal models would allow for cell-specific experimentation. VECs have been isolated from large animal adult models but due to their small population size, fragileness, and lack of specific markers, no reports of VEC isolations in embryos or adult small animal models have been reported. Here we describe a novel method that allows for the direct isolation of VECs from mice at embryonic and adult stages. Utilizing the Tie2-GFP reporter model that labels all endothelial cells with Green Fluorescent Protein (GFP), we have been successful in isolating GFP-positive (and negative) cells from the semilunar and atrioventricular valve regions using fluorescence activated cell sorting (FACS). Isolated GFP-positive VECs are enriched for endothelial markers, including CD31 and von Willebrand Factor (vWF), and retain endothelial cell expression when cultured; while, GFP-negative cells exhibit molecular profiles and cell shapes consistent with VIC phenotypes. The ability to isolate embryonic and adult murine VECs allows for previously unattainable molecular and functional studies to be carried out on a specific valve cell population, which will greatly improve our understanding of valve development and disease mechanisms.     

同期行冠状动脉旁路移植和心脏瓣膜置换术治疗冠心病合并心脏瓣膜病的临床研究

目的:总结同期行冠状动脉旁路移植(CABG)和心脏瓣膜置换术治疗冠心病合并心脏瓣膜病的临床经验。方法:回顾性分析我院收治的41例接受冠状动脉旁路移植同期行心脏瓣膜置换术的冠心病合并心脏瓣膜病患者的临床资料,对手术方法、主要并发症和术后处理方法进行分析总结。结果:41例患者中,行二次开胸4例(9.76%),应用IABP 2例(4.88%),发生低心排综合征6例(14.63%)、肾功能不全6例(14.63%)、肺功能不全7例(17.07%)、脑合并症1例(2.44%)、胸腔积液4例(9.77%),死亡6例(13.63%),其余患者康复出院。结论:CABG同期行心脏瓣膜置换术治疗冠心病合并心脏瓣膜病的近期疗效满意。术前改善心功能,成熟的手术技术,完全的心肌再血管化,良好的心肌保护,停机困难者尽早应用主动脉内球囊反搏(IABP)及加强术后处理是提高CABG同期行心脏瓣膜置换术疗效的重要措施。     

老年主动脉瓣钙化与冠心病合并心律失常的相关性探讨

目的:探讨老年患者主动脉瓣钙化与冠心病合并心律失常的相关性。方法:纳入解放军总医院疑诊为冠心病的老年住院患者276例,行冠状动脉造影,同期行超声心动图和24 h动态心电图检查,详细记录患者病史。根据超声结果,将患者分成主动脉瓣钙化(AVC)组和非主动脉瓣钙化(NAVC)组,比较两组冠心病合并心律失常的检出率,评价老年患者主动脉瓣钙化对冠心病合并心律失常的预测价值。结果:AVC组和NAVC组的年龄、吸烟史、高血压史、糖尿病史存在显著性差异(P0.05);AVC组冠心病的确诊率为93.7%,而NAVC组为80.6%,两组差异有统计学意义(P=0.002);AVC组冠心病合并心律失常检出率也显著性高于NAVC组(59.2%vs 35.1%,P=0.043)。结论:主动脉瓣钙化与冠心病合并心律失常密切相关,有望作为冠心病合并心律失常的高危患者有效的筛查指标。     

瓣膜手术同期射频消融改良迷宫术治疗心脏瓣膜病并发房颤患者的疗效及对血清细胞因子的影响

目的:分析瓣膜手术同期射频消融改良迷宫术治疗心脏瓣膜病并发房颤患者的疗效及对血清细胞因子的影响。方法:将80例心脏瓣膜病并发房颤患者依据简单随机法分为对照组和观察组,每组40例。对照组采用心脏瓣膜置换术治疗,观察组采用心脏瓣膜置换术同期射频消融改良迷宫术治疗,比较两组窦性心律转复情况,手术情况,手术前后心功能、血清金属蛋白酶组织抑制因子-1(TIMP-1)、基质金属蛋白酶-1(MMP-1)和基质金属蛋白酶-9(MMP-9)水平的变化以及术后并发症的发生情况。结果:观察组术后当天、术后1月、术后3月及术后6月的窦性心律转复率均显著高于对照组(P0.05),体外循环时间、主动脉阻断时间及术后24 h引流量均明显多于对照组(P0.05)。两组呼吸机使用时间和监护室时间比较差异无统计学意义(P0.05)。术后6个月,两组左室舒张末期内径、左室收缩末期内径、血清MMP-1和MMP-9水平均较术前显著下降,且观察组以上指标明显低于对照组;两组LVEF及血清TIMP-1水平较术前显著上升,且观察组以上指标均显著高于对照组(P0.05)。两组术后均无严重并发症发生。结论:瓣膜手术同期射频消融改良迷宫术治疗心脏瓣膜病并发房颤安全有效,早期窦性心律的转复率高,且可改善患者血清TIMP-1、MMP-1、MMP-9水平。     

