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Biomedical subjects

Patrick M McCarthy

Publications and source records attributed to Patrick M McCarthy.

At least 55 records · Page 3Linked to original sources
PubMed2004

Mitral valve repair without cardiopulmonary bypass or atriotomy using the coapsys device: device design and implantation procedure in canine functional mitral regurgitation model.

BACKGROUND: Myocor developed a unique system, the Coapsys annuloplasty system, to treat functional mitral regurgitation (MR) without cardiopulmonary bypass (CPB). This study was conducted to test the feasibility of the Coapsys implantation procedure in a canine functional MR model. METHODS: Functional MR with heart failure was induced in 9 dogs by rapid ventricular pacing (230 beats/min for 30 +/- 4 days). The Coapsys device, which consists of anterior and posterior epicardial pads connected by a subvalvular chord, was then surgically implanted. Under epicardial echocardiographic guidance, we placed the Coapsys device across the left ventricular chamber using the delivery instrument and needle assembly. We sized the Coapsys device by drawing the posterior leaflet and annulus toward the anterior leaflet with the sizing instrument. Final device size was selected when MR was minimized or eliminated as assessed by 2-dimensional color Doppler echocardiography. RESULTS: In all cases, we successfully implanted the Coapsys device without CPB or atriotomy. MR was reduced an average of 2 grades. No adverse events, such as hemodynamic compromise or structural valve damage, were noted. CONCLUSION: Coapsys device implantation was feasible and safe on a beating canine heart. All accessory tools used for device implantation were found useful.

Animals↗
PubMed2004

Surgical ventricular restoration: the RESTORE Group experience.

Congestive heart failure may be caused by late left ventricular (LV) dilation following anterior infarction. Early reperfusion prevents transmural necrosis, and makes the infarcted segment akinetic rather than dyskinetic. Surgical ventricular restoration (SVR) reduces LV volume and creates a more elliptical chamber by excluding scar in either akinetic or dyskinetic segments. The international RESTORE group applied SVR in a registry of 1198 post-infarction patients between 1998 and 2003. Early and late outcomes were examined and risk factors identified.Concomitant procedures included coronary artery bypass grafting in 95%, mitral valve repair in 22%, and mitral valve replacement in 1%. Overall 30-day mortality after SVR was 5.3% (8.7% with mitral repair vs. 4.0% without repair, p < .001) Perioperative mechanical support was uncommon (< 9%). Global systolic function improved postoperatively, as ejection fraction increased from 29.6 +/- 11.0% to 39.5 +/- 12.3% (p < .001) and left ventricular end systolic volume index decreased from 80.4 +/- 51.4 ml/m(2) to 56.6 +/- 34.3 ml/m(2) (p < .001). Overall 5-year survival was 68.6 +/- 2.8%, Logistic regression analysis identified EF < or = 30%, LVESVI > o = 80 ml/m(2), advanced NYHA functional class, and age > or =75 years as risk factors for death. Five-year freedom from hospital readmission for CHF was 78%. Preoperatively, 67% of patients were class III or IV, and postoperatively 85% were class I or II.SVR improves ventricular function and is highly effective therapy in the treatment of ischemic cardiomyopathy with excellent 5-year outcome.

Aged↗
PubMed2004

Does preoperative atrial fibrillation reduce survival after coronary artery bypass grafting?

BACKGROUND: Preoperative atrial fibrillation has been identified as a risk factor for reduced long-term survival after coronary artery bypass grafting. This study sought to determine whether atrial fibrillation is merely a marker for high-risk patients or an independent risk factor for time-related mortality. METHODS: From 1972 to 2000, 46,984 patients underwent primary isolated coronary artery bypass grafting; 451 (0.96% prevalence) had electrocardiogram-documented preoperative atrial fibrillation (n = 411) or flutter (n = 40). Characteristics of patients with and without atrial fibrillation were contrasted by multivariable logistic regression to form a propensity score. With this, comparable groups with and without atrial fibrillation were formed by pairwise propensity-matching to assess survival. RESULTS: Patients with preoperative atrial fibrillation were older (67 +/- 9.0 versus 59 +/- 9.8 years, p < 0.0001), had more left ventricular dysfunction (66% versus 52%, p < 0.0001) and hypertension (73% versus 59%, p < 0.0001), but less severe angina (39% moderate or severe versus 49%, p < 0.0001). Many of these factors are themselves predictors of increased time-related mortality. In propensity-matched patients, survival at 30 days and at 5 and 10 years for patients with versus without atrial fibrillation was 97% versus 99%, 68% versus 85%, and 42% versus 66%, respectively, a survival difference at 10 years of 24%. Median survival in patients with atrial fibrillation was 8.7 years versus 14 years for those without it. CONCLUSIONS: Atrial fibrillation in patients undergoing coronary artery bypass grafting is a marker for high-risk patients; in addition, atrial fibrillation itself substantially reduces long-term survival. Thus, if patients in atrial fibrillation require surgical revascularization, it is appropriate to consider performing a concomitant surgical ablation procedure.

