Metabolic abnormalities following heart transplantation in patients with idiopathic cardiomyopathy

The purpose of this study was to evaluate the risk factors for coronary artery disease associated with initiation of immunosuppressive therapy in patients with a pre-heart transplant diagnosis of idiopathic cardiomyopathy. This study was performed in 15 consecutive patients, mean +/- SEM age of 39 +/- 2 years, with a pre-operative diagnosis of idiopathic cardiomyopathy, who underwent cardiac transplantation at the Tri-Services General Hospital, Taipei, Taiwan, from July 1992 to June 1993. All patients were treated with cyclosporine, azathioprine and prednisolone, and the following measurements were performed prior to hospital discharge (mean +/- SEM) 36 +/- 3 days after successful transplantation: 1) fasting plasma lipid and lipoprotein concentrations; 2) plasma glucose and insulin concentrations in response to a 75 g oral glucose challenge; and 3) steady-state plasma insulin (SSPI) and glucose (SSPG) concentrations in response to a continuous infusion of somatostatin, insulin, and glucose. Since the SSPI concentrations are similar in all individuals, the SSPG concentrations provide an estimate of the ability of insulin to stimulate glucose disposal. Only six of the patients had a normal oral glucose tolerance test and the following diagnoses were found in the remaining nine patients: not diagnised (n = 3), impaired glucose tolerance (n = 4), and non-insulin-dependent diabetes (n = 2). Plasma lipid and lipoprotein concentrations were also frequently abnormal in the heart transplant patients; eight of the 15 patients had a plasma cholesterol > 5 mmol/l, nine had a high density lipoprotein (HDL)-cholesterol concentration < 1 mmol/l, and nine had a ratio of total to HDL-cholesterol > 5.0. Finally, the SSPG concentration was greater than 11.0 mmol/l in eight of the 15 patients, a value rarely exceeded in healthy volunteers. In conclusion, significant metabolic abnormalities were present at discharge in patients who had undergone successful cardiac transplantation for idiopathic cardiomyopathy. These metabolic abnormalities were probably caused by the use of immunosuppressive drugs. Given the magnitude of these changes, it would seem prudent to initiate therapeutic programs in patients with cardiac transplants that are not simply aimed at preventing rejection, but also address the metabolic abnormalities associated with the immunosuppressive agents used to prolong allograft survival.     

Heart transplantation in patients with diabetic end-organ damage before transplantation

Diabetes mellitus with preexisting end-organ damage (EOD) is considered a contraindication for heart transplantation. The outcome of such patients has not been well characterized. Among 138 patients transplanted between 12/88 and 7/94, 29 were diabetic (11 insulin-dependent); of these, 12 had preexisting EOD, defined as a creatinine clearance < or = 50 ml/min, a 24-hour urine protein concentration > or = 500 mg/L or typical symptoms of peripheral or autonomic polyneuropathy, and 17 had no EOD. We compared diabetics with and without EOD and non-diabetics (n = 109) for operative mortality, length of stay, serum creatinine, fasting glucose levels, and postoperative prednisone doses at 1,6, and 12 months. Actuarial survival and freedom from rejection and infection were analyzed. Both diabetic groups were significantly older than nondiabetics, Ischemic time, operative mortality, surgical technique, ICU- and total length of stay were similar. Actuarial survival and freedom from rejection were similar among the three groups. Infection rates including CMV did not differ. Serum creatinine levels increased in all groups compared to pretransplant levels (p = 0.001), but without significant differences among the groups. Post-transplant glucose levels at 6 and 12 months were higher for diabetic patients with EOD than for those without or for nondiabetics (183, 153, and 94 mg/dl at 6 months, p = 0.01; 202, 161, and 102 mg/dl at 12 months, p = 0.0001). Prednisone dosage was lower in diabetics with EOD at 6 months, but did not differ among the three groups at 12 months. The incidence of angiographically proven transplant vasculopathy did not differ at 1 and 2 years. Diabetics with preexisting EOD undergoing heart transplantation experience similar short- and intermediate-term results when compared to diabetics without EOD and nondiabetics. Metabolic control is more difficult to achieve, as indicated by higher fasting glucose levels. Larger and longer-term prospective studies have to confirm our findings, since the shortage of donor organs would increase if such patients were transplanted routinely.     

