Functional outcome after myocardial revascularization in ischemic left ventricular failure

BACKGROUND: Myocardial revascularization in patients with left ventricular failure (ejection fraction < 30%) offers survival comparable to heart transplantation. The functional outcome, however, has yet to be determined. In order to assess the clinical results in patients with LVEF < 30% undergoing coronary artery bypass grafts (CABG), 101 consecutive patients operated between 1/91 and 1/97 were reviewed retrospectively. METHODS: The patients were stratified according to presentation: 65 pts had angina (Group 1) and 36 congestive failure (Group 2). Mean age (62 +/- 7 vs 60 +/- 8 yrs), sex (90 vs 88% male), LVEF (0.28 +/- 0.04 vs 0.29 +/- 0.04), prior myocardial infarction (1.2 +/- 0.4 vs 1.2 +/- 0.5 episodes/pt), presence of vital myocardium at scintiscan or low-dose dobutamine echocardiography (92 vs 93%), need for preoperative IABP (3.1 vs 8.3%), aortic cross-clamp (53 +/- 21 vs 60 +/- 21 min) and cardiopulmonary bypass (104 +/- 31 vs 114 +/- 36 min) times were comparable. RESULTS: There was only 1 (1%) perioperative death due to low-output syndrome. Eleven pts (6 vs 5, Group 1 vs Group 2) had postoperative low-output syndrome, requiring IABP in 7 pts (4 vs 3). There were 14 (10 vs 4, Group 1 vs Group 2) deaths during follow-up (29 +/- 19 months, range 2-67), with an overall actuarial survival of 91 +/- 4 vs 100% at 1 yr and 74 +/- 9 vs 78 +/- 10% at 5 yrs in Group 1 vs Group 2, respectively (p = ns). Actuarial symptom-free survival was 89 +/- 4 vs 84 +/- 6% at 1 yr and 49 +/- 9 vs 28 +/- 11% at 5 yrs, respectively (p = 0.05). Despite the high recurrence of congestive failure (22 vs 66% in Group 1 vs Group 2, p = 0.004), improvement in functional class (3.1 +/- 0.8 vs 1.5 +/- 0.7 in Group 1 and 2.7 +/- 0.7 vs 1.8 +/- 0.5 in Group 2) and LVEF (0.28 +/- 0.04 vs 0.38 +/- 0.04 in Group 1 and 0.29 +/- 0.04 vs 0.40 +/- 0.06 in Group 2) was found in both groups at follow-up. CONCLUSIONS: In spite of improving early and late survival after revascularization for ischemic left ventricular failure, patients presenting with congestive failure have an unsatisfactory symptom-free survival. Further studies are necessary to ascertain the relative indications to revascularization or transplantation in this specific patient subgroup.     

Oropharyngeal synovial sarcoma. Report of one case]

OBJECTIVE: To assess the prognostic factors of myocardial recovery expected after coronary bypass surgery and the impact of surgical technique used, a prospective non-randomized study including a 1-year postoperative evaluation of left ventricular function was performed in patients with left ventricular dysfunction (left ventricular ejection fraction (LVEF) < 0.40). METHODS: From 1993 to 1996, 110 patients (mean age 61+/-11 years) were included in the study. The mean LVEF was 31+/-6%. All patients had preoperative radionuclide investigations based on the combination of stress/reinjection thallium single photon emission computed tomography (SPECT) and planar evaluation of LVEF; 88% of patients had reversible ischemic thallium defects. Two surgical technique were used: 53 patients received the left internal mammary artery with associated sequential vein graft, and 57 patients received only arterial grafts, internal mammary and gastroepiploic arteries. The mean number of distal anastomoses was 3.2+/-0.8 and 54% of patients had complete revascularization. At 1 year, all survivors had clinical evaluation and the same radionuclide investigations. RESULTS: The early mortality was 2.7%. At 1 year, 100 patients were surviving; on average, NYHA class decreased 1.9+/-0.8 to 1.4+/-0.6 (P < 0.01) and CCS class from 2.8+/-0.6 to 1+/-0.3 (P < 0.01). The mean LVEF increase from 31+/-9 to 34+/-10% (P < 0.01) and the mean LV end-diastolic volume decreased from 317+/-112 to 285+/-108 ml (n.s.). The postoperative improvement in LV function was higher in patients in NYHA class 3 or 4 before surgery (P < 0.05), when associated sequential vein graft had been used (P < 0.01), and in patients with low preoperative LVEF (P < 0.01). The postoperative LVEF improvement observed was significantly correlated with the improvement in left ventricular end-diastolic (LVED) volume and the improvement in redistribution/reinjection thallium uptake. Multivariate analysis showed that the surgical technique used and the preoperative LVEF were independent prognostic factors of the postoperative myocardial function recovery, with a significant positive impact of the vein use. CONCLUSION: This study confirms the excellent clinical results of coronary artery bypass grafting (CABG) in patients with coronary artery disease and LV dysfunction; improvement in LV function can be documented objectively and is correlated with reperfusion of hibernating myocardium. However, the extended use of arterial grafts does not allow to achieve the significant myocardial recovery observed with the use of one internal mammary artery (IMA) and associated sequential vein graft; it seems to be related to the preoperative selection of patients, but a direct negative impact of arterial grafts was documented and leads to be cautious in patients with severe LV dysfunction.     