Aged↗
PubMed2004

Edge-to-edge (Alfieri) mitral repair: results in diverse clinical settings.

BACKGROUND: Complex mitral regurgitation (MR) jets can make repair challenging; edge-to-edge (Alfieri) repair augments the repertoire of repair techniques. Objectives of this study were to demonstrate causes of MR amenable to edge-to-edge repair and to determine safety, obstructive potential, and durability of edge-to-edge repair. METHODS: From January 1997 to October 2001, 224 patients underwent Alfieri repair. Indications included ischemic cardiomyopathy (n = 143, 64%), myxomatous disease (n = 31, 14%), dilated cardiomyopathy (n = 27, 12%), and hypertrophic obstructive cardiomyopathy (n = 14, 6%). Concomitant ring annuloplasty was performed in 188 patients (84%). Two additional patients had takedown of an Alfieri repair in the operating room for obstruction. Preoperative MR was 4+ in 109 patients (50%) and 3+ in 65 (30%). Postoperative and follow-up mitral gradient and return of MR were assessed using 396 transthoracic echocardiograms and longitudinal analyses. RESULTS: Hospital mortality was 2% (5 of 224). Mitral valve mean gradient was low (3.7 mm Hg) and nonprogressive (p = 0.7), although peak gradient rose slightly, from mean 8.4 to 10.0 mm Hg (p = 0.01). During the first 3 postoperative months, absence of MR declined to 40%, and prevalence of 3+ MR increased to 14%, then rose slowly thereafter. Fourteen patients--12 within 2 years--underwent mitral valve reoperation, none for stenosis; 7 patients--6 within 2 years--underwent heart transplantation. CONCLUSIONS: Alfieri mitral repair can be used in a variety of settings with a low risk of creating mitral stenosis. However, in ischemic MR, steadily increasing prevalence of moderately severe and severe regurgitation after edge-to-edge repair suggests other techniques are needed.

Aged↗
PubMed2004

Elephant trunk procedure: newer indications and uses.

BACKGROUND: The elephant trunk procedure is used for extensive aortic aneurysms. We evaluated its safety, newer indications, and influence of second-stage completion on survival. METHODS: Records were reviewed for 94 consecutive patients (age 67 +/- 11 years, 47% men) who underwent the procedure between November 1990 and February 2003. The trunk was implanted as an extension of the ascending aorta and arch graft in 83 of 94 (88.3%) patients, distal arch graft in 8 of 94 (8.5%) patients, and in 3 distal to the left subclavian artery (3 of 94 patients [3.2%]). Aortic dissection was present in 37 (39.4%) patients and Marfan syndrome was present in 7 (7.4%). Twenty-three were reoperations (24.5%). In 9 patients, the trunk procedure was adjunctive in preparation for the second operation. In 15 patients, the anastomosis was completed between the left subclavian and common carotid arteries. Coronary artery bypass was performed in 36 (38.4%) and aortic valve operation in 55 (58.5%; 20 root sparing repairs, 16 composite grafts and 19 replacements) patients. RESULTS: There were two early 30-day in-hospital deaths (2.1%) and 5 permanent strokes (5.3%). Eleven died before the second-stage procedure. Forty-seven (57%) underwent second-stage procedures; 40 by thoracotomy and 7 by stent graft insertion, including 2 thoracoabdominal aneurysm repairs with visceral bypasses before stent grafting with 4 early deaths (8.5%). Five-year survival was 34% without a second-stage procedure versus 75% 3-year survival with it. CONCLUSIONS: With a current total of 142 elephant trunk procedures, we found it is safe and should be used more with initial cardiac surgery before descending or thoracoabdominal aorta repair.

Aged↗
PubMed2004

Does the arterial cannulation site for circulatory arrest influence stroke risk?