Psychiatric comorbidity and psychosocial markers in patients before heart, liver or lung transplantation

Organ transplant operations are regularly carried out in Switzerland at 6 transplantation centres. Between January 1995 and October 1996, 119 patients at Zurich University Hospital completed a semistructured psychiatric interview and the Transplant Evaluation Rating Scale (TERS). Inclusion criteria comprised all indications for organ transplant. Diagnostic evaluation was according to ICD-10. Of the 44 women and 75 men (mean age 40.2 years), 48 required a heart transplantation (HTPL), 37 a liver transplantation (LETPL), and 34 lung transplantation (LUTPL). 39 patients (32.8%) had one, and 15 (12.6%) 2 current psychiatric disorders. 65 of the 119 patients (54.6%) were without a current psychiatric disorder. The candidates for lung transplantation were the most psychologically healthy (68% had no psychiatric disorder). Approximately half of the heart and liver patients had at least one psychiatric disorder. The LETPL group had the highest prevalence of psychiatric comorbidity, with organic brain disorders present in a third of the patients. A quarter of all patients had stress disorders, panic disorder or a somatoform disorder. Full criteria for an affective disorder were not met by any patient. 61% enjoyed good to excellent family and social support, 29% had an unresolved conflict, and 11% had strong conflicts. Earlier coping behaviour appeared to be good to excellent in 57%, sufficient in 37%, and poor in 6%. Estimated compliance rate was found to be complete in 87%, partial or involving problems in 12% and unsatisfactory in 1%. We conclude that in transplant candidates psychiatric disorders and psychosocial problems are frequent and must be considered regularly during evaluation and the transplantation process. The results of this analysis and 3 case examples and the results of the study show the clinical importance of a detailed psychiatric and psychosocial examination as part of the evaluation of patients about to undergo life-saving organ transplant operations.     

Hyperlipoproteinemia in patients after heart transplantation

Hyperlipidaemia is one of the most frequent metabolic disorders after heart transplantation (HTx). The significance of hyperlipidaemia is stressed mainly in relation to graft vascular disease (GVD) which is the leading cause of death more than one year after transplantation. Recently the evidence on the role of hyperlipidaemia (HLP) in the pathogenesis of GVD is growing. Total cholesterol (TC), triglycerides (TAG) HDL-cholesterol (HDL-C) and LDL-cholesterol (LDL-C) were analysed cross-sectionally in 35 patients (30 males), aged 20-64 (median 40) years, more than one year after HTx. In 25 patients HTx was performed because of dilated cardiomyopathy (D-KMP), in 10 because of coronary artery disease (CAD). TC more than 5.6 mmol/l was detected in 29 (83%), TAG > 2.3 mmol/l in 15 (43%), LDL-C >3.6 mmol/l in 28 (80%) and HDL-C < 1.4 mmol/l in 25 (75%) of patients. There were no statistically significant differences in evaluated parameters found between the groups of patients operated on because of CAD and D-CMP, with and without glucose tolerance disorder and groups treated with higher (> 5 mg/D) and lower (.5 mg/D) dose of prednisone. Significant linear correlation of body mass index (BMI) and TAG or BMI and HDL/C resp. was confirmed. Pathogenesis of HLP after HTx is complex. Except of obesity, no unambiguous evidence of the role of glucose tolerance disorder or prednisone dose in immunosuppressive treatment were found. (Tab. 2, Fig. 3, Ref. 21.)     

Impaired heart rate variability in patients with symptomatic NYHA class II-III hypertrophic cardiomyopathy

Power spectral analysis of heart rate variability was performed to assess cardiac autonomic function using Holter monitoring in 19 hospitalized patients with symptomatic NYHA class II-III hypertrophic cardiomyopathy (sHCM), 20 ambulatory patients with asymptomatic NYHA class I hypertrophic cardiomyopathy (asHCM) and 20 normal control subjects. Power spectral analysis decomposed the heart rate variability into high-frequency power (HF: 0.15-0.40 Hz) and low-frequency power (LF: 0.04-0.15 Hz). HF was corrected by mean RR intervals (CCVHF). CCVHF values and LF/HF ratios were used as indices of vagal and sympathetic modulations, respectively. The sHCM group demonstrated no significant elevation in CCVHF during the nighttime as compared to the daytime, while asHCM and control groups showed significant CCVHF elevation during the nighttime (p < 0.05-0.01). The nighttime CCVHF, therefore, was significantly lower in the sHCM group than in the control or asHCM group (sHCM, 1.08 +/- 0.36%; control, 1.60 +/- 0.57%; asHCM 1.82 +/- 0.77%; sHCM vs. control or sHCM vs. asHCM, p < 0.01). All of these three groups showed significant reduction in LF/HF ratio during the nighttime as compared to the daytime (p < 0.01). However, the reduction in the sHCM group was not as great as that in the control group and there was a significant difference between the sHCM and control group (2.01 +/- 1.58 vs. 1.08 +/- 0.65, p < 0.05). Two patients in the sHCM group, who later died suddenly, demonstrated very low CCVHF throughout a 24-hour period (0.2-0.8%). Both vagal and sympathetic impairment with a predominance of vagal abnormalities is suggested in patients with symptomatic NYHA class II or III hypertrophic cardiomyopathy.     

