Congestive heart failure and ischaemic heart disease treated with trandolapril and verapamil. DAVIT Study Group. Danish Verapamil Infarction Trial

CLINICAL TRIALS WITH VERAPAMIL AND TRANDOLAPRIL: In the Danish Verapamil Infarction Trial II, verapamil improved survival in patients without heart failure but had no effect in patients with heart failure who were receiving diuretic treatment. In the Acute Infarction Ramipril Efficacy study ramipril improved survival in patients receiving diuretic treatment but had no effect in patients not receiving diuretics. COMBINATION WITH THERAPY WITH VERAPAMIL AND TRANDOLAPRIL: By combining verapamil with trandolapril we hypothesized that we could obtain an improvement in left ventricular function and prevent cardiac events. In an open study of 14 patients with angina pectoris and left ventricular ejection fraction below 40%, treatment with trandolapril-verapamil significantly improved left ventricular function. In a double-blind randomized study of 100 postinfarct patients with congestive heart failure the cardiac event rate was significantly lower in verapamil-trandolapril-treated than in the trandolapril-treated patients. These results indicate that the combined treatment with verapamil and trandolapril might be beneficial in patients with ischaemic heart disease and congestive heart failure.     

Noninvasive evaluation of a left ventricular pseudoaneurysm: complementary role of echocardiographic and nuclear techniques

This 45-year-old white male was evaluated for congestive heart failure initially ascribed to a rapidly progressive cardiomyopathy. Both radionuclide ventriculography and echocardiography correctly identified a left ventricular pseudoaneurysm as the cause for heart failure. Thallium-201 scintigraphy, by demonstrating a large perfusion defect, suggested a large ostium of the pseudoaneurysm. Following resection of the false aneurysm, a Dacron prosthesis was required to close a large posterior wall defect. We conclude that both radionuclide ventriculography and echocardiography can independently demonstrate a left ventricular pseudoaneurysm. The combined noninvasive approach is able to delineate various anatomical aspects of the pseudoaneurysm and help in planning adequate surgical intervention.     

Detection of left ventricular aneurysms by cross-sectional echocardiography

Real-time cross-sectional echocardiographic studies of the left ventricle were performed in 31 consecutive patients with angiographically proven left ventricular aneurysms (group I). In each of these patients the presence and location of the aneurysm was visualized by the cross-sectional echocardiography. In four patients discrepancy in the extent of the aneurysm was noted due either to failure of the cross-sectional technique to visualize the entire anterior wall of the ventricle (3) or failure of the single plane angiogram to adequately define the lateral extent of the aneurysm (1). Ventricular shape and contraction sequence in patients with aneurysms were compared with similar patterns in 20 patients with normal left ventricles (group II), and 20 patients with ischemic heart disease and localized ventricular dysfunction without aneurysm formation (group III). Other noninvasive methods for detecting aneurysms (including physical examination, chest roentgenography, electrocardiography, and M-mode echocardiography) were also evaluated in the aneurysm group. This report suggests that cross-sectional echocardiography is a useful method for detecting ventricular aneurysms noninvasively.     

Congenital left ventricular apical aneurysm

An aneurysm of the left ventricular apex was accidently discovered on chest X-ray in an otherwise healthy 3 1/2-year-old-girl. Pre-operatively performed heart catheterization and ciné-angiography were followed by successful surgical removal of the aneurysm. Microscopic examination showed that the three layers of the myocardium were present, although it was degenerated by fibrosis. This case belongs to the fibrous type of aneurysm, which is the most rare type, not associated with other developmental defects, usually asymptomatic until there is rupture and sudden death, or the condition is accidentally discovered on chest X-ray and treated surgically.     