Antitumor activity of human umbilical cord blood cells: A comparative analysis with peripheral blood and bone marrow cells

OBJECTIVES: To determine the predictive value of quantitative evaluation of myocardial viability on changes in left ventricular function, exercise capacity, and quality of life after coronary artery bypass grafting in patients with ischemic heart failure (congestive heart failure, New York Heart Association class > or = III) with and without angina. METHODS: Thirty-five patients, 14 with congestive heart failure and angina (CHF-angina) and 21 with congestive heart failure without angina (CHF-no angina) were studied at baseline and 6 months after coronary bypass grafting. Left ventricular function was evaluated with transthoracic echocardiography and radionuclide ventriculography. Myocardial viability was assessed with [18F]-2-fluoro-2-deoxy-D-glucose using positron emission tomography. Peak aerobic capacity (peak oxygen consumption) and anaerobic threshold were assessed with treadmill exercise test and quality of life with a questionnaire. RESULTS: A total of 286 of 336 dysfunctional left ventricular segments were viable. There were two perioperative deaths (5.7%) and three late deaths. Left ventricular ejection fraction increased from 23% +/- 7% to 32% +/- 9% (p < 0.0001), and a linear correlation was found between the number of viable segments and the changes in ejection fraction (r = 0.65; p = 0.0001). Receiver operating characteristics curve identified eight viable segments as the best predictor for increase of ejection fraction more than 5 percentage points. Peak oxygen consumption increased from 15 +/- 4 to 22 +/- 5 ml/kg per minute (p < 0.0001). Preoperatively, anaerobic threshold was identified in one patient from the CHF-angina group and in all from the CHF-no angina group and increased from 13 +/- 4 to 19 +/- 4 ml/kg per minute (p < 0.0001). Quality of life scores improved significantly in both groups. No correlation was found between the amount of viable dysfunctional myocardium and changes in exercise capacity or quality of life. CONCLUSIONS: In patients with postischemic congestive heart failure the amount of viable myocardium dictates the degree of improvement in left ventricular function after revascularization.     

Intermediate-term outcome of mitral reconstruction in cardiomyopathy

OBJECTIVE: Severe mitral regurgitation is a frequent complication of end-stage cardiomyopathy that contributes to heart failure and predicts a poor survival. We studied the intermediate-term outcome of mitral reconstruction in 48 patients who had cardiomyopathy with severe mitral regurgitation and were operated on between June 1993 and June 1997. METHODS: Ages ranged from 33 to 79 years (63 +/- 6 years) with left ventricular ejection fractions of 8% to 25% (16% +/- 3%). All patients were receiving maximal drug therapy and were in New York Heart Association class III-IV with severe, refractory 4+ mitral regurgitation. Operatively, all 48 had undersized flexible annuloplasty rings inserted, 7 had coronary bypass grafts for incidental disease, 11 had prior bypass grafts, and 11 also had tricuspid valve repair. RESULTS: One operative death occurred as a result of right ventricular failure. Postoperative transesophageal echocardiography revealed mild mitral regurgitation in 7 patients and no mitral regurgitation in 41. There were 10 late deaths, 2 to 47 months after mitral reconstruction. The 1- and 2-year actuarial survivals have been 82% and 71%. At a mean follow-up of 22 months, the number of hospitalizations for heart failure has decreased, and 1 patient has had heart transplantation. Significantly, New York Heart Association class improved from 3.9 +/- 0.3 before the operation to 2.0 +/- 0.6 after the operation. Twenty-four months after the operation, left ventricular volume and sphericity have decreased, whereas ejection fraction and cardiac output have increased. CONCLUSION: Whether this favorable modification of left ventricular function and geometry will persist remains unknown. However, mitral repair for cardiomyopathy with mitral regurgitation allows new strategies for these patients.     

