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Biomedical subjects

S Murali

Publications and source records attributed to S Murali.

At least 37 records · Page 2Linked to original sources
PubMed1999

Native heart complications after heterotopic heart transplantation: insight into the potential risk of left ventricular assist device.

BACKGROUND: In heterotopic heart transplantation, the donor heart is connected parallel to the recipient's diseased heart. Recipients continue to have risks, such as arrhythmia, thromboembolism, valvular heart disease, and ischemic heart disease which can develop in the native heart. It may serve as a clinical model to study long-term pathophysiologic processes in the native heart of patients with a left ventricular assist device. METHOD: We analyzed the prevalence of long-term complications related to the native heart in the heterotopic heart transplant and attempted to gain insight into the potential risk to a native heart after receiving a left ventricular assist device. RESULTS: Between December 1984 and December 1994, 16 patients (13 men, 3 women, ranging in age from 37 to 60 years) underwent heterotopic heart transplant at the University of Pittsburgh. The 1- and 5-year survival rate after the transplant was 81% and 44%, respectively. Actuarial freedom from complications related to the native heart after 1 year and 4 years was ventricular arrhythmia: 85%, 75%; ischemic disease: 85%, 64%; valvular disease: 100%, 88%; and thromboembolism: 85%, 58%. Of these complications, thromboembolism was not considered in determining actuarial freedom from complications because thromboembolism should be regarded as a device-related complication rather than as a native-heart-related complication for left ventricular assist device recipients. Consequently, actuarial freedom from all complications excluding thromboembolism was 70% after 1 year and 50% after 4 years. In addition, the hazard function curve remains constant up to 80 months after the operation without significant differences among the yearly ratios. CONCLUSIONS: This analysis suggests that cautious observation of the native heart's long-term performance is necessary for the left ventricular assist device recipient.

Adult↗
PubMed1999

Mechanical circulatory support with the Novacor LVAS: world-wide clinical results.

The Novacor left-ventricular assist system (LVAS) is an implantable, electrically powered device that is presently approved both in Europe and in the United States for temporary use as a bridge to cardiac transplantation in patients with advanced heart failure. The device has undergone significant evolution since its first implantation in 1984. This device provides a safe, and effective "bridge" to transplantation in select candidates. The world-wide experience as well as the experience at the University of Pittsburgh Health System with this device are discussed in this paper. The exciting results provide ample evidence for the potential use of this device as an "alternative" to transplantation, or "alternative" to medical therapy in the near future.

Clinical Trials as Topic↗
PubMed1998

Predicting short-term outcome in severely ill heart failure patients: implications regarding listing for urgent cardiac transplantation and patient selection for temporary ventricular assist device support.

BACKGROUND: The purpose of this study was to determine which patients on a cardiac transplantation list required a ventricular assist device. METHODS AND RESULTS: In a preliminary study, 26 patients with decompensated severe New York Heart Association class IV chronic heart failure were studied. Blood levels for sodium, hemoglobin, cytokines, neurohormones, and hemodynamics were obtained. During short-term follow-up of 40 days, 12 patients had undergone emergent implantation of a ventricular assist device (range 1-27 days, mean 5 days), 4 died (range 14-38 days, mean 26 days), and 5 were alive and receiving only medical therapy while waiting for a transplantation. In addition, five patients had undergone transplantation (range 5-29 days, mean 18 days, excluded from further analysis). Survival curves were constructed by comparing the incidence of death and the implantation of an emergent ventricular assist device in patients with values of a variable above or below the mean value (or median for nonnormally distributed data). There was a significantly greater incidence of death or need for a ventricular assist device in patients with higher levels of tumor necrosis factor-alpha (P = .008), lower levels of serum sodium and hemoglobin (P = .02 and P = .03, respectively), higher heart rates (P = .03), and higher plasma norepinephrine levels (P = .01). The Cox proportional hazards model demonstrated that only serum sodium (P = .03) independently predicted those patients who died or who required emergent left ventricular assist device. CONCLUSION: Numerous variables, particularly serum sodium, need to be considered when evaluating which patients on the transplant list require early assist device implantation or urgent transplantation. These preliminary observations merit confirmation in a larger patient population.

Adult↗
PubMed1998

Isometric muscle strength in alcoholic and nonalcoholic liver-transplantation candidates.