BACKGROUND: We investigated whether axillary/subclavian artery inflow with a side graft decreases the risk of stroke versus cannulation at other sites during hypothermic circulatory arrest. METHODS: Between January 1993 and May 2003, 1,352 operations with circulatory arrest were performed for complex adult cardiac problems. A single arterial inflow cannulation site was used in 1,336 operations, and these formed the basis for comparative analyses. Cannulation sites were axillary plus graft in 299 operations, direct cannulation of the aorta in 471, femoral in 375, innominate in 24, and axillary or subclavian without a side graft in 167. Retrograde brain perfusion was used in 933 (69%). A total of 272 (20%) were for emergencies, 432 (32%) were reoperations, and 439 (32%) were for dissections. A total of 617 (46%) had aortic valve replacement and 1,160 (87%) ascending, 415 arch (31%), and 248 descending (18%) aortic replacements. Indications also included arteriosclerosis (n = 301) and calcified aorta (n = 278). Primary comparisons were made by using propensity matching, and, secondarily, risk factors for stroke or hospital mortality were identified by multivariable logistic regression. RESULTS: Stroke occurred in 6.1% of patients (81/1,336): 4.0% (12/299) of those had axillary plus graft and 6.7% who had direct cannulation (69/1,037; p = 0.09; p = 0.05 among propensity-matched pairs). Operative variables associated with stroke included direct aortic cannulation, aortic arteriosclerosis, descending aorta repair, and mitral valve replacement. The risk of hospital mortality was higher (11%; 42/375) for patients who had femoral cannulation than axillary plus graft (7.0%; 21/299; p = 0.06; p = 0.02 among propensity-matched pairs). CONCLUSIONS: Axillary inflow plus graft reduces stroke and is our method of choice for complex cardiac and cardioaortic operations that necessitate circulatory arrest. Retrograde or antegrade perfusion is used selectively.

Aged↗
PubMed2004

A prospective multicenter trial of bipolar radiofrequency ablation for atrial fibrillation: early results.

BACKGROUND: The Cox-Maze III remains the gold standard for the surgical treatment of atrial fibrillation. However, the "cut-and-sew" technique is time consuming and technically challenging. The pulmonary veins are the source of ectopy in the majority of patients with atrial fibrillation. The safety and efficacy of bipolar radiofrequency to electrically isolate the pulmonary veins was evaluated in a prospective multi-center trial. METHODS: Beginning in January 2002, 30 patients at three medical centers underwent pulmonary vein isolation using bipolar radiofrequency and were followed for 6 months. Twenty-four of the patients also underwent a modified Cox-Maze III. Electrical isolation of the pulmonary veins was confirmed with intraoperative pacing. Pulmonary vein patency was assessed by magnetic resonance imaging or three-dimensional computed tomography in 15 patients at 1 month. RESULTS: Mean age was 60.9 +/- 11.7 years. Nineteen patients had paroxysmal atrial fibrillation. All pulmonary veins were isolated in every patient. The left pulmonary veins underwent 3.0 +/- 1.4 applications for a total of 26.4 +/- 10.5 seconds. The right pulmonary veins underwent 2.8 +/- 1.1 applications for a total of 26.3 +/- 12.6 seconds. There was no operative mortality. At 1 month, imaging revealed no evidence of pulmonary vein stenosis. At 6 months, 96% of patients were in normal sinus rhythm. CONCLUSIONS: The use of bipolar radiofrequency for electrical isolation of pulmonary veins and to replace other Cox-Maze III incisions is safe and effective at controlling atrial fibrillation. This emerging technology may shorten and simplify the surgical management of atrial fibrillation.

Aged↗
PubMed2004

Annular geometry and motion in human ischemic mitral regurgitation: novel assessment with three-dimensional echocardiography and computer reconstruction.