In situ detection of DNA fragmentation and expression of bcl-2 in human neuroblastoma: relation to apoptosis and spontaneous regression

In patients with alcoholic cardiomyopathy there is evidence that mild heart failure is reversible if patients abstain from alcohol, but there is no consensus whether the disease is progressive once structural myocardial dilation has evolved. The aim of the present study was to compare the long-term course of congestive heart failure due to alcoholic and idiopathic dilated cardiomyopathy. Of 75 patients with overt congestive heart failure, 23 had alcoholic cardiomyopathy and were compared to 52 patients with idiopathic cardiomyopathy. The mean age was 48 +/- 12 years. Despite medical therapy, heart failure class New York Heart Association III-IV was present in 52% of patients with alcoholic and 47% of patients with idiopathic cardiomyopathy (not significant). Their mean left ventricular ejection fraction was 30 +/- 12% vs 28 +/- 12% and left ventricular end-diastolic volumes were 264 +/- 125 ml and 254 +/- 100 ml respectively (not significant). Overall survival at 1, 5 and 10 years was 100%, 81% and 81% for the group with alcoholic dilated cardiomyopathy and 89%, 48% and 30% for the group with idiopathic cardiomyopathy, respectively (P = 0.041), and the difference was even greater for transplant-free survival P = 0.005). Clinical and invasive signs of left and right heart failure as well as left ventricular dimensions were predictive of a fatal outcome; however, symptom duration and left ventricular volumes were only predictive in patients with idiopathic cardiomyopathy, suggesting that in the two patient groups different mechanisms may lead to death. Mortality in patients with severe congestive heart failure and left ventricular dilatation due to alcoholic cardiomyopathy is significantly lower than that in patients with idiopathic cardiomyopathy and similar degrees of heart failure. Thus, despite structural changes inherent in marked left ventricular dilatation, disease progression in alcoholic dilated cardiomyopathy is different from that in idiopathic cardiomyopathy and thus may have implications for the choice of therapy.     

Differences in the stimulation of NO synthesis during heat shock in genetically different rats]

OBJECTIVES: In certain younger patients with congestive heart failure (CHF), Doppler/echocardiography has identified a "restrictive" pattern of early diastolic ventricular filling characterized by very rapid early filling and a steep deceleration slope. We asked whether a similar restrictive pattern can be identified in very old patients with CHF, and if so, what are its clinical correlates and prognostic implications. DESIGN: Retrospective cohort with prospective follow-up. SETTING: Academic long-term care facility. PARTICIPANTS: Thirty-nine residents with clinical CHF (age 89 +/- 5 (SD) years) MEASUREMENTS: Transmitral Doppler flow, clinical characteristics, recurrent CHF episodes, hospitalizations, and mortality were measured. RESULTS: Fifteen (38%) of the subjects had restrictive filling patterns, characterized by a ratio of early to late flow (E/A) > 1.00 and 24 (62%) had nonrestrictive patterns. The restrictive pattern was associated with a longer duration of CHF, more angina, and higher rate of symptomatic recurrences of CHF. CONCLUSION: A restrictive diastolic filling pattern may represent a late stage in the evolution of congestive heart failure when left ventricular filling pressure is markedly increased. The treatment of CHF in older patients may need to account for different patterns of diastolic filling.     

Complex cases in heart surgery

Between January 1968 and December 1993, 837 patients underwent cardiac operations with were either complex or performed in the presence of a life threatening disease of other vital organs. Of them 74 (8.8%) patients have died within 30 days after the operation. A substantial number of the operations and associated operative death included left ventricular (LV) aneurysmectomy or plication or LV endoaneurysmectomy with coronary artery bypass (CAB) grafts with or without other cardiac procedures, cardiac reoperations, CAB grafts and mitral or aortic valve replacement, combined mitral and aortic valve replacement (MAVR) with or without tricuspid valve replacement and CAB grafts, CAB grafting for an end-stage coronary artery disease (CAD), emergency CAB grafts for an acute myocardial infarction with cardiogenic shock, complex internal thoracic artery (ITA) grafting, and miscellaneous. The best results were achieved in CAB grafts for an end-stage CAD, complex ITA grafting, CAB grafts with mitral or aortic valve replacement, cardiac reoperations. MAVR and miscellaneous. This is probably, related to an intensive treatment of congestive heart failure (CHF) before the operation, pretreatment with the oxygen free radical inhibitor (allopurinol), selective use of an intraaortic balloon assist device and LV venting, routine use of hemoconcentrator (ultrafiltration) during cardiopulmonary bypass in those with CHF, thorough myocardial protection and a complete coronary revascularization.     