Intensity of isometric muscle contractions was measured in alcoholic subjects with cirrhosis (N = 42), nonalcoholic subjects with cirrhosis (N = 33), and normal controls (N = 31). Muscle strength and endurance were comparable in the alcoholic and nonalcoholic cirrhotic subjects for all variables. Both cirrhotic groups were inferior to normal controls for all variables. The quantity x frequency (Q x F) index reported for the period during peak alcohol consumption correlated with 6 muscle-force variables, accounting for 9-20% of the variance. Alcoholic and nonalcoholic cirrhotic subjects did not differ in Quality of Life Inventory (QOLI) scales. Significant correlations, however, were found for the alcoholic cirrhotic subjects but not for the nonalcoholic cirrhotic subjects between quality-of-life indices and muscle strength and endurance. Muscle weakness is thus differentially associated with quality of life in alcoholic cirrhotic subjects as compared with nonalcoholic subjects with cirrhosis even though level of strength and endurance in the two groups is comparable.

Adult↗
PubMed1998

Clinical relevance of in vitro propagation of activated lymphocytes from endomyocardial biopsy samples of pediatric heart transplant recipients.

In vivo activated T-lymphocytes can be cultured from endomyocardial biopsy samples of human cardiac allografts, sometimes even in the absence of histological rejection. We investigated the clinical relevance of this "lymphocyte growth assay" in pediatric heart transplant recipients. Specifically, we wished to determine if: (i) positive lymphocyte growth from EMB samples in the absence of significant rejection identifies a patient as being at increased risk for the development of acute rejection; (ii) withdrawal or major dose reduction of corticosteroids in the presence of lymphocyte growth results in high risk of rebound rejection; and (iii) presence of lymphocyte growth during acute rejection helps predict the response to treatment. Cultures were performed on 789 consecutive EMB samples from 65 pediatric heart transplant recipients in media containing 30 U/ml of recombinant IL-2. T-lymphocytes were cultured from 16% of EMB samples with low grade rejection (grade 0-1b) and from 34% of EMB samples with grade 2-4 rejection. EMB samples obtained early post-transplant (<180 days) were significantly more likely to yield positive lymphocyte growth compared to biopsies obtained late for any given rejection grade. Lymphocyte growth was comparable between patients managed with cyclosporine or tacrolimus based immunosuppression. For 227 EMB samples without rejection, a subsequent EMB sample was obtained within 12 weeks. Lymphocyte cultures were positive in 47 of these 227 EMB samples (21%), and in 19 out of 47 (40%) cases acute rejection (grade 2-4) was present on the follow-up EMB sample. By contrast, of 180 biopsies without growth, only 29 (16%) showed rejection at the next EMB (p<0.0001). When a follow-up biopsy was performed within 12 weeks of corticosteroid withdrawal, "rebound rejection" was observed in 3 out of 10 (30%) cases where the previous EMB sample yielded positive lymphocyte growth and in 4 out of 38 (11%) cases when it did not (p=0.29). The presence of lymphocyte growth in association with rejection was also predictive of whether rejection would resolve following high dose intravenous corticosteroid therapy (persistent rejection in 33 out of 50 (66%) cases with positive growth, versus 25 out of 80 (31%) cases without growth (p<0.0001)). Thus, positive lymphocyte growth is strongly associated with higher grade of rejection and earlier time from transplantation. Lymphocyte growth in the absence of rejection indicates high risk for rejection within the next 12 weeks. Growth in association with acute rejection indicates high probability of persistence of rejection following treatment with high dose corticosteroids.

Adolescent↗
PubMed1997

Intravenous immune globulin in the therapy of myocarditis and acute cardiomyopathy.

BACKGROUND: Although an autoimmune pathogenesis has been postulated for dilated cardiomyopathy, immunosuppressive therapy has not been shown to be effective in clinical trials. Immune modulatory therapy with immune globulin is an effective therapy for Kawasaki disease in children, and recent data suggest that it improves ventricular function in children with new-onset dilated cardiomyopathies. The role of immune globulin therapy in adults with this disorder has not previously been evaluated. METHODS AND RESULTS: Ten patients were treated with high-dose intravenous immune globulin infusions (2 g/kg). All were hospitalized with NYHA class III to IV heart failure, left ventricular ejection fraction (LVEF) < 0.40, and symptoms for < 6 months at the time of presentation. One patient died before the completion of therapy. The remaining 9 were discharged, and LVEF was reassessed 12 months after therapy. LVEF improved from 0.24 +/- 0.02 (mean +/- SEM) at baseline to 0.41 +/- 0.04 at follow-up (P = .003). All 9 patients improved functionally to NYHA class I to II, and there have been no subsequent hospitalizations for heart failure during the course of follow-up. CONCLUSIONS: In this series of patients with new-onset dilated cardiomyopathy treated with high-dose immune globulin, LVEF improved 17 EF units. The effectiveness of intravenous immune globulin therapy in this disorder should be evaluated in a randomized, multicenter trial.