Acute myocarditis and left ventricular aneurysm as presentations of systemic lupus erythematosus

A case of systemic lupus erythematosus (SLE) associated with fever, heart failure, and left ventricular (LV) aneurysm is reported. A diagnosis of SLE was suspected owing to the presence of active lymphocytic myocarditis and fibrinous endocarditis at LV endomyocardial biopsy and was confirmed by identification of 4 of the 11 criteria proposed by the American Rheumatism Association for the definition of SLE. A 2-month period of steroid therapy was followed by a remarkable recovery of LV function and progression of endomyocarditis to a healed phase at control LV biopsy. The LV aneurysm disappeared, likely because thrombosis occurred as a result of the hypercoagulable state accompanying the presence of anticardiolipin antibodies. This is the first reported case of LV aneurysm induced by SLE and is a rare clinicohistologic documentation of the effectiveness of steroid treatment on lupus endomyocarditis.     

Atrial septal aneurysm: a new classification in two hundred five adults

Atrial septal aneurysm is a localized "saccular" deformity, generally at the level of the fossa ovalis, which protrudes to the right or the left atrium or both. For 39 months we prospectively analyzed 205 consecutive patients in whom atrial septal aneurysm was diagnosed echocardiographically. The direction and movement of atrial septal aneurysms were carefully studied in multiple views, and, according to our findings, we now propose a new classification: type 1R if the bulging is in the right atrium only, type 2L if the bulging is in the left atrium only, type 3RL if the major excursion bulges to the right atrium and the lesser excursion bulges toward the left, type 4LR if the maximal excursion of the atrial septal aneurysm is toward the left atrium with a lesser excursion toward the right atrium, type 5 if the atrial septal aneurysm movement is bidirectional and equidistant to both atria during the cardiorespiratory cycle. We found an incidence of 1.9%, a mean age of 63 years (25 to 97 years), a female/male ratio of 2:1, valvular regurgitation 74%, hypertension 64%, left ventricular hypertrophy 38%, coronary heart disease 32%, patent foramen ovale 32%, pulmonary hypertension 31%, stroke 20%, dysrhythmias 16%, valvular prolapse 15%, and atrial septal defect 3%. No differences were found between mobile and motionless types of atrial septal aneurysm. However, differences were found between predominantly left bulging or right bulging atrial septal aneurysm (134 versus 57 patients), as well as other variables. All types of atrial septal aneurysm have particular clinical or echocardiographic characteristics. The new classification is a complete, simple, and practical form. Atrial septal aneurysm is associated with congenital and acquired heart diseases but also can present as an isolated abnormality.     

Left ventricular aneurysm and peripheral embolism as cause of atypical foot pain

Sudden occlusion of a peripheral artery by embolization or acute thrombosis results in acute ischemia. This is most commonly associated with sudden onset of severe pain, numbness and pallor. Chronic ischemia from peripheral vascular disease results in intermittent claudication. We present a case of peripheral embolization from a left ventricular aneurysm in a previously asymptomatic male who presented to the emergency department complaining of two weeks of pain in his left great toe. Included in the discussion are important diagnostic tests for peripheral thromboembolism and ventricular aneurysm as well as suggestions for emergency department management.     

Recurrent left ventricular false aneurysm

A recurrent left ventricular false aneurysm 5 years after patch repair and causing progressive congestive heart failure was readily diagnosed by echocardiography and heart catheterization. Its substrate was suture dehiscence of undetermined origin. Urgent repair was successful. The long-term prognosis is guarded.     

Doppler echocardiographic assessment of left atrial and left ventricular function during right bundle branch block]

Electrocardiographic, echocardiographic and Doppler echocardiographic studies were performed in 44 patients with coronary heart disease and complete right bundle branch block. The patients were found to have an impaired phase pattern of left ventricular systole and diastole as more prolonged length of its isometric relaxation and contraction, lower economic feasibility and efficiency of its contraction, moderate dilation and hypertrophy. Hemodynamic abnormalities in the left heart in these patients are closely correlate with the changes in the phase pattern of right ventricular systole and they turn out to be so greater as the degree of its hypertrophy is. In complete right bundle branch block, left ventricular pump dysfunction leads to decreased cardiac output and cardiac index, increased total peripheral vascular resistance, thus predisposing to impaired greater circulation.     

