Autologous skeletal myoblast transplantation for severe postinfarction left ventricular dysfunction

Background Little direct information is available on the effect of C-Reactive Protein (CRP) lowering on the reduction of recurrent atrial fibrillation (AF)

Methods and Results We compared low-dose glucocorticoid therapy (16 mg methylprednisolone for 4 weeks tapered to 4 mg for 4 months) and placebo in 104 patients who had experienced persistent AF with a median concentration of CRP 114 mg/dL (min=001, max=258) Methylprednisolone reduced recurrent AF (primary end-point) from 50% in the placebo group to 96% in the glucocorticoid group and permanent AF (expanded end-point) from 29% in the placebo group to 2% in the glucocorticoid group Survival distributions for methylprednisolone were significantly different (for both primary and expanded end-point, \batchmode \documentclass[fleqn,10pt,legalpaper]{article} \usepackage{amssymb} \usepackage{amsfonts} \usepackage{amsmath} \pagestyle{empty} \begin{document} \(P{<}0001\) \end{document}) In multivariate Cox analysis, average CRP concentrations during follow-up were significant predictors of the primary end-point, with a relative risk 672 (\batchmode \documentclass[fleqn,10pt,legalpaper]{article} \usepackage{amssymb} \usepackage{amsfonts} \usepackage{amsmath} \pagestyle{empty} \begin{document} \(P=0006\) \end{document}) and the expanded end-point, with a relative risk of 1167 (\batchmode \documentclass[fleqn,10pt,legalpaper]{article} \usepackage{amssymb} \usepackage{amsfonts} \usepackage{amsmath} \pagestyle{empty} \begin{document} \(P=00006\) \end{document})

Conclusions CRP concentration is a risk factor for recurrent and permanent AF Methylprednisolone successfully prevents recurrent and permanent AF

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Relationship between C-reactive protein concentrations during glucocorticoid therapy and recurrent atrial fibrillation.

https://www.annalsthoracicsurgery.org/article/S0003-4975(04)02012-0/pdf

C-reactive protein is a risk indicator for atrial fibrillation after myocardial revascularization.

Research into cardiac autonomic control has received great interest in the past 20 years, and we are now at a critical juncture with regard to the clinical translation of the experimental findings. A rush to develop clinical interventions and implant a range of devices aimed at cardiac neuromodulation therapy has occurred. This interest has been driven by research, superimposed on commercial opportunities and perhaps the more relaxed regulatory framework governing implantable devices and interventions compared with that for pharmacotherapy. However, many of the results of the clinical trials into these therapies have been disappointing or conflicting. This lack of positive results is partly attributable to a scramble to find simple solutions for complex problems that we do not yet fully understand. Are there reasons to be optimistic? In this Review, we highlight areas in the field of cardiac autonomic control that we feel show the most promise for clinical translation and areas in which our current range of blunt tools need to be refined to bring about long-term success in treating arrhythmias.

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The autonomic nervous system and cardiac arrhythmias: current concepts and emerging therapies.

Reference values of indices of spontaneous baroreceptor reflex sensitivity

In patients with acute or chronic myocarditis, arrhythmias are a common and often the only clinical symptom in the natural course of the disease. The potentially malignant tachy- and bradyarrhythmias are of particular significance in the differential diagnosis of sudden cardiac death in myocarditis. Factors responsible for the increased incidence of cardiac arrhythmias are structural changes, parameters of ventricular dynamics and vascular changes. On the one hand, inflammatory processes in the cardiac myocytes and interstitium can lead directly to fluctuations in membrane potential. Fibrosis and scarring of the myocardial tissue and secondary hypertrophy and atrophy of the myocytes favor the development of ectopic pacemakers, late potentials and reentry as a result of inhomogeneous stimulus conduction. Furthermore, parameters of ventricular dynamics such as increased wall tension, increased myocardial oxygen consumption and diminished coronary reserve in the case of disturbed systolic or diastolic left ventricular function also contribute to the increased incidence of arrhythmias. Lastly, vascular factors can further increase the arrhythmogenicity of the inflamed myocardium through the disturbance of micro- and macrovascular perfusion and the resulting myocardial ischemia. Non-invasive rhythmological evaluation by 24 h Holter ECG, measurement of ventricular late potentials and heart rate variability can be used for orienting risk stratification of the at-risk patient with myocarditis. Programmed atrial and ventricular electrophysiological stimulation also has a relatively high predictive value for spontaneous ventricular tachyarrhythmias. It should be emphasized that, at the present time, optimal electrophysiological parameters with a high predictive value do not exist. In a selected patient population, immunosuppressive therapy in addition to conventional antiarrhythmic therapy can lead to the reduction or complete suppression of spontaneous and inducible arrhythmias. Nevertheless, in the interim, further precautionary antiarrhythmic measures such as serial antiarrhythmic treatment, VT ablation and ACID implantation are necessary in patients with malignant cardiac arrhythmias. Right ventricular myocardial biopsy for demonstration or exclusion of myocarditis is an important additional examination which can improve the differential diagnosis and treatment of patients with cardiac arrhythmias of unclear etiology.