Acute Disease↗
PubMed1997

Exercise-related ventilatory abnormalities and survival in congestive heart failure.

This retrospective study of 104 New York Heart Association class 1 to 4 heart failure patients undergoing exercise stress testing with gas exchange analysis demonstrated that the ventilatory equivalent for carbon dioxide at anaerobic threshold is useful in determining prognosis in patients with severe congestive heart failure, particularly when used in combination with peak exercise oxygen consumption. A ventilatory equivalent for carbon dioxide >50 and peak oxygen consumption < or =15.0 ml/kg/min defines a very high-risk patient group who should be prioritized for transplantation.

Carbon Dioxide↗
PubMed1997

Circulating interleukin-6 in severe heart failure.

In a group of patients with New York Heart Association class IV heart failure, significant relations between interleukin-6 and tumor necrosis factor-alpha, and between levels of both interleukin-6 and tumor necrosis factor-alpha and plasma levels of norepinephrine were observed. The present study also demonstrates that in patients with heart failure, elevated levels of tumor necrosis factor-alpha and interleukin-6 may be present even without cachexia.

Adult↗
PubMed1997

Effects of long-term infusion of prostacyclin (epoprostenol) on echocardiographic measures of right ventricular structure and function in primary pulmonary hypertension. Primary Pulmonary Hypertension Study Group.

BACKGROUND: Right heart failure is an important cause of morbidity and mortality in primary pulmonary hypertension. In a recent prospective, randomized study of severely symptomatic patients, treatment with prostacyclin (epoprostenol) produced improvements in hemodynamics, quality of life, and survival. This article describes the echocardiographic characteristics of participants in this trial; the relationship of echocardiographic variables to hemodynamic parameters, exercise capacity, and quality of life; and the echocardiographic changes associated with prostacyclin therapy. METHODS AND RESULTS: The 81 patients enrolled in this multicenter trial were randomized to treatment with a long-term infusion of prostacyclin in addition to conventional therapy (n = 41) or conventional therapy alone (n = 40) for 12 weeks. Echocardiograms and assessments of hemodynamics, exercise capacity, and quality of life were performed before and after the treatment phase. On baseline evaluation, patients had marked right ventricular dilatation and dysfunction, abnormal septal curvature, and significant tricuspid regurgitation with a high regurgitant velocity. Pericardial effusions were common. More pronounced abnormalities in right heart structure and function were associated with higher pulmonary arterial and mean right atrial pressures, lower cardiac index, and impaired exercise capacity but had no predictable relationship to quality-of-life indicators. The 12-week infusion of prostacyclin had beneficial effects on right ventricular size, curvature of the interventricular septum, and maximal tricuspid regurgitant jet velocity. CONCLUSIONS: The echocardiographic manifestations of severe primary pulmonary hypertension reflect abnormalities in hemodynamics and exercise capacity. Prostacyclin has beneficial effects on right heart structure and function that may contribute to the clinical improvement and prolonged survival observed with this drug.

Adult↗
PubMed1997

Intermediate-term outcome of variable dose mitomycin C filtering surgery.