BACKGROUND: Annular geometry and motion in functional ischemic mitral regurgitation are incompletely understood. Three-dimensional echocardiography demonstrates saddle-shaped annular geometry, but standard methodology does not enable quantification of annular motion. Therefore, a novel technique using three-dimensional echocardiography and computer software was used to characterize alterations in mitral annular geometry and motion in patients with ischemic mitral regurgitation. METHODS: We developed a computer program to reconstruct the mitral annulus based on spatial coordinates from three-dimensional echocardiography. Data were obtained at end-diastole and end-systole in 7 patients with ischemic mitral regurgitation and 5 normal control subjects. Mitral annular motion was quantified by calculating the displacement area of the annulus between end-diastole and end-systole. RESULTS: Comparison of ischemic mitral regurgitation and control patients revealed differences in annular geometry and motion at end-diastole. Annular perimeter was greater in ischemic mitral regurgitation patients (10.7 +/- 0.7 cm versus 8.6 +/- 0.2 cm in control group; p < 0.03), with increased intertrigonal distance in ischemic mitral regurgitation patients (2.8 +/- 0.3 cm versus 2.1 +/- 0.1 cm; p < 0.06). These changes resulted in increased annular orifice area in ischemic mitral regurgitation patients (9.1 +/- 1.2 cm2 versus 5.7 +/- 0.3 cm2; p < 0.03). Ischemic mitral regurgitation patients had altered annular motion, with reduced movement of the posterior annulus (5.4 +/- 0.7 cm2 versus 8.7 +/- 1.1 cm2; p < 0.03). CONCLUSIONS: Computer analysis of data obtained from three-dimensional echocardiography demonstrates altered annular geometry and motion in patients with ischemic mitral regurgitation. Patients with ischemic mitral regurgitation have annular dilatation, with an increase in anterior and posterior annular perimeters; this is accompanied by an increase in the intertrigonal distance and restriction of annular motion.

Aged↗
PubMed2004

PET abnormalities in patients with nonischemic cardiomyopathy.

BACKGROUND: The abnormalities in dilated cardiomyopathy (DCM) are generally considered diffuse and to affect the left ventricle in a global manner. However, regional wall motion abnormalities and metabolic defects may also occur to varying, but unclear degrees. QRS width and metabolic defects on positron emission tomography (PET) correlate with survival. We sought to ascertain the prevalence of regional defects in DCM by multiple imaging modalities and to establish the relationship between QRS width and these defects. METHODS: In consecutive patients with advanced nonischemic DCM, undergoing cardiac transplant evaluation, we reviewed multiple imaging modalities (PET, 2-dimensional echocardiography, and radionuclide ventriculography) to quantify the incidence of regional metabolic and wall motion abnormalities and correlate them with clinical and electrocardiographic parameters. RESULTS: Of 44 patients studied, PET imaging revealed scar in 91% of patients, with a mean of 25 +/- 18% of the left ventricle involved, predominantly in the distribution of the left anterior descending artery. Regional wall motion abnormalities occurred in 51% of patients who underwent echocardiography and 59% of patients who underwent nuclear scintigraphy (with only 70% concordance). QRS duration on the surface electrocardiogram correlated positively with the degree of scarring (r=.52, P=.0007). CONCLUSIONS: The presence of scar (matched perfusion and metabolic defects) on PET scanning in patients with advanced DCM is not always indicative of coronary disease. Thus coronary angiography is usually required to define the etiology of systolic dysfunction. The extent of scar correlates with QRS duration. This may have implications for the application of cardiac resynchronization therapy.

Adult↗
PubMed2004

Contemporary outcomes of outpatients referred for cardiac transplantation evaluation to a tertiary heart failure center: impact of surgical alternatives.

BACKGROUND: The growing epidemic of congestive heart failure in the setting of limited donor-organ availability has mandated continued development and increased utilization of medical and surgical alternatives to cardiac transplantation. We sought to assess current disposition and outcomes of patients recently referred for transplant evaluation to a single high-throughput tertiary referral center. METHODS AND RESULTS: We performed a retrospective observational review of consecutive patients with advanced heart failure who were assessed initially in an outpatient setting by a heart failure cardiologist, with a view to transplant or nontransplant surgical alternatives between 1995 and 2000. Of 1174 consecutive referrals (mean age 55.1 [+/-12.7], 74% male), 588 (50%) were recommended for medical treatment (mean age 55.3 [+/-12.4], 72% male) and 200 (17%) for nontransplant surgery, principally coronary artery bypass grafting, mitral valve repair, infarct exclusion, partial left ventriculectomy, or combinations thereof (mean age 57.8 [+/-10.6], 76% male). A minority, 418 (36%), were initially listed for cardiac transplantation (mean age 53.5 [+/-13.9], 80% male). Of these, 74 (18% of listed) died waiting (34 on left ventricular assist device support), 45 were delisted (27 for improved clinical status), and 217 (18% of referred group) have been transplanted. The 3-year survival (Kaplan-Meier) was equivalent (82%) in the transplanted and nontransplant surgery groups (excluding partial left ventriculectomy patients). CONCLUSION: In current clinical practice less than one fifth of transplant referrals are ultimately transplanted, reflecting both a limited donor supply and the application of alternative, nontransplant strategies. Medium-term survival in patients suitable for alternative surgical strategies equals that of cardiac transplantation.