Revascularization of the circumflex artery with mechanical stabilization: initial experience

OBJECTIVES: To evaluate the short-term result of the coronary artery revascularization without cardiopulmonary bypass for triple vessel disease, including the circumflex territory performed on the stabilized beating heart. METHODS: Prospective study conducted on the first 35 consecutive patients with triple vessel disease operated upon without cardiopulmonary bypass by a single surgeon (RC) at the Montreal Heart Institute between October 1996 and March 1997. RESULTS: Mean age of patients was 64 +/-1.6 years and the majority were men (30). Most common risk factors were hypercholesterolemia (65%) and familial history (55%) of ischemic heart disease. Main surgical indication was unstable angina (74%) and mean preoperative left ventricular ejection fraction was 53 +/- 3%. Hundred and twelve bypass were constructed averaging 3.2 +/- 0.1 grafts/patients of which 39 were made on branches of the circumflex artery. Average ischemic time was 34.17 +/- 2.17 minutes. The internal thoracic artery, saphenous vein, and radial artery were used as a vascular conduit in 44, 67, and 1 occasions respectively. There was one operative mortality, and one non Q perioperative myocardial infarction (CK-MB: 89 U/L). No patient required aortic counterpulsation balloon assistance. The average postoperative CK-MB (U/L) were 12.2 +/- 1.9, 15.2 +/- 3.2, and 10.3 +/- 1.7 at 1, 24 and 48 hours respectively. During the post-operative period 26% (9) of the patients presented atrial fibrillation, 6.5% (2) early reexploration for bleeding, and 63% (22) did not require transfusion. Average stay in hospital was 6.1 +/- 45 days. Coronary grafts were angiographically assessed in the first 10 patients and at the postmortem exam in one and displayed a 100% patency with 93.5% (29/31) adequate runoff. Conclusion: Triple vessel coronary artery disease revascularization is feasible on the beating heart without cardiopulmonary bypass with excellent short-term clinical and angiographic results.     

Right ventricular ejection fraction is an independent predictor of survival in patients with moderate heart failure

OBJECTIVES: We sought to study the relationship between survival and right ventricular ejection fraction (RVEF) in a subgroup of patients with moderate congestive heart failure (CHF). BACKGROUND: It has been demonstrated that RVEF is an independent predictor of survival in patients with advanced CHF. METHODS: Cardiopulmonary exercise testing and radionuclide angiography (to determine right and left ventricular ejection fraction) were prospectively performed in 205 consecutive patients with moderate CHF (140 patients in New York Heart Association [NYHA] class II, 65 in class III). RESULTS: Left ventricular ejection fraction was 29.3%+/-10.1%, RVEF was 37.5%+/-14.6% and peak oxygen consumption (VO2) was 16.2+/-5.4 ml/min/kg (60.2%+/-19% of maximal predicted VO2). After a median follow-up period of 755 days, there were 44 cardiac-related deaths, 3 deaths from noncardiac causes and 15 transplantations of whom 2 were urgent; 1 patient was lost to follow-up. Multivariate analysis showed that three variables-NYHA classification, percent of maximal predicted VO2 and RVEF-were independent predictors of both survival and event-free cardiac survival. Left ventricular ejection fraction and peak VO2 normalized to body weight had no predictive value. The event-free survival rates from cardiovascular mortality and urgent transplantation at 1 year were 80%, 90% and 95% in patients with an RVEF <25%, with a RVEF > or =25% and <35% and with a RVEF > or =35%, respectively. At 2 years, survival rates were 59%, 77% and 93% in the same subgroups, respectively. CONCLUSIONS: In addition to the NYHA classification and to the percent of maximal predicted VO2, RVEF is an independent predictor of survival in patients with moderate CHF.     

Hemodynamic effects of a calcium channel promoter, BAY y 5959, are preserved after chronic administration in ischemic heart failure in conscious dogs

BAY y 5959 is a dihydropyridine derivative that binds to L-type calcium channels in a voltage-dependent manner and promotes calcium entry into the cell during the plateau of the action potential by influencing mean open time. Because myofilament responsiveness to calcium is preserved in congestive heart failure (CHF), the inotropic responsiveness to this compound should be preserved in CHF, and tolerance should not develop despite long-term treatment. To test these hypotheses, CHF was induced in 14 chronically instrumented dogs by daily (30 +/- 5 days) intracoronary microsphere injections. The effects of BAY y 5959 (2-h i.v. infusions of 3 microg/kg/min and 10 microg/kg/min) were determined before heart failure, after heart failure was established and then 2 h after the end of a 5-day continuous BAY y 5959 intra-atrial infusion. Before CHF, the positive inotropic effect of BAY y 5959 at a dose of 10 microg/kg/min [left ventricular dP/dt (LVdP/dt) increased from 2955 +/- 132 mmHg to 4897 +/- 426 mmHg, P < .05] was associated with bradycardia (HR decreased from 92 +/- 4 to 78 +/- 6 b/min, P <.05), slight increases in mean arterial pressure (it increased from 100 +/- 2 mmHg to 113 +/- 5 mmHg, P <.05) and did not alter left ventricular end-diastolic pressure. In CHF, BAY y 5959 continued to induce dose-dependent increases in left ventricular systolic pressure, LVdP/dt and mean arterial pressure, as well as causing bradycardia and a significant decrease in left ventricular end-diastolic pressure. After a 5-day infusion of BAY y 5959, base-line LVdP/dt and left ventricular end-diastolic pressure improved. The responses of LVdP/dt and mean arterial pressure to BAY y 5959 were similar to those of the control state. The sustained responses in CHF and after long-term infusion suggest that BAY y 5959 may be an effective and potent inotropic agent for treatment of CHF that does not lead to tolerance to its positive inotropic effects.     