PURPOSE: Trabeculectomy with adjunctive mitomycin C is associated with high success rates in studies with follow-up of less than 1 year. This report evaluates the visual and intraocular pressure (IOP) outcome in eyes after trabeculectomy with adjunctive mitomycin C 1 to 3 years after surgery in a predominantly white group (98.1%). METHODS: The records of 157 eyes of 157 consecutive patients, aged 18 or older, who underwent mitomycin C trabeculectomies for uncontrolled glaucoma of various causes were reviewed. All surgeries were performed between April 1991 and June 1993. The concentration of mitomycin C varied from 0.2 to 0.5 mg/ml and was applied for 30 seconds to 5 minutes (only one patient received 0.2 mg/ml). Of the 157 eyes, 110 eyes were at high risk for failure (previous surgeries or inflammatory glaucoma). Thirty-nine eyes had preoperative IOP < or = 21 mmHg. RESULTS: The mean preoperative IOP was 29.4 +/- 10.3 mmHg. This was reduced to 13.0 +/- 7.6 mmHg at 1 year, 11.5 +/- 6.4 mmHg at 2 years, and 13.4 +/- 7.3 mmHg at 3 years. Cumulative survival rate by life-table analysis was 94.2% +/- 1.9% at 1 year, 92.1% +/- 2.4% at 2 years, and 88.7% +/- 4.0% at 3 years, where failure was defined as reoperation for control of IOP. Complications included cataract formation-progression (n = 31), hyphema (n = 26), choroidal detachment (n = 21), hypotony maculopathy (n = 5), and endophthalmitis (n = 2). Vision deteriorated in 29 eyes and improved by 2 or more Snellen visual acuity lines in 29 eyes. CONCLUSION: The IOP reduction after mitomycin C filtering surgery is sustained in the intermediate-term, 1 to 3 years, follow-up period.

Adult↗
PubMed1997

Ventilatory drive during exercise in congestive heart failure.

BACKGROUND: Continuous increases in the ventilatory equivalent for carbon dioxide (the ratio of minute ventilation to carbon dioxide production, an index of ventilatory drive) during exercise in patients with congestive heart failure would suggest that factors other than carbon dioxide excessively stimulate ventilation during exercise, and may be an important factor in exercise-related dyspnea and fatigue in these patients. METHODS AND RESULTS: Eighty-five patients with congestive heart failure and 17 normal control subjects underwent symptom-limited exercise testing with gas-exchange analysis. Patients were divided into four functional classes (A-D, Weber's classification) based on peak exercise oxygen consumption. In all heart failure patient groups and in control subjects the ventilatory equivalent for carbon dioxide decreased (P < .005, class D; P < .0001, all other groups) from rest to anaerobic threshold. Three isolated patients showed a continuous increase in ventilatory drive during exercise (mean peak oxygen consumption 13.7 mL/kg/min). In the lowest functional class (D) the ventilatory equivalent for carbon dioxide was greater than in all other groups at rest, at anaerobic threshold, and at peak exercise (P < .01). CONCLUSIONS: In all heart failure groups and in normal control subjects ventilatory drive, as determined by the ventilatory equivalent for carbon dioxide, decreases during exercise, Continuous increases in ventilatory drive during exercise are infrequently seen, suggesting that factors other than carbon dioxide production do not excessively stimulate ventilation in heart failure patients during exercise.

Adult↗
PubMed1996

Right ventricular performance and contractile reserve in patients with severe heart failure. Assessment by pressure-area relations and association with outcome.

BACKGROUND: Right ventricular (RV) performance appears to be important in patients with severe heart failure. Although clinical assessments of RV function previously have been limited to load-dependent ejection phase indices, a new method has been developed using the relatively load-insensitive concepts of pressure-volume relations with automated echocardiographic measures of RV cross-sectional area as a surrogate for volume. METHODS AND RESULTS: Sixteen patients with New York Heart Association functional class IV heart failure and group mean left ventricular ejection fraction of 20 +/- 5% were studied. RV pressure-area loops were recorded on-line from echocardiographic measures of RV area and high-fidelity pressure during transient inferior, vena caval balloon occlusions. RV contractile reserve was assessed as its functional response to an increase in dobutamine from 5.7 +/- 4.1 to 13.1 +/- 4.7 micrograms/kg per minute. Complete data sets were available in 13 patients. Group mean RV end-systolic elastance (E'es) and maximal elastance (E'max) increased with augmented dobutamine infusion (2.9 +/- 1.5 to 5.5 +/- 3.3 mm Hg/cm2 and 3.3 +/- 1.6 to 6.4 +/- 3.9 mm Hg/cm2, respectively; P < .01 versus baseline), although individual responses were variable. During a 30-day follow-up, 9 patients remained unstable, requiring continuous intravenous inotropic therapy; 6 of these had profound deterioration requiring mechanical circulatory support. The remaining 4 patients had a comparatively good short-term outcome with clinical stability. A 100% increase in RV E'es or E'max was associated with a good short-term outcome (P < .05). CONCLUSIONS: RV performance can be assessed by pressure-area relations in patients with heart failure. RV contractile reserve in response to increases in dobutamine was associated with a good short-term outcome and may be of prognostic value in patients with severe heart failure.

Adult↗
PubMed1996

Comparison of metabolic, ventilatory, and neurohumoral responses during light forearm isometric exercise and isotonic exercise in congestive heart failure.

