Simultaneous MIDCAB and subtotal gastrectomy in an elderly patient with severe ischemic heart disease

An 81 year old man with severe ischemic heart disease and left ventricular dysfunction was scheduled for a subtotal gastrectomy for his advanced gastric cancer. His cardiac function was so poor that we performed minimally invasive coronary artery bypass grafting (MIDCAB; coronary artery bypass grafting without cardiopulmonary bypass for LAD through a small left thoracotomy), just before the abdominal operation. Anesthesia was induced and maintained with fentanyl, vecuronium and sevoflurane. To control heart rate below 60 bpm during local coronary occlusion for bypass grafting, edrophonium 5 mg was administered just before the occlusion. During the bypass grafting procedure, the patient's heart rate was maintained at 50-60 bpm and his hemodynamic profile slightly declined but was permissible. After bypass grafting, his cardiac performance was improved with low dose dobutamine. Subsequently subtotal gastrectomy was carried out. His postoperative course was uneventful. Combined MIDCAB and abdominal operation may be beneficial for selected patients with severe ischemic heart disease.     

Surgical treatment of ischemic heart disease complicated with severe left ventricular dysfunction: experience in 200 cases

BACKGROUND: The study was designed to evaluate short and long-term benefits of coronary artery bypass graft in patients with coronary artery disease and severely depressed left ventricular ejection fraction and to identify contemporary risk factors associated with significantly greater mortality in this high-risk subgroup. METHODS: From 1985 to 1995, 200 consecutive pts with EF < or = 0.30 underwent CABG. Among these patients, 60% were older than 70 years. NYHA functional class III/IV was present in 31% of pts. Preoperative mean cardiac index was 2.7 +/- 7 l/min/m2, mean pulmonary artery pressure was 29.9 +/- 7 mm Hg and contractility score (generated by appropriate software for left ventricular kinesis analysis) mean value was 50.1 +/- 11.6 points. Urgent operation was required in 32 pts (16%). The majority of pts were completely revascularized. RESULTS: Operative mortality was 9% (18 pts). Low output syndrome was the most common postoperative complication (13.5%) followed by ventricular arrhythmia (8%), mean length of postoperative hospitalization for survivors was 13 +/- 10 days. Of 23 possible operative risk factors evaluated, four were associated with significantly greater mortality: cardiac index < or = 2.1 l/min/m2, urgent operation, contractility score > or = 80 and associated surgical procedures. Survivors experienced significant improvement in CHF class (p < 0.001) and follow up EF (p < 0.001). Kaplan-Meier estimate of survival at 1 year, 5 years and 8 years was 85%, 65% and 54%. CONCLUSION: Through more careful assessment of preoperative risk factors, patients selection and perioperative management, actually coronary artery bypass graft may be offered to pts with low ejection fraction with reduced morbidity and mortality.     

Effect of relatively low dose amiodarone therapy on left ventricular function in patients with ventricular tachyarrhythmias

The effect of oral amiodarone (AMD) therapy on left ventricular (LV) function was evaluated retrospectively in Japanese patients with ventricular tachyarrhythmias and congestive heart failure. Seventeen patients were treated with oral AMD (maintenance dose 191+/-52mg/day) for more than 12 months. Fractional shortening (FS) on echocardiography revealed a trend towards an increase in the short-term (3 months) (p=0.06), but was not significant in the long-term follow-up period (more than 12 months) after AMD therapy. In 8 patients with 1 episode of myocardial infarction, FS revealed a trend towards an increase (p=0.09). In all of the 4 patients with dilated cardiomyopathy whose LV end-diastolic diameter was increased, FS was decreased in the long-term follow-up. Neither hospitalization frequency nor New York Heart Association classification were reduced by AMD therapy. In conclusion,oral AMD therapy did not cause LV function to recover significantly and could not improve the clinical course in patients with ventricular tachyarrhythmias. However, if the underlying disease is not progressive, AMD therapy may improve LV function.     