Temporary mechanical left heart support. Recovery of heart function in patients with end-stage idiopathic dilated cardiomyopathy

BACKGROUND: Implantation of a mechanical cardiac support system (MCSS) in patients with idiopathic dilated cardiomyopathy (IDC) may improve cardiac function and allow explantation of the device. Our experience now includes 13 patients who have been "weaned" from MCSS and we report about the overall results of this treatment as well as the effects of ventricular unloading on cardiac function, anti-beta 1-adrenoceptor-autoantibody (A-beta 1-AAB) level and the degree of myocardial fibrosis. METHODS: 13 patients with non-ischemic IDC who had been admitted here in cardiogenic shock (CI < 1.61.min-1.m2, left ventricular ejection fraction [LVEF] < 16% and left ventricular internal diameter in diastole [LVIDd] > 68 mm) and who all tested positive for A-beta 1-AABs were implanted with an uni-(12 patients) or a biventricular (1 patient) mechanical assist device. Echocardiographic evaluation and A-beta 1-AAB-level-monitoring was routinely performed after implantation and explantation of the MCSS and the degree of myocardial fibrosis was assessed at the time of implantation and after explantation. RESULTS: During a mean duration of mechanical support of 236 +/- 201 days (range: 30 to 794 days), LV-EF improved to a mean of 46% and LVIDd decreased to a mean value of 56 mm in these 13 patients. A-beta 1-AABs decreased and disappeared 11.7 weeks after implantation of the device and did not reincrease thereafter. The highly pathologic degree of fibrosis at the time of implantation diminished to normal values about 1 year after explantation. One patient died of anesthesiologic complications and another patient shortly presented with a new episode of cardiac insufficiency 6 months after explantation. He was implanted again with an univentricular assist device was successfully transplanted 3 weeks later. Mean observation period of the remaining 11 patients now amounts to 12.6 +/- 9.77 (range: 3 to 26) months after explantation of the device--as of May, 31, 1997--with a cumulative observation period of 139 patient months. CONCLUSION: Temporary implantation of a MCSS may normalize cardiac function in selected patients with IDC. The striking degree of myocardial fibrosis can reduce to normal values after explantation of the device. A-beta 1-AABs disappear during ventricular unloading and do not increase thereafter. "Weaning" from mechanical device may constitute an alternative treatment to cardiac transplantation in selected patients.     

Perspectives of patients with terminal renal failure: quality of life and psychological adjustment before and in the first year after heart transplantation

This prospective study was designed to compare quality of life, life satisfaction, and subjective ratings of health before and at variable time intervals after heart transplantation (HTx). 175 patients were included between February 1994 and December 1997. Every six months before and 1 1/2, 3, 6, and 12 months after HTx, they received the following standardized and validated questionnaires: German SF 36, heart failure and specific transplant symptom list, global quality of life assessment, Munich life quality dimension list, expected/experienced life changes after HTx. Inclusion criteria were the acceptance of the patient on the waiting list for HTx, good command of the German language, and a minimum age of 18 years. During data evaluation, median (Me), mean (M), and standard deviation (SD) were created from individual parameters. Quality of life was rated as very poor by 84% of patients with congestive heart failure. Only 6 weeks after HTx, 74% rated their quality of life as significantly better. Before HTx 80% were very unsatisfied about their health status and 87% about physical performance. Six weeks after HTx, this parameter improved significantly and 76% were very satisfied about their health status and 50% about physical performance. While somatic changes expected before HTx corresponded well with experienced ones, psychological improvements were smaller than expected, but one year after HTx they were significant (before: M = 3.66; SD = 0.9; Range (R) = 3.78 vs 12 months postop: M = 4.61; SD = 0.6; R = 2.67; p < 0.05). Quality of life correlated before HTx best with subjectively rated health (r = 0.61, p < 0.01) and 6 months after with satisfaction about health status (r = 0.76, p < 0.01). Only in 25% were expected improvements fulfilled regarding sexual activity/satisfaction, professional situation, and recreational activities. 90% of post-transplant patients reported physical complaints, most by effects of immunsuppression, but were coping well. The study shows that already 6 weeks after successful HTx all quality of life parameters improved significantly. Despite some unfulfilled expectations and complaints, the postoperative life situation of HTx patients appeared significantly improved.     