Inflammation of the myocardium as an arrhythmia trigger

Bei Patienten mit akuter oder chronischer Entzundung des Herzmuskels stellen Herzrhythmusstorungen im naturlichen Verlauf ein haufiges, gelegentlich das einzige klinisch fasbare Symptom dar. Den potentiell malignen tachykarden und bradykarden Arrhythmieformen kommt in der Differentialdiagnose des plotzlichen Herztodes bei der Myokarditis besondere Bedeutung zu. Fur die erhohte Inzidenz von Herzrhythmusstorungen sind strukturelle, ventrikel-dynamische und vaskulare Faktoren verantwortlich zu machen. Zum einen konnen direkt entzundliche Vorgange an den Herzmuskelzellen und dem Interstitium Membranpotentialschwankungen hervorrufen. Die Ausbildung von Fibrose und Narben im Herzmuskelgewebe sowie eine sekundare Entwicklung von Hypertrophie und Atrophie der Herzmuskelzellen begunstigen die Entstehung von ektopen Automatiezentren, Spatpotentialen und Kreiserregungen durch eine inhomogene Erregungsleitung. Zusatzlich beeinflussen ventrikeldynamische Grosen wie die erhohte Wandspannung, ein erhohter myokardialer Sauerstoffverbrauch sowie die erniedrigte Koronarreserve bei Vorliegen einer systolischen und/oder diastolischen Funktionsstorung des linken Ventrikels die erhohte Inzidenz von Arrhythmien. Daruber hinaus konnen vaskulare Faktoren durch eine begleitende mikro- bzw. makrovaskular bedingte Perfusionsstorung mit konsekutiver Myokardischamie die Arrhythmogenitat des entzundeten Myokards weiter steigern. Eine Risikostratifizierung des gefahrdeten Patienten mit Myokarditis gelingt orientierend durch eine nichtinvasive rhythmologische Abklarung mittels 24-h-Holter-EKG, Messung der ventrikularen Spatpotentiale und der Herzfrequenzvariabilitat. Einen vergleichsweise hohen pradiktiven Wert in Hinblick auf spontane ventrikulare Tachyarrhythmien ermoglicht daruber hinaus die Durchfuhrung einer programmierten atrialen und ventrikularen elektrophysiologischen Stimulation. Es ist zu betonen, das optimale elektrophysiologische Parameter mit hohem pradiktivem Wert derzeit nicht zur Verfugung stehen. Begleitend zu einer konventionellen antiarrhymischen Therapie kann in einem selektionierten Patientenkollektiv eine immunsuppressive Therapie zu einer verminderten bzw. vollstandigen Suppression spontaner und induzierbarer Arrhythmien fuhren. Dennoch sind uberbruckend weitere antiarrhythmische Masnahmen zur Absicherung bei Patienten mit malignen Herzrhythmusstorungen wie eine serielle antiarrhythmische Einstellung, eine VT-Ablation und die AICD-Implantation erforderlich. Zur Verbesserung der Differentialdiagnostik und Therapie von Patienten mit Herzthythmusstorungen ungeklarter Atiologie stellt die Entnahme von rechtsventrikularen Herzmuskelbiopsien zum Nachweis bzw. Ausschlus einer Myokarditis eine wichtige Zusatzuntersuchung dar.

Entzündung des Myokards als Arrhythmietrigger

Einleitung. Zur Untersuchung von Patienten mit einem erhohten Risiko des plotzlichen Herztodes sind die Analyse ventrikularer Spatpotentiale, der Herzfrequenzvariabilitat und der Baroreflexsensitivitat hilfreich. Jedoch gelingt die Vorhersage eines malignen arrhythmischen Ereignisses bislang nicht mit genugender Genauigkeit. Zur besseren Risikoabschatzung sind weitere Methoden notwendig. In dieser Arbeit soll die Wertigkeit der Chemoreflexsensitivitat fur die Vorhersage ventrikularer Tachyarrhythmieereignisse untersucht werden.