Comparison of myocardial contrast echocardiography and low-dose dobutamine stress echocardiography in predicting recovery of left ventricular function after coronary revascularization in chronic ischemic heart disease

BACKGROUND: Dobutamine stress echocardiography (DSE) and myocardial contrast echocardiography (MCE) can predict recovery of left ventricular function after myocardial infarction. DSE also has been shown to predict left ventricular functional recovery after revascularization in chronic ischemic heart disease, whereas MCE has not been evaluated in such patients. This study was performed to compare DSE and MCE in the prediction of left ventricular functional recovery after revascularization in patients with chronic ischemic heart disease. METHODS AND RESULTS: MCE and DSE were performed in 35 patients with chronic coronary artery disease and significant wall motion abnormalities (mean ejection fraction, 0.36 +/- 0.09). Regional wall motion was scored by use of a 16-segment model wherein 1 = normal or hyperkinetic, 2 = hypokinetic, 3 = akinetic, and 4 = dyskinetic. Each segment was evaluated for contractile reserve by DSE and perfusion by MCE. Revascularization (coronary artery bypass graft [n = 13] and percutaneous transluminal coronary angioplasty [n = 10]) was successful in 23 patients. Follow-up echocardiograms were done to assess wall motion 30 to 60 days later. In 238 segments with resting wall motion abnormalities, perfusion was more likely to present than contractile reserve (97% versus 91%, P < .02). Revascularization resulted in functional recovery in 77 of 95 hypokinetic segments (81%) but only 18 of 57 akinetic segments (32%, P < .0001). DSE and MCE were not significantly different in predicting functional recovery of hypokinetic segments. In akinetic segments, DSE and MCE had similar sensitivities (89% versus 94%, respectively) and negative predictive values (93% and 97%, respectively) in predicting functional recovery. However, DSE had a higher specificity (92% versus 67%, P < .02) and positive predictive value (85% versus 55%, P < .02) than MCE in predicting functional recovery. CONCLUSIONS: Both contractile reserve by DSE and perfusion by MCE are predictive of functional recovery in hypokinetic segments after coronary revascularization in patients with chronic coronary revascularization in patients with chronic coronary artery disease. In akinetic segments, myocardial perfusion by MCE may exist in segments that do not recover contractile function after revascularization. Thus, contractile reserve during low-dose dobutamine infusion is a better predictor of functional recovery after revascularization in akinetic segments than perfusion.     

Coronary artery bypass grafting in cases with poor left ventricular function

From January 1987 through June 1992, 18 patients with poor left ventricular function (left ventricular ejection fraction [LVEF] less than 0.3) underwent elective isolated primary coronary artery bypass surgery. The mean age was 56.4 years (range, 46 to 72 years), and 15 were males and 3 were females. Mean pre-operative LVEF measured by ventriculography was 0.26 +/- 0.03 (range, 0.19 to 0.30). Sixteen patients (88.9%) had a prior myocardial infarction and 9 (50%) had a history of congestive heart failure. Complete revascularization was the goal for all patients, and the mean number of bypass grafts was 3.0 +/- 0.8 per patient. The left anterior descending coronary artery (LAD) was revascularized in all patients. There were no operative deaths. Post-operative LVEF improved significantly from 0.26 +/- 0.03 to 0.42 +/- 0.11 (p = 0.0002), and the regional left ventricular wall motion improved in the diaphragmatic and posterobasal regions (p < 0.01). The patency of the grafts was 93.9% in all, and 100% for LAD. The mean follow-up period was 77 months, and the overall actuarial survival rate was 88.9% at 10 years. During follow-up periods, two patients died of congestive heart failure (CHF), and two required three rehospitalizations because of CHF. The overall cardiac event free rate was 75.8% at 10 years. In patients with poor left ventricular function, surgical revascularization can be performed safely, but congestive heart failure sometimes occurs during follow-up periods and may be the cause of death. Therefore alternate forms of therapy such as cardiac transplantation and/or TMLR should be considered in selected patients.     