A case of de novo translocation 16;21: trisomy 16q phenotype and origin of the aberration

We reviewed our experience over a 12 month period with using minimally invasive direct coronary artery bypass (MIDCAB) for the management of high-risk patients with three-vessel coronary artery disease. Twenty patients (4 females, mean age 67 years) received left internal mammary artery (LIMA) grafts to the left anterior descending (LAD) coronary artery. Associated co-morbidity included: severe chronic renal failure, severe extensive arteriopathy, chronic obstructive airway disease, poor general condition and severely impaired left ventricular function. There was one early postoperative mortality and no other cardiac-related morbidity. Graft patency investigated, using angiography was 90%, and 5 patients underwent follow-up angioplasty to other coronary arteries. All patients remain entirely angina free at a follow-up period between 3 and 12 months. We conclude that MIDCAB is a safe and effective approach for managing high-risk patients with three-vessel coronary artery disease.     

Effects of dichloroacetate in patients with congestive heart failure

BACKGROUND: Conventional approaches to management of congestive heart failure (CHF) rely on drugs that increase myocardial contractility or reduce ventricular afterload. These approaches often improve cardiac symptoms and survival, but may be associated with significant deleterious effects. An alternative approach is to enhance myocardial energy production. Dichloroacetate (DCA) stimulates pyruvate dehydrogenase activity and accelerates aerobic glucose, pyruvate, and lactate metabolism in myocardial cells. These alterations would be expected to improve myocardial function. HYPOTHESIS: The purpose of the investigation was to assess the efficacy of DCA in patients with left ventricular systolic dysfunction and to examine the mechanism by which improvement occurs. METHODS: A total of 25 patients (16 men, 9 women; age range 31-72 years, mean 59) with CHF and ejection fraction < or = 40% received an intravenous infusion of 50 mg/kg DCA over 15 min. Indices of systolic and diastolic function were obtained by two-dimensional and Doppler echocardiography performed at baseline, 30 min, and 60 min following completion of DCA infusion. RESULTS: Baseline ventricular ejection fraction was 27.3 +/- 9.1%; 17 patients (68%) had nonischemic cardiomyopathy. Heart rate increased after DCA infusion from 73.9 +/- 14.5 to 79.2 +/- 14.9 beats/min at 60 min; p = 0.02. Left ventricular diastolic and systolic volumes increased at 30 min compared with baseline (248.7 +/- 98.1 vs. 259.6 +/- 99.6; p = 0.04, and 180.1 +/- 80.4 vs. 192.2 +/- 84.9; p = 0.002, respectively), but stroke volume (49.2 +/- 19.1 vs. 48.9 +/- 18.1; p = 0.9) and ejection fraction (27.3 +/- 9.1 vs. 25.7 +/- 9.8; p = 0.2) were unchanged. Indices of diastolic function were also unchanged. CONCLUSION: Dichloroacetate infusion in patients with CHF is not associated with improvement in noninvasively assessed left ventricular function.     

Extensive endarterectomy of the left anterior descending coronary artery combined with coronary artery bypass grafting

BACKGROUND: Complete revascularization of a diffusely diseased left anterior descending (LAD) coronary artery can be accomplished by extensive endarterectomy in conjunction with coronary artery bypass grafting (CABG). The present study was designed to assess the safety of the procedure, and which techniques lead to the best short- and long-term results. METHODS: Between January 1990 and October 1994 106 patients underwent extensive open endarterectomy of the LAD coronary artery combined with CABG at our institution. This group constituted 4.9% of all patients undergoing CABG during this period. The mean age of those studied was 64.4 +/- 9.2 years and 92% were male. In 22 patients (21%) the procedure was a repeat CABG and 12% had had percutaneous transluminal coronary angioplasty prior to the operation. Ninety-one per cent of the patients were in Canadian Cardiovascular Society (CCS) angina class 3 or 4, 91% had three-vessel disease and 36% had unstable angina at the time of surgery. The mean preoperative left ventricular ejection fraction was 53.6 +/- 14.9% (range, 15-80%). The internal mammary artery (IMA) was used to bypass the LAD coronary artery in 40 patients (38%) and a saphenous vein graft (SVG) was used in 66 patients. In 25 of the IMA bypass group an additional venous patch was used (IMA+P). RESULTS: The overall mortality rate was 9.4% (10 patients), including seven immediate postoperative deaths. When the IMA was used as a conduit the mortality rate was only 5.0%. There were seven (6.6%) postoperative non-fatal myocardial infarctions. There was a low incidence of other postoperative complications, similar to that following CABG without endarterectomy performed during the same period. Multivariate analysis identified emergency operation, two-vessel endarterectomy and female sex as independent risk factors for mortality. Upon follow-up study of 94 hospital survivors (98%), at a mean of 26.5 months (range, 1-48 months), all endarterectomy patients were in CCS class 1 or 2. Seventy-eight patients (83%) had an excellent postoperative exercise tolerance and the left ventricular function was preserved. The 4-year survival rates were 88% and 96% and the cardiac event-free survival rates were 74% and 87% in the SVG and IMA groups respectively. CONCLUSIONS: Complete revascularization of the diffusely diseased LAD coronary artery can be accomplished by adjunctive open endarterectomy with a degree of operative risk (mortality 9% and incidence of non-fatal myocardial infarction 7%). The immediate and medium-term results are improved when the IMA is used as a conduit, with or without additional venous patch. Independent risk factors for mortality were two-vessel endarterectomy, female sex and emergency operation. The long-term results revealed an overall survival rate of 92% and a cardiac event-free survival rate of 79% at 4 years, as well as excellent functional results.     