Chemoreflex- und Baroreflexsensitivität bei Patienten mit überlebtem plötzlichem Herztod

BACKGROUND The treatment of life threatening ventricular arrhythmias with implantable cardioverter/defibrillators (ICD) has become the therapy of choice; the survival benefit of ICD treatment compared to drug therapy in patients with aborted sudden cardiac death (SCD) and hemodynamically unstable ventricular tachycardia has been proven In addition for the primary prevention of SCD in high risk patients, ICD therapy is gaining growing acceptance PATIENTS AND METHODS We analyzed the long-term follow-up of 274 consecutive patients (211 male, 63 female, age 59 +/- 12 years, left ventricular ejection fraction 39 +/- 15%) provided with an ICD between 1984 and 1998 The aim of the study was to ascertain the survival rate in different subgroups and to discover determining factors of ICD discharge and prognosis RESULTS Long-term survival probability at 10 resp 14 years was 84 resp 65% for the total collective, and the freedom of event probability (neither shocks nor antitachycardiac pacing from the ICD) to 28% each The risk to die from SCD was below 3% over time The most pronounced differences regarding prognosis ensued from dividing the collective into heart insufficiency stages Thus in NYHA class I and II versus III and IV, the cumulative event rate was 61% vs 82% at 5 years, and survival rate amounted to 94 vs 63% at 5 years and 87% vs 30% at 14 years (p < 0001) Calculating the relative benefit of ICD therapy survival benefit provided by the ICD was shown to decrease significantly after 5 years for patients in NYHA class III/IV, while it increased progressively for patients in NYHA class I/II up to 10 years Additional determinants of prognosis and ICD discharge rate were identified left ventricular ejection fraction, age and tendency for the basic cardiac disease, however neither the result of electrophysiological testing nor the results of non-invasive risk stratification In patients with ischemic heart disease, revascularization procedures improved prognosis only in tendency, while the effect of ICD therapy was significant In patients with the non-obstructive form of hypertrophic cardiomyopathy ICD, discharges occurred in about 50% of patients; in contrast patients with surgical myectomy for obstructive cardiomyopathy showed no events during follow-up In patients with chronic inflammatory heart disease and normal left ventricular function (LVF), a very low event rate was expected if patients were treated by immunosuppressive drugs Patients with dilated cardiomyopathy did not differ from patients with ischemic heart disease with respect to prognosis and ICD discharge rate CONCLUSION Significant determinants of prognosis and ICD discharge rate are left ventricular function, age and with limitations the basic cardiac disease In contrast to patients with better LVF relative survival benefit decreases significantly after 5 years in patients with a worse LVF Patients with aborted SCD and preserved LVF experience half the ICD discharges compared to patients with poor LVF and gain at the same time a normalization of life expectancy Causative treatment of the basic disease has an impact on the overall prognosis and event rate, but should in general not influence the decision for IDC implantation in high risk patients

[14-year experience with implantable cardioverter/defibrillators: determination of prognosis and discharge behavior].

Hintergrund: Die Behandlung lebensbedrohlicher ventrikularer Arrhythmien mittels implantierbarer Cardioverter/Defibrillatoren (ICD) ist inzwischen zur Therapie der ersten Wahl geworden; der Uberlebensvorteil der ICD-Therapie bei Patienten mit uberlebtem plotzlichen Herztod und hamodynamisch kompromittierenden ventrikularen Tachykardien ist gegenuber einer medikamentosen Therapie erwiesen Auch in der Primarpravention des plotzlichen Herztodes setzt sich bei Hochrisikopatienten zunehmend die ICD-Therapie durch Uber Langzeitverlaufe jenseits von 10 Jahren ist jedoch bislang wenig bekannt

H. Dees

Papers

Inflammation of the myocardium as an arrhythmia trigger

Entzündung des Myokards als Arrhythmietrigger

Chemoreflex- und Baroreflexsensitivität bei Patienten mit überlebtem plötzlichem Herztod

[14-year experience with implantable cardioverter/defibrillators: determination of prognosis and discharge behavior].

14 Jahre Erfahrung mit implantierbaren Cardioverter/Defibrillatoren: Determinanten der Prognose und des Auslöseverhaltens