Determinants of inducible ventricular tachycardia in patients with clinical ventricular tachyarrhythmia and no apparent structural heart disease

Thirty-seven patients with symptomatic ventricular tachyarrhythmia and no apparent structural heart disease were evaluated with multiple cardiovascular tests to establish the relationship between the results of programmed electric stimulation and other clinical and arrhythmia variables. Of 37 patients, 12 (32%) had inducible sustained ventricular tachycardia. Factors associated with the results of programmed electric stimulation included a history of ventricular tachycardia > or = 30 seconds requiring intervention for termination and global right heart abnormality documented by echocardiography. During treatment for a mean follow-up of 50 months, 29 patients did well, 6 patients had recurrences of major arrhythmia symptoms, 1 was lost to follow-up and 1 had a noncardiac death. Those patients with an adverse outcome were more likely to have inducible ventricular tachycardia. Thus certain clinical and echocardiographic data are associated with the results of programmed electric stimulation, which in turn have important prognostic value in this group of patients. Sustained ventricular tachycardia is unlikely to be induced in patients with no evidence of structural heart disease and clinical nonsustained ventricular tachycardia.     

Diagnosis and management of ischemic heart disease in the patient scheduled to undergo electroconvulsive therapy

The cardiovascular risk of electroconvulsive therapy (ECT) is a product of the stress of ECT itself and the severity and stability of coronary artery disease (CAD), as well as other cardiovascular factors. ECT itself represents a relatively low-risk procedure. Patient-specific risk can be defined by a combination of clinical evaluation and noninvasive testing, much of which is aimed at detecting the presence and staging the severity and stability of CAD. Patients at high risk of a cardiac complication include those with severe or unstable symptoms of CAD, and they should undergo extensive cardiac evaluation before ECT Patients at low risk likely need no further evaluation and can undergo ECT. Patients at intermediate risk should have careful clinical evaluation, and most likely noninvasive evaluation, which should include some form of stress testing. Medical therapy should be continued and/or maximized in all patients with CAD. It is expected that with careful screening, patients with established CAD can undergo ECT safely.     

A comparison of transesophageal and transthoracic echocardiographic assessment of left ventricular function in pediatric patients with congenital heart disease

OBJECTIVE: To determine the quantitative utility of transesophageal echocardiographic assessments of left ventricular function in pediatric patients with congenital heart disease by evaluating the variability between observers and between echocardiographic windows. DESIGN: Retrospective, blinded analysis. SETTING: University-associated pediatric hospital. PARTICIPANTS: Transthoracic and transesophageal echocardiographic images of 25 pediatric patients with congenital heart disease were reviewed. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: End-diastolic area, end-systolic area, and fractional area change were measured from short-axis images of the left ventricle at the midpapillary level by two separate investigators. These measurements were compared by the method of Bland and Altman and Sheiner and Beal. Significant differences in measurements of end-diastolic and end-systolic area by different observers were noted, but they were systematic. A similar situation was noted for the comparison of transthoracic and transesophageal measurements of end-diastolic and end-systolic area. In the comparison of fractional area change between observers or windows, bias and absolute prediction error were lower, with 95% confidence limits of bias or absolute prediction error of 10% or less. CONCLUSIONS: The potential error in the measurement of fractional area change in 10% under optimal conditions. This would suggest that the assessment of ventricular function in the operating room or intensive care unit, under less than optimal conditions, should be viewed as a qualitative, rather quantitative, measurement. There may be significant interobserver and interwindow variability.     

Mid-diastolic potential is related to the reentrant circuit in a patient with verapamil-sensitive idiopathic left ventricular tachycardia

We report a case of verapamil-sensitive idiopathic ventricular tachycardia in which a mid-diastolic potential (MDP) 45 msec preceding the Purkinje potential (P potential) was recorded. Pacing during the tachycardia caused concealed entrainment, and the stimulus-QRS interval was equal to the P potential-QRS interval. The interval between the last pacing stimulus and the next P potential (postpacing interval) was longer than the ventricular tachycardia cycle length, but the MDP was orthodromically activated. These findings suggest that the MDP was on the reentrant circuit and the P potential was not on the reentrant circuit, but a bystander.     

Echocardiographic assessment of left ventricular function. Investigation of infants, children and teenagers without heart disease

Echocardiography was used to study left ventricular function in 75 infants, children and teenagers without heart disease. Normal values for echocardiographic parameters of left ventricular contractility were obtained and are presented in Tables. Systolic time intervals were measured from aortic cusp echoes and the normal range and correlation to heart rate and age are given. Computer analyses of echocardiograms from the left ventricle and the anterior mitral leaflet were done and normal values for the instantaneous velocities thus derived are given. To test the normal variation of left ventricular function with time 12 children were examined repeatedly during 1 wk. 95% tolerance limits for the variation of the different functional parameters are given. To test the reproducibility of the echocardiographic measurements 11 children with various forms of heart disease were examined consecutively by two different observers and the 95% tolerance limits for the difference between measurements were calculated.     