Restrictive criteria for heart transplantation candidacy maximize survival of patients with advanced heart failure

BACKGROUND: The shortage of organ donors and the amelioration of medical management of advanced heart failure mandate strict selection of heart transplant candidates on the basis of the need and probability of success of transplantation, with the aim of maximizing survival of patients with advanced heart failure, both with and without transplantation. This study analyzes the impact of restricting the criteria for heart transplantation candidacy on the outcome of patients with advanced heart failure referred for transplantation. METHODS: Survival and freedom from major cardiac events (death, resuscitated cardiac arrest, transplantation while supported with inotropes or mechanical devices) were compared between patients listed during 1990 to 1991, when standard criteria were applied (group 1, n = 118), and patients listed during 1993 to 1994, when only patients requiring continuous/recurrent intravenous inotrope therapy in spite of optimized oral medications and outpatients showing actual progression of the disease were admitted to the waiting list (group 2, n = 88). Survival and freedom from cardiac events (defined as above plus listing in urgent status) were also calculated in stable outpatients evaluated in 1993 to 1994, who were potential heart transplant candidates according to standard criteria but were not listed because of restrictive criteria (group 3, n = 52, New York Heart Association functional class > or = III, mean echocardiographic ejection fraction 0.22 +/- 0.05, mean peak oxygen consumption 12.3 +/- 1.5 ml/kg/min, mean follow-up 19 +/- 10 months). RESULTS: Thirty-one percent, 40%, and 50% of group 1 patients versus 58%, 65%, and 77% of group 2 patients underwent transplantation within 3, 6, and 12 months after listing (p < 0.0007). The 1- and 2-year survival rates after listing were 80% and 71% in group 1 versus 85% and 84% in group 2 (p < 0.0001). Freedom from death/urgent transplantation was lower in group 2 than in group 1 (55% and 48% versus 72% and 59% at 6 and 12 months, respectively; p < 0.0001). In patients undergoing transplantation, the postoperative survival rate was similar (87% and 91% at 2 years in group 1 and group 2, respectively). Two years after heart transplantation candidacy was denied, 86% of group 3 patients were alive, and 74% were event-free. CONCLUSIONS: Restricting the admissions to the waiting list to patients with refractory/progressive heart failure improved survival rates after listing by increasing the probability to undergo transplantation in a short time. Selection of most severely ill candidates did not affect postoperative survival. Survival and freedom from cardiac events were good in patients with advanced but stable heart failure, in spite of their severe functional limitation. Thus restrictive criteria for heart transplantation candidacy allows maximal survival benefit from both medical therapy and transplantation.     

Improvement in quality of life in patients with heart failure who undergo transplantation

BACKGROUND: Very few studies have examined quality of life longitudinally in heart failure patients from before or after heart transplantation. The purpose of this study was to compare quality of life of patients with heart failure at the time of listing for a heart transplant with that 1 year after the operation. Major dimensions of quality of life measured in this study were health, physical and emotional functioning, and psychosocial functioning. METHODS: A convenience sample of 148 patients (80% male and mean age 52 years) was recruited from a midwestern and southern medical center. Data were collected from chart review and six patient-completed instruments: the Heart Transplant Symptom Checklist, Sickness Impact Profile, Heart Transplant Stressor Scale, Jalowiec Coping Scale, Quality of Life Index, and Rating Question Form. Informed consent was obtained, and patients who agreed to participate in the study completed the booklet of self-administered instruments. Statistical analyses included frequencies, measures of central tendency, paired t-tests, and Wilcoxon signed-ranks tests. RESULTS: Total symptom distress decreased significantly overall from before to after heart transplantation (before = 0.19 versus after = 0.15, p < 0.0001). Patients rated themselves as having significantly poorer health while listed as a heart transplant candidate than at 1 year after surgery (before = 4.5 versus after = 7.5, p < 0.0001). Although the overall level of functional disability was fairly low before and 1 year after transplantation, patients still reported significant improvement after surgery (before = 0.21 versus 1 year after = 0.13, p < 0.0001). No significant differences were found in total stress, which was low to moderate (before = .026 versus 1 year after = 0.26, p = not significant), coping use (before = 0.48 versus 1 year after = 0.48, p = not significant), or coping effectiveness (before = 0.40) versus 1 year after = 0.42, p = not significant), from before to 1 year after heart transplantation. However, changes in types of symptoms, functional disability, stressors, and coping were noted over time. Overall satisfaction with life, which was fairly high at both time periods, increased significantly from the time of listing for a transplant to 1 year after surgery (before = 0.72 versus 1 year after = 0.82, p <0.0001), and overall quality of life improved significantly from before to after heart transplantation (before = 5.5 versus after = 7.8, p < 0.0001). CONCLUSIONS: End-stage heart failure patients had improved quality of life from before to 1 year after heart transplant due to less total symptom distress, better health perception, better overall functional status, more overall satisfaction with life, and improved overall quality of life. However, post-transplant patients still experienced some symptom distress, functional disability, and stress, but were coping well.     