First report of a human isolate of Erwinia persicinus

Left ventricular thrombus is a complication of myocardial infarction, ventricular aneurysm, cardiomyopathy, and myocarditis. Left ventriculotomy has been the standard approach for removal of left ventricular thrombus. This approach has produced an unacceptable incidence of ventricular dysfunction, arrhythmias, and aneurysm formation. We describe a case of left ventricular thrombus with systemic embolization in a patient with myocarditis. Video-assisted cardioscopy allowed visualization and removal of the thrombus via an aortotomy, thereby avoiding a left ventriculotomy.     

Long-term results of visually guided left ventricular reconstruction as single therapy to treat ventricular tachycardia associated with postinfarction anteroseptal aneurysm

INTRODUCTION: Postinfarction ventricular tachycardia (VT), anteroseptal aneurysm, and ventricular dysfunction are commonly associated and predict a poor long-term prognosis. Surgical left ventricular reconstruction, which includes double plication of the anterior and septal wall, can improve ventricular function. This article analyzes the long-term efficacy of such a procedure to control recurrence of VT in a group of 50 consecutive patients. METHODS AND RESULTS: The study group consisted of 50 consecutive patients operated on between December 1986 and December 1994. The group comprised 44 men and 6 women. The mean age was 56+/-11 years. All patients had spontaneous VT following an anterior myocardial infarction. Twenty-five patients had two or more episodes of VT (eight presented as cardiac arrest, nine as syncope). Coronary artery disease was limited to the left anterior descending artery in 27 patients. An anteroseptal aneurysm was present in 49 patients. All patients had VT induced by programmed ventricular stimulation before surgery, and left ventricular reconstruction was performed without intraoperative mapping in all cases. Total mortality, VT recurrence, and sudden death rate were the endpoints of the study. In-hospital mortality was 8%. Postoperative left ventricular ejection fraction improved from 0.38 to 0.50 (P<0.05). Only two patients had postoperative inducible VT. Overall survival, VT recurrence rate, and sudden death rate were 73%, 12%, and 10%, respectively, after a median follow-up period of 6.25 years (0 to 8 years). CONCLUSION: Visually guided left ventricular reconstruction with septal and anterior wall plicature can be utilized effectively to treat recurrent VT associated with postinfarction anteroseptal aneurysm.     

Analysis of right ventricular function during bypass of the left side of the heart by afterload alterations in both normal and failing hearts

This study investigated the mechanism of right ventricular failure during bypass of the left side of the heart by precisely assessing right ventricular function with use of a conductance catheter. Bypass of the left side of the heart was established with a centrifugal pump in 10 mongrel dogs weighing 11 to 19 kg. Right ventricular function during left heart bypass was evaluated by two parameters that were both derived from measurement of relative change in right ventricular volume by the conductance catheter technique. One parameter was the right ventricular end-systolic pressure-volume relationship as a load-independent index, and the other was the peak right ventricular pressure-right ventricular stroke volume relationship as a "force-velocity relationship." These parameters were measured in both normal and failing hearts while afterload was increased by bilateral intrapulmonary balloon inflation. Moreover, changes in these relationships were observed by varying assist ratios of left heart bypass from 0% to 100%. Failing heart models were induced by normothermic aortic clamping for 20 minutes. The right ventricular end-systolic pressure-volume relationship in normal hearts did not change, irrespective of the assist ratio of left heart bypass, whereas that in failing hearts decreased from 4.25 +/- 1.41 mm Hg/ml without bypass of the left side of the heart to 3.53 +/- 1.30 mm Hg/ml after 100% assist of left heart bypass (p < 0.05). In the peak right ventricular pressure-right ventricular stroke volume relationship, right ventricular stroke volume was almost constant in normal hearts when afterload was increased regardless of the assist ratio of left heart bypass. Moreover, right ventricular stroke volume was maintained at a higher level during bypass of the left side of the heart compared with that without left heart bypass. However, that slope of the relationship in failing hearts was inversely linear and became significantly steeper after 100% assist of bypass of the left side of the heart compared with that without left heart bypass (-0.131 +/- 0.042 versus -0.051 +/- 0.038, p < 0.005). Therefore ++these two slopes of the relationship intersected at a point that was considered the critical point of afterload during bypass of the left side of the heart. In other words, right ventricular stroke volume was decreased by 100% left heart bypass above the critical point of afterload. In conclusion, this study demonstrates not only that bypass of the left side of the heart results in an increase in right ventricular stroke volume in both normal and failing hearts at the physiologic range of afterload, but also that right ventricular function against higher afterload is impaired by 100% assist of bypass of the left side of the heart in failing hearts.     