Adult↗
PubMed2004

Echocardiographic assessment of regional ventricular function after device-based change of left ventricular shape.

We assessed the effects of implantation of Myosplint (Myocor, Maple Grove, Minn), a device that changes left ventricular (LV) cross-sectional shape from circular to bilobar, on regional LV function. A total of 10 open-chest dogs with tachycardia-induced cardiomyopathy were studied before and after Myosplint implantation. LV cross-sectional epicardial echocardiography at the papillary muscle level was performed along with acquisition of hemodynamic data. LV normalized thickening, fractional thickening, end-diastolic thickness, and end-diastolic curvatures were calculated for 10 LV segments. Myosplint implantation did not affect LV hemodynamics, but decreased average end-diastolic curvature (P <.0001) and increased its segmental heterogeneity (P <.0001). There was no change in average fractional thickening, whereas normalized thickening increased (P =.05). In contrast, segmental heterogeneity of both normalized and fractional thickening increased (P =.02 and P =.01, respectively). Structural modeling confirmed that Myosplint implantation increases regional stress heterogeneity and curvature heterogeneity. LV cross-sectional shape markedly affects regional LV performance.

Animals↗
PubMed2004

Cardiac angiotensin II receptors as predictors of transplant coronary artery disease following heart transplantation.

AIMS: We tested the hypothesis that cardiac angiotensin II (Ang II) receptor gene transcription may predict the development of transplant coronary artery disease (TCAD) following heart transplantation. METHODS AND RESULTS: We examined the gene transcripts of Ang II type 1 (AT1R) and type 2 receptors (AT2R) in endomyocardial biopsy specimens from 50 heart transplant recipients. The progression of TCAD was measured as change in maximal intimal thickness (CMIT) and change in plaque volume (CPV) by intravascular ultrasound (IVUS) examinations from baseline to one year after transplantation. The development of transplant vasculopathy was defined as a CMIT of > or = 0.3 mm over one year. The level of AT(1)R mRNA was associated with that of AT2R in transplanted hearts (regression coefficient=1.77, 95% CI 0.85-2.89, p<0.0001). AT1R and AT2R gene transcripts were univariate predictors of CMIT (AT1R: regression coefficient 0.10, 95% CI 0.06-0.14, p<0.0001; AT2R: regression coefficient 0.28, 95% CI 0.17-0.40, p<0.0001 ) or CPV (AT1R: regression coefficient 0.41, 95% CI 0.17-0.65, p<0.0001 ; AT2R: regression coefficient 1.25, 95% CI 0.49-2.01, p=0.002 ). By one year, 21 (46%) transplant recipients showed evidence of transplant vasculopathy and the rest did not. The vasculopathic group demonstrated a higher level of expression of cardiac AT1R than the non-vasculopathic group (3.7+/-2.9 vs 1.6+/-1.7 folds; p=0.006). The level of AT(1)R mRNA in transplanted heart was identified as a discriminator that predicted the development of transplant vasculopathy with a sensitivity of 75% and specificity of 83%. CONCLUSIONS: Cardiac Ang II receptor gene transcripts are associated with the progression of TCAD following heart transplantation. Only AT1R gene transcripts predicted the development of transplant vasculopathy in this preliminary study. These findings potentially support a role of Ang II receptors in the progression of TCAD following cardiac transplantation.

Acute Disease↗
PubMed2004

Changes in mitral annular and left ventricular dimensions and left ventricular pressure-volume relations after off-pump treatment of mitral regurgitation with the Coapsys device.