Partial left ventriculectomy with mitral valve preservation in the treatment of patients with dilated cardiomyopathy

OBJECTIVE: This study reports initial results of partial left ventriculectomy performed with preservation of the mitral valve in the treatment of 27 patients with idiopathic dilated cardiomyopathy. METHODS: Patients were in New York Heart Association class III or IV. Partial ventriculectomy was performed as an isolated procedure in four patients and associated with mitral annuloplasty in 23 patients. There were four hospital deaths (14.8%) and the remaining patients were followed for 11.2 +/- 6 months. RESULTS: Decrease of left ventricular diastolic diameter (81.8 +/- 8.7 to 68.5 +/- 7.6 mm, p < 0.001) and improvement of left ventricular wall shortening (12% +/- 3.1% to 18.1% +/- 3.9%, p < 0.001) were demonstrated by echocardiography after the operation. Left ventricular radioisotopic angiography showed reduction of diastolic volume (495 +/- 124 ml to 352 +/- 108 ml, p < 0.001) and increase of ejection fraction (17.7% +/- 4.6% to 23.7% +/- 8.8%, p < 0.001). Right-sided heart catheterization demonstrated improvement of stroke index (24.3 +/- 7.7 ml/m2 to 28.3 +/- 7.6 ml/m2, p < 0.01) and decrease of pulmonary wedge pressure (23.2 +/- 8.8 mm Hg to 17 +/- 7 mm Hg, p < 0.01). Similar results were documented at 6 and 12 months of follow-up. Functional class improved from 3.6 +/- 0.5 to 1.4 +/- 0.6 (p < 0.001). However, seven patients died at midterm follow-up because of heart failure progression or arrhythmia-related events, and survival rate was 59.2% +/- 9.4% from 6 to 24 months of follow-up. CONCLUSIONS: Partial left ventriculectomy performed with preservation of the mitral valve improves left ventricular function and congestive heart failure in patients with dilated cardiomyopathy. Nevertheless, the high incidences of heart failure progression and arrhythmia-related deaths observed after this procedure preclude its wide clinical application.     

Dynamic cardiomyoplasty: clinical follow-up at 12 years

OBJECTIVE: The purpose of this study is to evaluate the long-term outcome of dynamic cardiomyoplasty. This surgical technique was conceived to assist the failing heart. The many proposed mechanisms of action of cardiomyoplasty are: (1) systolic assist; (2) limitation of ventricular dilation; (3) reduction of ventricular wall stress (sparing effect); (4) ventricular remodeling with an active girdling effect; (5) angiogenesis; and (6) a neurohumoral effect. METHODS: We investigated 95 patients in our hospital undergoing this procedure due to severe chronic heart failure, refractory to optimal medical treatment. Patients had a mean age of 51 +/- 12 years. The etiology of heart failure was ischemic 55%, idiopathic 34%, ventricular tumor 6%, and other 5%. The mean follow-up was 44 months. RESULTS: The mean New York Heart Association (NYHA) functional class improved postoperatively from 3.2 to 1.8. Average radioisotopic left ventricular (LV) ejection fraction increased from 17 +/- 5 to 27 +/- 4% (P < 0.05). Stroke volume index increased from 32 +/- 7 to 43 +/- 8 ml/beat per m2 (P < 0.05). The heart size remained stable over the long term. Following cardiomyoplasty, the number of hospitalizations due to congestive heart failure was reduced to 0.4 hospitalizations/patient per year (preoperative: 2.5, P < 0.05). Computed tomography scans showed at long term a preserved latissimus dorsi muscle structure in 84% of patients. Survival probability at 7 years is 54%. Six patients underwent heart transplant after cardiomyoplasty (mean delay: 25 months), due to the natural evolution of their underlying heart disease. There were no specific technical difficulties. CONCLUSIONS: Clinically, this procedure reverses heart failure, improves functional class and ameliorates quality of life. The latissimus dorsi muscle histological structure is maintained at long-term, when postoperative electrostimulation is performed, avoiding excessive stimulation. Cardiomyoplasty may delay or prevent the progression of heart failure and the indication of cardiac transplantation.     