Detection of hepatitis C virus RNA from the heart of patients with hypertrophic cardiomyopathy

We investigated hepatitis C virus (HCV) infection in 35 patients with hypertrophic cardiomyopathy and 40 patients with ischemic heart disease who were consecutively admitted to our hospital. Frequency of positive anti-HCV antibody was significantly higher in patients with hypertrophic cardiomyopathy (6 of 35 patients, 17.1%) than that in patients with ischemic heart disease (1 of 40 patients, 2.5%, p = 0.036). In three of these six patients with hypertrophic cardiomyopathy, HCV RNA was detected in myocardial tissue. In two of these three patients, HCV RNA was detected from biopsy and autopsy specimens of the ventricles, but not in the serum, suggesting that HCV may replicate in myocardial tissue and may be relevant to ventricular hypertrophy. Thus, HCV infection may play a role in the development of hypertrophic cardiomyopathy.     

Coronary surgery can be an alternative to heart transplantation in selected patients with end-stage ischemic heart disease

Patients with ischemic heart disease (IHD) low ejection fraction (EF), and congestive heart failure (CHF), are usually referred for orthotopic heart transplantation (OHT). This study reports our experience with coronary artery bypass grafting (CABG) in patients initially referred for OHT, and suggests guidelines to facilitate the choice of procedure (OHT or CABG). Between January 1990 and December 1991, 32 patients with IHD, proposed for OHT, underwent CABG 31/32 patients were male, the mean age was 58 +/- 12 years (40 to 70). Congestive heart failure was present in all patients and was the main symptom. The mean EF was 23 (14 to 31%), mean cardiac index (CI) 2.4 l/min per m2 (1.6 to 3.1 l/min per m2), mean pulmonary artery mean pressure (MPAP) 26 (20 to 37 mmHg) and mean pulmonary wedge pressure 16 (12 to 22 mmHg). Every patients underwent a myocardial viability study by thallium scintigraphy (n = 32) and/or by positron emission tomography (n = 10). The perioperative mortality was 9.3% (3/32). All long-term survivors (n = 27) are in NYHA Class II with a complete follow-up (mean 18 +/- 6 months). Ejection fraction control either by angiography (n = 15) or by single photon emission computed tomography (n = 12) showed an increase of up to 38% (22%-46%). Three determinant factors influenced the choice of CABG. 1) CI > 21/min per m2, 2) MPAP < 35 mmHg. 3) Detection of myocardial viability.(ABSTRACT TRUNCATED AT 250 WORDS)     

Psychological stress symptoms before and after autologous bone marrow transplantation in patients with solid tumors

This study sought to examine patterns of changes of psychological stress symptoms in autologous bone marrow transplantation (ABMT) recipients. Forty-nine patients affected by solid tumors were assessed using the Symptom Questionnaire on admission to hospital (before high-dose chemotherapy and ABMT) and before discharge. Symptoms of anxiety and anger tended to decrease and relaxation of improve over time. Nevertheless, on admission to hospital 30-50% of the patients reported severe to moderate symptoms of anxiety and depression. Before discharge, the prevalence was still high (20-35%). The implications of these findings are discussed in terms of the need to monitor the evolution of emotional functioning of cancer patients undergoing ABMT.     