OBJECTIVE: The objective of this study was to evaluate the changes in mitral annular and left ventricular dimensions and left ventricular pressure-volume relations produced by the Myocor Coapsys device that has been developed to treat functional mitral regurgitation (MR) off-pump. METHODS: The Coapsys device, which consists of anterior and posterior epicardial pads connected by a sub-valvular chord, was implanted in seven dogs with functional MR resulting from pacing induced cardiomyopathy. The Coapsys device was then sized by drawing the posterior leaflet and annulus toward the anterior leaflet. During sizing, MR grade was assessed using color flow Doppler echocardiography. Final device size was selected when MR was eliminated or minimized. Following implantation, heart failure was maintained by continued pacing for a period of 8 weeks. Mitral annular and left ventricular dimensions and left ventricular pressure-volume relations were evaluated by two-dimensional echocardiography and a conductance catheter, respectively, at pre-sizing, post-sizing, and after 8 weeks. RESULTS: All implants were performed on beating hearts without cardiopulmonary bypass. Mean MR grade was reduced from 2.9+/-0.7 at pre-sizing to 0.7+/-0.8 at post-sizing (P<0.001), and was maintained at 0.8+/-0.8 after 8 weeks (P<0.01). The septal-lateral dimensions were significantly reduced at both mitral annular level [2.4+/-0.2 cm at pre-sizing, 1.5+/-0.3 cm at post-sizing (P<0.001) and 1.8+/-0.3 cm after 8 weeks (P<0.05)] and mid-papillary level [4.1+/-0.4 cm at pre-sizing, 2.4+/-0.2 cm at post-sizing (P<0.001) and 3.3+/-0.4 cm after 8 weeks (P<0.001)]. The end-systolic pressure-volume relation shifted leftward at post-sizing with a significantly steeper slope (P=0.03). There was a significant (P=0.03) leftward shift of the end-diastolic pressure-volume relation at post-sizing. After 8 weeks, these changes in pressure-volume relations tended to return to pre-sizing relations. CONCLUSIONS: The Coapsys device significantly reduced MR by treating both the mitral annular dilatation and the papillary muscle displacement. Despite these significant dimensional changes, the Coapsys device did not negatively affect the left ventricular pressure-volume relations.

Animals↗
PubMed2004

Cytoskeletal structure and recovery in single human cardiac myocytes.

BACKGROUND: Mechanical support of the failing human heart with a left ventricular assist device (LVAD) normalizes many components of myocyte structure and function. We hypothesized that recovery of the cytoskeleton, a major site of mechanotransduction in cardiac myocytes, is crucial for sustained improvement of myocardial function. We therefore measured the effects of LVAD support on 4 cytoskeletal proteins in single human heart cells. METHODS: Myocytes were isolated from non-failing (NF), hypertrophied (H), failing (F) and LVAD-supported failing (L) human hearts. Protein quantitation was performed using Western blot analysis and cellular distribution was determined by immunolabeling and confocal microscopy. RESULTS: alpha-actinin did not differ in cells from H or F as compared with NF, and L had no effect. Vinculin was not quantitatively different in H or F vs NF, but localization at the intercalated disks was significantly decreased in H and absent in F, and this pattern was consistently reversed in L. Desmin protein was significantly increased in F vs NF, both in quantity and distribution, and these increases were reversed in L. beta-tubulin was increasingly polymerized in H and F, and the hyperpolymerization was reversed in L. CONCLUSIONS: On the level of the single cardiomyocyte, major proteins of the cytoskeleton are significantly altered in hypertrophied and failing human hearts. These alterations are reversed by mechanical unloading with an LVAD, suggesting that the cytoskeleton is not the limiting factor in determining full cardiac recovery.

Actinin↗
PubMed2004

Neurohormonal response to left ventricular reconstruction surgery in ischemic cardiomyopathy.

OBJECTIVES: Activation of the neuroendocrine axis in congestive heart failure is of prognostic significance, and neurohumoral blocking therapy prolongs survival. The hypothesis that surgical reduction of left ventricular size and function decreases neuroendocrine activation is less established. We evaluated the neurohormonal response to left ventricular reconstruction surgery in ischemic cardiomyopathy. METHODS: Norepinephrine, plasma renin activity, and angiotensin II were measured in 10 patients before and 12 months after left ventricular reconstruction. In an additional 5 patients, brain natriuretric peptide was measured before and 3 months postoperatively. Three-dimensional cardiovascular imaging was used to assess ejection fraction and left ventricular end-diastolic volume index. RESULTS: Concurrent with improvements of New York Heart Association functional class (2.9 +/- 0.5 preoperatively vs 2.0 +/- 0.4 postoperatively, P <.001), ejection fraction (23.9% +/- 6.6% vs 36.2% +/- 6.2%, P <.01), and left ventricular end-diastolic volume index (140.8 +/- 33.8 mL/m(2) vs 90.6 +/- 18.3 mL/m(2), P <.01), considerable reductions were observed for median plasma profiles of norepinephrine (562.0 pg/mL vs 319.0 pg/mL, P <.05), plasma renin activity (5.75 microg/L/h vs 3.45 microg/L/h, P <.05), angiotensin II (41.0 ng/mL vs 23.0 ng/mL, P =.051), and brain natriuretric peptide (771.0 pg/mL vs 266.0 pg/mL, P <.05). The more plasma renin activity or angiotensin II decreased after left ventricular reconstruction, the higher was the increase in ejection fraction (R = -.745, P <.05 [plasma renin activity]; R = -.808, P <.05 [angiotensin II]). CONCLUSIONS: Surgical improvements of ejection fraction and left ventricular end-diastolic volume index by left ventricular reconstruction were accompanied by improvement of both the neuroendocrine activity and the functional status in patients with congestive heart failure. Whether this favorable neurohormonal response is predictive of an improved survival requires further evaluation.