Quantitative analysis of muscle fibre type and myosin heavy chain distribution in the frog hindlimb: implications for locomotory design

Previous short-term studies demonstrated that treatment with clonidine produced significant hemodynamic improvement in patients with congestive heart failure (CHF). In this study we followed 12 CHF patients (10 M, 2 F age 63+/-11, 10 with ischemic cardiomyopathy and 2 with dilated cardiomyopathy) treated with 0.15 or 0.075 mg oral clonidine twice daily for 13+/-5 months (range 6-23). with functional evaluation at baseline, 6 weeks and 6 months. There was suppression of circulating catecholamines, associated with significant ameliorations in NYHA class, in duration of exercise tolerance (from 246+/-68 sec to 362+/-30 and 459+/-70 sec, respectively p < 0.02), in ejection fraction (from 32+/-7% to 35+/-5 and 39+/-7% p < 0.04) and in left ventricular enlargement as assessed echocardiographically. There were also improvements in a number of electrophysiologic parameters calculated by computerized analysis of ambulatory ECG tapes, such as heart rate variability, indicating diminished propensity to malignant arrhythmias, as confirmed by decreases in the numbers of isolated premature ventricular contractions, couplets and episodes of non-sustained ventricular tachycardia. The data suggest that chronic central sympathetic suppression with clonidine in CHF results in significant functional amelioration and improved electrophysiologic stability.     

Two types of fetishism

OBJECTIVE: To evaluate the effects of myocardial viability assessment with positron emission tomography on cardiac revascularization decision-making and consequential outcomes of patients with multivessel coronary artery disease. METHODS: Thirty-three patients with multivessel coronary disease and heart failure were studied in this series, using 13NH for myocardial perfusion and F-18-deoxy-glucose for myocardial metabolism. Viable myocardium (mis-matched perfusion-metabolism) was visually and quantitatively analyzed in anterior, apical, septal, inferior, and lateral segments of the left ventricle. Left ventricular ejection fraction (LVEF) was also measured with first-pass radionuclide angiocardiography. RESULTS: Based on the assessment of myocardial viability, 19 patients (group A) with sufficient viable myocardium underwent revascularization (coronary bypass graft and/or angioplasty), and 14 patients (group B) without sufficient viable myocardium received conservative medical treatment. During an average of 17-month follow-up, there were 2 (10.5%) deaths in group A and 2 in group B (14.3%) deaths (P > 0.5). Patients with revascularization showed significantly improved average LVEFs post-revascularization, without revascularization procedure-related mortality; patients with medical treatment had an initial average LVEF of 25% and class II-III (NYHA) average cardiac function with a survival rate of 86% in average, which was better than that reported in literature. CONCLUSION: Positron emission tomography is useful in myocardial viability assessment for cardiac revascularization decision-making through precisely selecting suitable patients for revascularization and avoiding operations on those who will not benefit, which results in promising effects on outcomes of patients with multivessel coronary disease and severe left ventricular dysfunction.     

Mortality of the institutionalized old-old hospitalized with congestive heart failure

BACKGROUND: Congestive heart failure is a major cause of mortality and morbidity in the elderly but the disease impact on the oldest and sickest population has not been defined. OBJECTIVES: To review the mortality and hospital readmission rate of institutionalized elderly persons with congestive heart failure and to examine the relation of baseline characteristics to subsequent clinical outcomes. METHODS: This was a retrospective analysis based on chart review of 231 residents of the Philadelphia (Pa) Geriatric Center (63 congregate housing tenants and 168 nursing home residents) 80 years and older, hospitalized with congestive heart failure from 1989 to 1995. Patients' demographic data and clinical, electrocardiographic, and echocardiographic findings were obtained from their initial (index) hospitalization records. Subsequent outcomes were obtained from their outpatient (nursing home or office) records. RESULTS: Thirteen percent died during the index hospitalization but the total mortality during the follow-up period was 87%. One hundred forty-six patients (63%) died in the first year with a mean +/- SD survival of 4+/-4 months and a readmission rate of 3.9 per patient-year. Eighty-five patients survived the first year with a readmission rate of 1.2 per patient-year and 54 patients subsequently died, with a mean +/- SD survival of 28+/-12 months. The first-year decedents and survivors were comparable in sex, age, medical history, and electrocardiographic findings. However, patients who died in the first year, compared with survivors, were more likely to be nursing home residents (81% vs 59%), have New York Heart Association class IV heart failure (54% vs 32%), have impaired left ventricular function by echocardiogram (53% vs 32%), and have renal insufficiency (32% vs 11%). CONCLUSIONS: Very elderly persons with congestive heart failure had a guarded long-term prognosis. Nursing home residency, class IV heart failure, impaired left ventricular function, and renal insufficiency were associated with higher risk for early death and repetitive hospitalizations.     