Laparoscopic cholecystectomy in patients previously treated with heart transplantation. A clinical case

A 46-years old patient who had already undergone cardiac transplantation was scheduled for laparoscopic cholecystectomy following a diagnosis of cholelithiasis. In this particular case we were not faced with any problems even in presence of a denervated heart. Since the patient was immnosuppressed, we had to look for the best compromise between the need of monitoring closely the most important vital parameters and contemporarily reducing invasivity as much as possible. Capnometry was of paramount importance, enabling us to prevent and to correct high paCO2 values. The rapid recovery of the patient allowed us to begin with food intake and oral immunosuppressive therapy already 24 hours after the operation and to discharge the patient on the third day after surgery. Laparoscopic cholecystectomy represented a successful choice and a satisfying procedure both for the anaesthesiologist and for the patient, particularly regarding the minimal invasivity and the rapid recovery, which were considered of great importance in the immunodepressed patient.     

Clinical experience with heart transplantation in infants

Patients with typical symptoms of biliary tract disease but no gallstones on ultrasonography may benefit from cholecystectomy for presumed chronic acalculous cholecystitis. We retrospectively analyzed the outcome of 50 patients with a preoperative diagnosis of chronic acalculous cholecystitis based upon history (chronic or recurrent, postprandial right upper quadrant abdominal pain), the absence of acid-peptic disease, and normal biliary sonography treated with laparoscopic cholecystectomy (LC) and transcholecystic cholangiography from 1991 to 1996. All patients had preoperative cholecystokinin-stimulated hepatobiliary scintigraphy (CCK-HBS). There were 42 women and 8 men with a mean age of 43 years. CCK-HBS was abnormal in 45 patients (< or = 35 per cent gallbladder ejection fraction or nonfilling of the gallbladder). There was no postoperative mortality and one morbidity (urinary retention). All patients had microscopic evidence of chronic cholecystitis. At mean follow-up of 30 months, (range, 7-62 months) 39 patients (78%) were free of abdominal pain. Thirty-five of 45 patients with abnormal CCK-HBS were pain free (positive predictive value, 0.78). Four of five patients with normal CCK-HBS were pain free (negative predictive value, 0.20). The positive and negative likelihood ratios for CCK-HBS were 0.99 and 1.13, respectively, confirming that this test was not useful for predicting benefit from LC. Seven patients with persistent right upper quadrant pain had abnormal postoperative sphincter of Oddi manometry; they improved after endoscopic sphincterotomy. Patients with symptoms typical of biliary colic with normal gallbladder sonography and absence of acid-peptic disease benefit from LC in the majority of cases. Those who remain symptomatic after LC may benefit from endoscopic retrograde cholangiopancreatography with sphincter of Oddi manometry and endoscopic sphincterotomy when manometry is abnormal.     

Comparison of clinical and morphologic cardiac findings in patients having cardiac transplantation for ischemic cardiomyopathy, idiopathic dilated cardiomyopathy, and dilated hypertrophic cardiomyopathy

This article compares intergroup and intragroup clinical and morphologic findings in patients with ischemic cardiomyopathy (IC), idiopathic dilated cardiomyopathy (IDC), and dilated hypertrophic cardiomyopathy (HC) undergoing cardiac transplantation (CT). Few previous publications have described findings in native hearts explanted at the time of CT. The explanted heart in 92 patients having CT was examined in uniform manner with particular attention to the sizes of the ventricular cavities and the presence of and extent of ventricular scarring. Of the 92 hearts examined, 47 had IC, 35 had IDC, and 10 had dilated HC. Although considerable degrees of intragroup variation occurred, the mean degree of left ventricular dilatation was similar among the patients with IC, IDC, and dilated HC. All patients with IC had left ventricular free wall scarring more extensive than that involving the ventricular septum, but the intragroup variation in the amounts of scarring was considerable. Nine of the 10 patients with dilated HC also had ventricular wall scarring, but it was more extensive in the ventricular septum than in the left ventricular free wall and involvement of the right ventricular wall also was present. Eight (23%) of the 35 IDC patients also had grossly visible ventricular scars but they were small and only 1 of the 8 had coronary narrowing and that was not in the distribution of the scarring. Narrowing of 1 or more epicardial coronary arteries >75% in cross-sectional area by plaque was present in all 47 IC patients, in 8 of the 35 IDC patients (7 had no ventricular scars), and in none of the 10 dilated HC patients. Coronary angiography was the major clinical tool allowing separation of the IC, IDC, and HC patients. Coronary angiography did not detect narrowing in any of the 8 patients with IDC who were found to have coronary narrowing on anatomic study. Thus, among patients with IC, IDC, and dilated HC having CT, distinctive anatomic features allow separation of patients with IC, IDC, and dilated HC, but within each group considerable variation in left ventricular cavity size and extent of ventricular scarring occurs.