Aged↗
PubMed2004

Tricuspid valve repair: durability and risk factors for failure.

OBJECTIVES: To compare durability of tricuspid valve annuloplasty techniques, identify risk factors for repair failure, and characterize survival, reoperation, and functional class of surviving patients. METHODS: From 1990 to 1999, 790 patients (mean age 65 +/- 12 years, 51% New York Heart Association functional class III or IV, and mean right ventricular systolic pressure 56 +/- 18 mm Hg) underwent tricuspid valve annuloplasty for functional regurgitation using 4 techniques: Carpentier-Edwards semi-rigid ring, Cosgrove-Edwards flexible band, De Vega procedure, and customized semicircular Peri-Guard annuloplasty. Of these patients, 89% had concomitant mitral valve surgery. A total of 2245 follow-up transthoracic echocardiograms were retrieved. Tricuspid regurgitation was analyzed, and risk factors for worsening regurgitation were identified, by multivariable ordinal longitudinal methods. RESULTS: Tricuspid regurgitation 1 week after annuloplasty was 3+ or 4+ in 14% of patients. Regurgitation severity was stable across time with the Carpentier-Edwards ring (P =.7), increased slowly with the Cosgrove-Edwards band (P =.05), and rose more rapidly with the De Vega (P =.002) and Peri-Guard (P =.0009) procedures. Risk factors for worsening regurgitation included higher preoperative regurgitation grade, poor left ventricular function, permanent pacemaker, and repair type other than ring annuloplasty. Right ventricular systolic pressure, ring size, preoperative New York Heart Association functional class, and concomitant surgery were not risk factors. Tricuspid reoperation was rare (3% at 8 years), and hospital mortality after reoperation was 37%. CONCLUSIONS: Tricuspid valve annuloplasty did not consistently eliminate functional regurgitation, and across time regurgitation increased importantly after Peri-Guard and De Vega annuloplasties. Therefore, these repair techniques should be abandoned, and transtricuspid pacing leads should be replaced with epicardial leads.

Aged↗
PubMed2004

The Coapsys device to treat functional mitral regurgitation: in vivo long-term canine study.

OBJECTIVE: We evaluated the capability of the Myocor Coapsys device (Myocor, Inc, Maple Grove, Minn) to reduce functional mitral regurgitation in a canine model of dilated cardiomyopathy. METHODS: Functional mitral regurgitation with heart failure was induced in 7 dogs by rapid ventricular pacing. The Coapsys device, which consists of anterior and posterior epicardial pads connected by a subvalvular chord, was then implanted. Heart failure was maintained by continued pacing for 8 weeks. Hemodynamic and echocardiographic measurements were performed at pre- and postsizing and after 8 weeks. The Coapsys subvalvular chord was cut to verify that maintenance of valve competency was due to the device. RESULTS: All implants were performed off-pump without atriotomy. Mitral regurgitation was reduced in all animals; mean mitral regurgitation grade was reduced from 2.9 +/- 0.7 to 0.7 +/- 0.8 (P =.00005) and was maintained at 0.8 +/- 0.8 after 8 weeks, without hemodynamic compromise or structural damage to the mitral valve. Mitral regurgitation returned to 3.6 +/- 0.8 (P =.102 versus presizing) after cutting the Coapsys subvalvular chord. CONCLUSION: The Coapsys device consistently and chronically reduced functional mitral regurgitation. This device is in clinical trials in the United States.

Animals↗