Maximal treadmill exercise responses were compared with light forearm isometric exercise responses in patients with chronic, stable heart failure (n = 14), and normal sedentary controls (n = 11). Isometric exercise was performed to exhaustion with 25% of maximal voluntary contraction. Gas-exchange analysis was used to determine oxygen consumption (VO2), carbon dioxide production (VCO2), and minute ventilation (VE) during exercise. Significant correlations were observed in normal controls, but not in patients with heart failure, between peak isotonic exercise and peak isometric exercise for VO2 (r = 0.75, p = 0.001) and VCO2 (r = 0.67, p <0.03), and between submaximal isotonic exercise (50% of peak) and peak isometric exercise for VO2 (r = 0.75, p = 0.007), VCO2 (r = 0.67, p = 0.02), and VE (r = 0.71, p = 0.01). At 90 seconds after isometric exercise in both groups, significant correlations (p <0.05) were observed with peak isotonic exercise for VE (r = 0.62 normals, and r = 0.63 heart failure). Plasma norepinephrine increased significantly (p <0.01) after both isotonic and isometric exercise in patients with heart failure, although peak values were greater with isotonic than with isometric exercise (p = 0.01). Plasma atrial natriuretic peptide and renin activity did not change with either isotonic or isometric exercise. In conclusion, maximal isotonic exercise responses are not predictive of peak isometric VO2 or VCO2 in patients with heart failure. However, VE during maximal isotonic exercise predicts postisometric exercise ventilation in both normals and patients with heart failure; this may determine the extent of dyspnea that patients with heart failure experience with isometric activities of daily living.

Adult↗
PubMed1996

A comparison of continuous intravenous epoprostenol (prostacyclin) with conventional therapy for primary pulmonary hypertension.

BACKGROUND: Primary pulmonary hypertension is a progressive disease for which no treatment has been shown in a prospective, randomized trial to improve survival. METHODS: We conducted a 12-week prospective, randomized, multicenter open trial comparing the effects of the continuous intravenous infusion of epoprostenol (formerly called prostacyclin) plus conventional therapy with those of conventional therapy alone in 81 patients with severe primary pulmonary hypertension (New York Heart Association functional class III or IV). RESULTS: Exercise capacity was improved in the 41 patients treated with epoprostenol (median distance walked in six minutes, 362 m at 12 weeks vs. 315 m at base line), but it decreased in the 40 patients treated with conventional therapy alone (204 m at 12 weeks vs. 270 m at base line; P < 0.002 for the comparison of the treatment groups). Indexes of the quality of life were improved only in the epoprostenol group (P < 0.01). Hemodynamics improved at 12 weeks in the epoprostenol-treated patients. The changes in mean pulmonary-artery pressure for the epoprostenol and control groups were -8 percent and +3 percent, respectively (difference in mean change, -6.7 mm Hg; 95 percent confidence interval, -10.7 to -2.6 mm Hg; P < 0.002), and the mean changes in pulmonary vascular resistance for the epoprostenol and control groups were -21 percent and +9 percent, respectively (difference in mean change, -4.9 mm Hg/liter/min; 95 percent confidence interval, -7.6 to -2.3 mm Hg/liter/min; P < 0.001). Eight patients died during the study, all of whom had been randomly assigned to conventional therapy (P = 0.003). Serious complications included four episodes of catheter-related sepsis and one thrombotic event. CONCLUSIONS: As compared with conventional therapy, the continuous intravenous infusion of epoprostenol produced symptomatic and hemodynamic improvement, as well as improved survival in patients with severe primary pulmonary hypertension.

Adult↗
PubMed1996

A prospective trial of tacrolimus (FK 506) in clinical heart transplantation: intermediate-term results.