BMP7基因沉默抑制钙盐诱导猪主动脉瓣膜间质细胞成骨分化

目的:探究小干扰RNA(small interference RNA,siRNA)介导的骨形态发生蛋白7(bone morphogenetic protein7,BMP7)基因沉默对钙盐诱导猪主动脉瓣膜间质细胞成骨分化的影响及机制,为钙化性主动脉瓣膜病(calcific aortic valve disease,CAVD)的干预及治疗提供理论依据。方法:非CAVD瓣膜组织(non-CAVD组)取自手术治疗的主动脉夹层患者,CAVD瓣膜组织(CAVD组)取自因钙化性主动脉瓣狭窄而进行主动脉瓣膜置换术的患者,采用免疫组化和Western blot法检测non-CAVD组和CAVD组中BMP7、Runt相关转录因子2(Runx2)的蛋白质表达水平。选取健康家猪处死后即刻于无菌条件下取主动脉瓣叶,采用胶原酶连续消化法分离主动脉瓣膜间质细胞,观察其形态特征,并用免疫荧光染色行表型鉴定。采用脂质体转染法将BMP7-siRNA转染猪主动脉瓣膜间质细胞,采用qPCR和Western blot法验证BMP7表达的变化;利用钙盐培养基诱导细胞成骨分化,建立体外主动脉瓣膜间质细胞钙化模型后,采用ALP染色和茜素红S染色实验分别检测细胞早期及晚期成骨分化能力;采用qPCR和Western blot法分别检测细胞成骨相关基因及蛋白质Runx2、OCN和OPN的表达情况。并用Western blot法检测BMP7下游信号通路中Smad1/5/8的磷酸化水平。结果:BMP7和Runx2蛋白在CAVD组中表达明显高于non-CAVD组。成功分离出原代猪主动脉瓣膜间质细胞,α-平滑肌肌动蛋白(α-SMA)及波形蛋白(vimentin)染色阳性,血管性血友病因子(von willebrand factor,vWF)染色阴性。转染BMP7-siRNA后猪主动脉瓣膜间质细胞中BMP7的mRNA和蛋白质水平均明显下调,早期及晚期成骨分化能力均明显降低。沉默BMP7基因的表达,可下调Runx2、OCN和OPN的基因及蛋白质表达,且磷酸化的Smad1/5/8(p-Smad1/5/8)蛋白水平明显降低。结论:BMP7基因沉默抑制钙盐诱导的主动脉瓣膜间质细胞的成骨分化能力,BMP7/Smads信号通路可能在该过程中发挥重要作用。     

丙氨酰谷氨酰胺对体外循环瓣膜置换术患者的肺保护作用

目的:探讨丙氨酰谷氨酰胺对体外循环瓣膜置换术患者肺屏障功能的影响。方法:择期体外循环(cardiopulmonary bypass,CPB)下行心脏瓣膜置换术患者60例,随机分为3组,每组20例,分别为生理盐水组(C组)、复方氨基酸注射液组(A组)和Ala-GLn组(G组)。G组泵注丙氨酰谷氨酰胺0.4 g/(kg·d),A组和C组分别泵注等量的复方氨基酸注射液和生理盐水,三组均持续输注24 h。分别于:麻醉后(T_0)、开胸后CPB前(T_1)、主动脉开放30 min(T_2)、关胸(T_3)、术后5 h(T_4)、术后24 h(T_5)、术后48 h(T6),经静脉采血3 m L,检测血浆IL-6、TNF-α和SP-A的含量;采动脉血进行血气分析;观察ICU机械通气时间。结果:与T_0比较,三组患者在T_2、T_3、T_4、T_5时间点的血清TNF-α和IL-6含量均显著升高(P0.05);G组患者血清TNF-α和IL-6的浓度显著低于C组和A组(P0.05);与T_0比较,三组患者在T_2~T_5各时间点的SP-A水平显著升高(P0.05),G组患者血清SP-A含量显著低于C组和A组(P0.05);与T_0比较,三组患者在T_2~T_5时的RI值显著升高(P0.05),G组患者RI值显著低于C组和A组(P0.05);G组的机械通气时间比C组和A组显著缩短(P0.05)。结论:丙氨酰谷氨酰胺能降低体外循环瓣膜置换术患者的炎症反应,保护肺泡屏障功能,具有一定的肺保护作用。