Evaluation of platelet function and tissue plasminogen activator activity in ischemic heart disease depending on concurrence with hyperlipoproteinemia and aspirin therapy

Platelet activation, impairment of fibrinolysis and dyslipidemia are important factors in the pathogenesis and progression of ischemic heart disease. Aspirin therapy will reduce platelet activation both by its negative effect on platelet aggregation (SPA) and by inhibition of granule release which liberates such mediators as platelet factor 4 (PF4) and plasminogen activator inhibitor 1 (PAI-1). The present study was performed in 57 patients with ischemic heart disease (IHD), divided into groups depending on coexistent hyperlipoproteinemia (HLP) and aspirin treatment. The control group included 21 healthy individuals, matched for age and sex. Parameters of hemostasis (SPA, PF4, PAI-1) and concentration of lipid fractions (TC, TG, LDL, HDL) were measured in plasma. Increased PF4 levels were found in all groups with IHD, irrespective of hyperlipoproteinemia or aspirin treatment. Enhanced SPA and higher PAI-1 were limited to group IHD-HLP without aspirin. Highest PAI-1 activities were observed after stimulation of platelets in vitro. In conclusion, patients with IHD and hyperlipoproteinemia presented most pronounced platelet activation and impairment of fibrinolysis. Aspirin had a beneficial effect on these changes. Lower activities of PAI-1, in patients treated with aspirin, can be ascribed to its reduced release from platelets. Aspirin did not satisfactorily reduce the level of PF4, although it strongly inhibited SPA.     

P wave terminal force and persisting ST elevations in chronic ischemic heart disease. Prediciton of left ventricular motility and diastolic pressure

In order to define the homeostatic mechanisms which affect the secretion of human chorionic somatomammotropin (hCS), we have determinated its plasma levels by a radioimmunoassay method in normal, prediabetic, and chemically diabetic pregnant women in basal conditions and after stimuli. Oral glucose failed to modify hCS plasma levels as also did continuous intravenous glucose infusion. Rapid acute intravenous glucose decreased them, suggesting that only sudden changes in maternal plasma glucose can exert a regulatory effect on hCS secretion. In travenous arginine increased hCS levels, new evidence of the great similarity of structure and function between growth hormone and hCS.     

Hyperbaric oxygenation and antiaggregants: effects on platelet function in patients with ischemic heart disease

The study of free-radical processes elucidated concentrations of O2 producing a negative effect in chronic obstructive bronchitis sufferers with respiratory insufficiency (RI). In RI of the second and third degree concentration of inhaled O2 should not exceed 50%. In this concentration O2 toxicity is not evident, unbalance of the system free radical-antiradical activity is less pronounced, O2 transport from the lungs to the tissue reaches optimal level. A course of oxygen therapy (20 daily sessions lasting 30 min., 50% O2) is not toxic, promoted activation of SOD and alleviation of arterial hypoxemia.     

Is the time domain signal-averaged electrocardiogram helpful in patients with ventricular tachycardia without apparent structural heart disease?

The signal-average electrocardiogram (SAECG) has been a screening method for identifying patients at risk for ventricular tachycardia (VT) in the setting of coronary artery disease (CAD). Its significance in patients with VT unrelated to CAD or left ventricular dysfunction is undetermined. In order to define the value of SAECG in this patient population further, we compared the time domain SAECG at 25, 40, and 80 Hz filters in 35 patients with clinically symptomatic VT in the absence of structural heart disease was compared with 10 normal controls and 10 patients with CAD and inducible VT. SAECG data in patients without structural heart disease were intermediate between normal controls and patients with CAD. No single or combined SAECG criterion helped to differentiate between patients with inducible and noninducible VT. There was no concordance to other arrhythmia testing. It was concluded that signal-averaged electrocardiography may have little screening value in VT unrelated to CAD or left ventricular dysfunction.