Between January 1, 1989, and December 31, 1994, we have treated 122 primary heart recipients with FK 506 (group I) and 121 with cyclosporine (group II). Fifty patients in the cyclosporine (CyA) group received no lympholytic induction (CyA alone) and 71 others received lympholytic induction with either rabbit antithymocyte globulin or OKT3 (CyA+LI). The mean follow-up was longer in the FK 506 group than in the CyA groups (3.2 +/- 1.3 vs 2.3 +/- 1.8 years; p< 0.01). Patient survival did not differ on the basis of the type of immunosuppression used. At 3 months after transplantation, the freedom from rejection in the FK 506 group was higher than that of the CyA-alone group (47% vs 22%, p < 0.01) but similar to that of the CyA+LI group (47% vs 53%). The linearized rejection rate (episodes/100 patient-days) of the FK 506 group (0.09 episodes) was lower (p < 0.05) than that of the CyA-alone group (0.26) and the CyA+LI group (0.13). The requirement for pulsed steroids to treat rejection was less in common in the FK 506 group than in either CyA group. Eighteen patients in the CyA group had refractory rejections; all resolved with FK 506 rescue. Two patients in the FK 506 group had refractory rejection that resolved with total lymphoid irradiation (n=1) and methotrexate therapy (n=1). Patients receiving FK 506 had a lower risk of hypertension and required a lower dose of steroids. Although the mean serum creatinine concentration at 1 year was higher in the FK 506 group, this difference disappeared after 2 years. No patients required discontinuation of FK 506 because of its side effects. Our intermediate-term results indicate that FK 506 compares favorably with CyA as a primary immunosuppressant in heart transplantation.

Adult↗
PubMed1996

Transplant candidate's clinical status rather than right ventricular function defines need for univentricular versus biventricular support.

We have studied our experience since 1988 with 31 patients who required a mechanical circulatory bridge to transplantation and also had biventricular failure (mean right ventricular ejection fraction 11.8%) to better define the need for biventricular or total artificial heart support versus univentricular support. Clinical factors including preoperative inotropic need, fever without detectable infection, diffuse radiographic pulmonary edema, postoperative blood transfusion, and right ventricular wall thickness were compared with hemodynamic parameters including cardiac index, right ventricular ejection fraction, central venous pressure, mean pulmonary arterial pressure, and total pulmonary resistance for ability to predict need for mechanical or high-dose inotropic support for the right ventricle. Patients were grouped according to need for right ventricular support after left ventricular-assist device implantation: none (group A, 14) inotropic drugs (group B1, 7), and right ventricle mechanical support (group B2, 10). There were no differences in preimplantation hemodynamic variables. Groups B1 and B2 had significantly lower mixed venous oxygen saturation (39.2% vs 52.5% in group A; p < 0.001), greater level of inotropic need (p < 0.02), greater impairment of mental status, and lower ratio of right ventricular ejection fraction to inotropic need (0.37 vs 0.56 for group A; p < 0.02) before left ventricular-assist device implantation. A significant discriminator between groups B1 and B2 was the presence of a fever without infection within 10 days of left ventricular-assist device implantation (43% in group B1 vs 70% in group B2). Group B2 had more patients with preimplantation pulmonary edema seen on chest radiography and a greater requirement for postoperative blood transfusion (5 units of cells in group B1 vs 14.8 units in group B2. Right ventricular wall thickness at left ventricular-assist device explantation was 0.83 cm in group B2 vs 0.44 cm in group B1 (p < 0.05). Transplantation rates after bridging were 100% in group A, 71% in group B1, and 40% in group B2. Clinical factors that reflect preimplantation degree of illness and perioperative factors that result in impairment of pulmonary blood flow or reduced perfusion of the right ventricle after left ventricular-assist device implantation are now considered to be more predictive of the need for additional right ventricular support than preimplantation measures of right ventricular function or hemodynamic variables.

Adolescent↗
PubMed1996

Treatment of chronic unstable angina pectoris: use of a totally implantable programmable device for continuous intrathecal infusion of opiates: case report.

We report the case of a 70-year-old man with a 17-year history of angina pectoris, who had previously suffered two documented myocardial infarctions and undergone multiple diagnostic cardiac catheterizations, two coronary artery bypass operations, and several percutaneous transluminal coronary angioplasty procedures. The patient had experienced unstable angina for the past 3 years refractory to maximal medical therapy and was unsuitable for further attempts at revascularization. After a successful trial of epidural infusion of morphine, a totally implantable programmable continuous-infusion device with an intrathecal catheter was implanted in the patient on August 18, 1993, resulting in maintained pain resolution. His gardening, carpentry, and other activities of daily living were limited only by shortness of breath. Six months later, the pump treatment did not mask the development of a myocardial infarction. To the best of our knowledge, this is the first report of the use of continuous intrathecal infusion of morphine or the use of a totally implantable programmable infusion device for angina pectoris. We propose that in carefully selected patients with chronic unstable angina, continuous intrathecal infusion of morphine may relieve effort-induced pain without resulting in myocardial infarction.

Aged↗