Safety and cost-effectiveness of MIDCABG in high-risk CABG patients

BACKGROUND: Myocardial revascularization without cardiopulmonary bypass has been proposed as a potential therapeutic alternative in high-risk patients undergoing coronary artery bypass grafting. To evaluate this possibility we compared 15 high-risk (HR) patients in whom minimally invasive direct coronary artery bypass grafting was used as the method of revascularization with 41 consecutive patients who underwent conventional coronary artery bypass grafting during 1 month. METHODS: Patients undergoing myocardial revascularization without cardiopulmonary bypass were significantly older than their low-risk (LR) counterparts (72.2 +/- 11.6 versus 63.3 +/- 9.7 years, p = 0.006). The demographic profile for HR versus LR patients was as follows: female patients, 60.0% versus 26.8%, p = 0.02; diabetes, 20.0% versus 24.4%, p = 0.7; prior stroke, 33.3% versus 7.4%, p = 0.03; chronic obstructive pulmonary disease, 60.0% versus 9.8%, p < 0.0001; peripheral vascular disease, 33.3% versus 12.2%, p = 0.03, congestive heart failure, 26.6% versus 9.8%, p = 0.09; impaired left ventricular (ejection fraction < 0.40), 40.0% versus 17.0%, p = 0.07; urgent operation, 86.6% versus 46.3%, p < 0.0001; and redo operation, 20.0% versus 0%, p = 0.003. RESULTS: There were no deaths in the HR group and one death in the LR group. The average intensive care unit stay was 1.1 +/- 0.5 days in HR patients versus 1.6 +/- 1.6 days in LR individuals (p = 0.2), and the average hospital stay was 6.1 +/- 1.8 versus 7.3 +/- 4.4 days, respectively (p = 0.3). We used an acuity risk score index developed by the Adult Cardiac Care Network of Ontario to predict outcome in the HR group. The expected intensive care unit stay in HR patients was 4.1 +/- 1.2 days (versus the observed stay of 1.1 +/- 0.5 days, p < 0.0001), and the expected hospital stay was 12.5 +/- 1.5 days (versus the observed stay of 6.1 +/- 1.8 days, p < 0.0001). The expected mortality in the HR group was 6.1% versus 0%, p = 0.3. A cost regression model was used to examine predicted versus actual cost (in Canadian dollars) for the HR patient cohort (based on Ontario Ministry of Health funding). The expected cost for the HR cohort would have been $11,997 per patient. In contrast, the average cost for these 15 patients was $5,997 per patient, an estimated cost saving of 50%. CONCLUSIONS: Myocardial revascularization without cardiopulmonary bypass appears to be a safe and cost-effective therapeutic modality for HR patients requiring myocardial revascularization.     

Very Long-Term Memory for Information Taught in School

The long-term relative benefits of thrombolysis and mechanical reperfusion therapy following acute myocardial infarction (AMI) have not been established. The purpose of this study was to compare left ventricular function, left ventricular remodeling and late outcome after AMI for different reperfusion therapies. Thirty consecutive patients suffering their first anterior wall myocardial infarction with coronary stenoses limited to the left anterior descending coronary artery were studied. They included 10 patients who underwent intracoronary thrombolysis (ICT), 10 who underwent PTCA and 10 who underwent noninterventional medical treatment. All patients underwent coronary angiography (CAG) during the acute phase of AMI and also during the follow-up period, and left ventriculography during the follow-up period and clinical follow-up was performed (mean clinical follow-up period: 53 +/- 31 months). No significant difference in global ejection fraction was noted among the groups, although the end-diastolic volume index (EDVI) in the PTCA group (79.4 +/- 17.5 ml/m2) was significantly smaller than in the noninterventional (106.1 +/- 25.1 ml/m2) and ICT (107.9 +/- 28.3 ml/m2) group (p < 0.05). The regional wall motion index (RWMI) for the anterior region in the PTCA group (-2.7 +/- 0.8) was greater (p < 0.05) than in the noninterventional (-3.4 +/- 0.6) and ICT (-3.3 +/- 0.6) groups. A significant linear correlation was found between EDVI and % diameter stenosis and also between RWMI and % diameter stenosis following reperfusion (p = 0.01). There was no difference in the incidence of cardiac death, nonfatal reinfarction, bypass surgery or congestive heart failure among the groups. Disturbed left ventricular regional wall motion and remodeling benefit most from angioplasty because of prompt restoration of adequate blood flow. However, there was no difference in late outcomes following AMI among the three groups.