Hypoplastic left heart syndrome in the second trimester

Hypoplastic left heart syndrome is a relatively common congenital anomaly with a high mortality even after palliative postnatal surgery. The case presented had a normal cardiac cavity and great artery dimensions at 19 weeks of gestation but bright left ventricular myocardial echoes, impaired left ventricular shortening, and no detectable forward flow in the left ventricular outflow tract. Autopsy showed left ventricular subendocardial calcification. This demonstrates a likely early stage in the evolution of hypoplastic left heart syndrome, which has a variable time course. The abnormal left ventricular myocardial performance associated with low left ventricular output results in a failure of growth of the left heart rather than there being a primary failure of embryogenesis.     

Corticosteroid therapy in cardiac sarcoidosis

Corticosteroid treatment of cardiac sarcoidosis is not conclusive, although sarcoid granulomas in the heart may be more responsive to steroid therapy than in other organs. Healing of sarcoidosis lesions in the heart results in fibrosis and sinning of the myocardium, which may lead to aneurysm formation causing congestive heart failure or sudden death. Congestive heart failure is the leading cause of death in patients with cardiac sarcoidosis in Japan. It is reasonable to initiate steroid therapy as soon as the diagnosis of cardiac sarcoidosis is established in order to prevent fibrosis. Early initiation of steroid therapy with conventional treatment for specific cardiac manifestations (antiarrhythmic therapy, pacemaker implantation and heart failure medication) should bring improvement in the left ventricular systolic and diastolic function with prevention from malignant arrhythmias. Systemic disorder represents a contraindication to organ transplantation, but heart transplantation is now a feasible treatment for patients with end-stage cardiac sarcoidosis with congestive heart failure.     

The effects of simulated akinetic and dyskinetic aneurysms on left ventricular systolic function: clinical implications

OBJECTIVE: Scant attention has been directed towards quantifying the degree of mechanical disadvantage produced by akinetic and dyskinetic aneurysms. The purpose of this study was to evaluate the mechanical disadvantages of simulated akinetic and dyskinetic aneurysms on left ventricular function. METHODS: An elaborate experimental apparatus consisting of a computer-controlled water pressure chamber in which is suspended a model rubber ventricle was developed. The system has been shown to reproduce accurately the ventricular and aortic pressures found in vivo. In this study, a procedure was designed to simulate akinetic and dyskinetic aneurysms of various sizes on ventricular function. RESULTS: The results indicated that an akinetic aneurysm produces little or no mechanical disadvantage with respect to ventricular pressure since systolic paradox is minimal. However, a dyskinetic aneurysm, irrespective of size, will usually compromise ventricular function due to paradoxical systolic expansion in the bulging aneurysmic sac. In vivo, other factors, such as blood coagulation and rhythm disturbances, may influence these results. CONCLUSIONS: An akinetic aneurysm causes little or no mechanical disadvantage while the dyskinetic aneurysm, irrespective of size. will restrict ventricular function. The experimental simulation system, notwithstanding its limitations, thus provides a unique procedure to quantify akinetic and dyskinetic aneurysms.     

The use of latissimus dorsi muscle flap in reconstructive heart surgery

Dynamic cardiomyoplasty is a technique for ventricular assistance indicated for the correction of left ventricle aneurysm and for cardiomyopathies in which heart transplantation is contraindicated. In this article, our first four patients to undergo cardiomyoplasty (from February 1991 until April 1992) with a left latissimus dorsi island flap, rotated into the thorax after a 3-week training period, are reviewed. Therapeutic indications were cardiomyopathy with contraindication for heart transplant in patients 1 and 4 and associated to surgery for left ventricle aneurysm for patients 2 and 3. Patient 1 died 4 months after surgery because of a cerebral embolism when he was at functional class II. The other three patients remain at functional class I, carrying out normal activities. All the data were evaluated with the paired t test. Ejection fraction values (obtained through echocardiography and scintigraphy studies) and maximum minute flow rate of blood (measured with an echo-Doppler) have increased significantly (p < 0.001, p < 0.05, and p < 0.01, respectively) after heart surgery. Clinical improvement has been found after cardiomyoplasty, which correlates with an increase in ejection fraction and maximum minute flow rate of blood.     

A study of the relationship between temperature and the infectivity of Schistosoma mansoni and Schistosoma haematobium cercariae

An unusual form of left ventricular aneurysm affecting young Negroes has recently been described at the aortic or mitral valve ring; constitutional factors have been postulated. A 4-year-old Negro boy was observed with a left ventricular submitral aneurysm, probably one of the largest and one of the most calcified to be reported. Tuberculous lymphadenitis involving some of the mediastinal lymph nodes was found on postmortem examination; tuberculosis was believed to be a secondary contributing factor. A review of the literature disclosed only 5 other children with calcified left ventricular aneurysms, of which 2 were of the subvalvular type.     

Critical controls for juice safety

Operations for ischemic heart disease complicated by the appearance of postinfarction left ventricular aneurysm were fulfilled on 94 patients. The modified operation after V. Dor used in 55 patients allowed fulfilling interventions on the damaged parts of the interventricular septum excluding the application of foreign patches. Intrahospital lethality was 7.6%.     

In vivo and in vitro evaluation of the pulsatile mode of a magnetically suspended centrifugal pump

The authors have been developing a magnetically suspended centrifugal pump (MSCP). They have devised a pulsatile mode for the MSCP, which was generated by altering rotational speed. This article describes in vitro and in vivo studies with the pulsatile mode of the MSCP. Hemolysis tests were performed in two identical circuits to compare the nonpulsatile (NP) mode and the pulsatile (P) mode. In vivo studies were performed in sheep. First, biventricular assisted circulation was instituted in the left heart with the MSCP and in the right heart with the Biopump. The native heart was induced to ventricular fibrillation. Second, a left ventricular assisted circulation was instituted as the native heart was beating. An inflow cannula was inserted into the left atrium in one sheep and into the left ventricle in the other. The normalized indices of hemolysis of the NP and P groups were 0.0025 +/- 0.0018 g/100 L, and 0.0032 +/- 0.0024 g/100 L (N = 4, not significant). During ventricular fibrillation in the P mode, the pulse pressure was 14 mmHg (the rotational speed: 1,500 to 2,600 rpm). In a beating heart, at atrial withdrawal, the pulse pressure increased from 10 to 24 mmHg (2,100 +/- 500 rpm), while at ventricular withdrawal, it decreased from 17 to 40 mmHg (2,000 +/- 500 rpm) on P mode. The MSCP in pulsatile mode did not increase hemolysis. At ventricular withdrawal, it was easier to produce a pulsation than at atrial withdrawal. The pulsatile mode of the MSCP is applicable to a left ventricular assist system.     

False aneurysm of the left ventricle and coronary aneurysms in Beh?et disease

A false left ventricular aneurysm and coronary artery aneurysm were discovered in a 29 year old patient with Beh?et's syndrome. The operation under cardiopulmonary bypass consisted of closing the neck of the false aneurysm by an endo-aneurysmal approach with a Gore-Tex patch. The coronary artery aneurysms were respected. There were no postoperative complications. Cardiac involvement is rare in Beh?et's syndrome (6%). The originality of this case is the association of two aneurysmal pathologies: the coronary and ventricular aneurysms due to the angiitis and the myocardial fragility induced by ischaemia.