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PubMed1995

The effect of enalapril on mortal and morbid events in patients with hypertension and left ventricular dysfunction.

The objective of this study was to examine the effect of enalapril on morbid and mortal events in patients with left ventricular dysfunction and hypertension using a retrospective analysis of patients with systolic left ventricular dysfunction (ejection fraction < or = 0.35) who participated in the Studies of Left Ventricular Dysfunction (SOLVD). Among the 6797 patients who were randomized to enalapril or placebo, 2652 had history of hypertension, 1508 had systolic blood pressure (SBP) > or = 140 mm Hg, and 985 had diastolic blood pressure (DBP) > or = 90 mm Hg. During average follow-up of 40 months, the rate of hospitalization for congestive heart failure was lower in the enalapril group than the placebo group among patients with history of hypertension (20.6% v 28.3%, P < .001, relative risk [RR] 0.664), and among those with elevated DBP (16.5% v 26.0%, P < .001, RR = 0.574), or SBP (19.5% v 27.7%, P < .001, RR = 0.647) at baseline. These risk ratios were similar to those observed in patients without history of hypertension (RR = 0.647). Also, the decreased rates of mortality, myocardial infarction, stroke, and unstable angina observed in SOLVD were seen, with similar relative risks, in patients with (RR = 0.927, 0.836, 0.979, 0.900, respectively) and without (RR = 0.866, 0.729, 0.775 and 0.743) history of hypertension as well in those with elevated SBP (RR = 0.841, 0.806, 0.707, 0.867) or DBP (RR = 0.791, 0.889, 0.755, 0.872) at baseline.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗

PubMed2004

Impact of diabetes on mortality in patients with myocardial infarction and left ventricular dysfunction.

BACKGROUND: Diabetes is a major risk factor for developing coronary heart disease. In patients with diabetes who survived myocardial infarction (MI), less is known about subsequent morbidity and mortality. We evaluated the effects of diabetes in post-MI patients with left ventricular dysfunction on cardiovascular events and death. METHODS: The Survival and Ventricular Enlargement, a randomized, double-blind, placebo-controlled multicenter trial, evaluated the efficacy of captopril vs placebo in 2231 patients following acute MI with left ventricular dysfunction defined as an ejection fraction less than or equal to 40%. Patients were randomly assigned to captopril or placebo 3 to 16 days following MI and were followed up for 2 to 5 years (mean, 3.5 years). RESULTS: Among the 2231, 496 (22.2%) were patients with a history of diabetes, of which 168 (33.9%) were treated with insulin. Patients with diabetes were significantly older; more likely to be women; have a history of prior MI or hypertension; be obese or manifest Killip class II or greater; and have higher systolic blood pressure, pulse pressure, and heart rate, as well as lower ejection fraction. During follow-up, 31.3% of patients with diabetes and 20.1% of nondiabetic patients died (P<.001). Furthermore, 50% of the patients with diabetes had at least 1 major cardiovascular event compared with 32.3% among the nondiabetic patients (P<.001). In multivariate analysis that adjusted for all significant differences in baseline characteristics, patients with diabetes had a 39% higher total mortality (P = .001) and 49% more cardiovascular events (P = .001). Among the patients with diabetes, baseline insulin treatment was associated with a greater risk of death (41.1% vs 26.2%; P = .001) and cardiovascular events (58.3% vs 45.7%; P = .008). CONCLUSIONS: In patients who survived MI with left ventricular dysfunction, diabetes increased risk of death from all causes even after controlling for differences in other risk factors. Patients with diabetes treated with insulin have a particularly higher mortality risk. Patients with diabetes who survived MI with left ventricular dysfunction, in particular those receiving insulin, are at high risk of subsequent mortality and cardiovascular events and thus require intensive risk factor modification, as well as evaluation for novel therapies.

Aged↗

PubMedDate not supplied

Management of asymptomatic chronic aortic regurgitation with left ventricular dysfunction: a decision analysis.

STUDY OBJECTIVE: To determine the optimal strategy for the timing of aortic valve replacement in patients with chronic, severe aortic regurgitation with left ventricular dysfunction. DESIGN: Decision analysis comparing early surgery (timed at the onset of left ventricular dysfunction) with delayed surgery (timed at the onset of symptoms) using data from the literature and expert opinion for variables in a representative case scenario (40-year-old man with bicuspid aortic valve disease). SETTING: Tertiary care center doing valve replacement surgery. MEASUREMENTS AND MAIN RESULTS: The early-surgery approach was preferred based on quality-adjusted life years. Sensitivity analysis showed that the result was not affected by the following variables within their derived ranges: rate of symptom development after onset of left ventricular dysfunction for the delayed-surgery approach, perioperative mortality for both approaches, and occurrence of major nonfatal stroke or congestive heart failure for both approaches. Although the decision was sensitive to the yearly postoperative mortality rates, the delayed-surgery operative mortality rate had to be almost as low as the early-surgery rate to change the preference to the delayed-surgery approach. The preference could also change if survival were much more important to the patient in the first five years than after five years or if the patient disliked living on anticoagulants enough to value a year on anticoagulants as worth only 80% of a year not on anticoagulants. CONCLUSION: This decision analysis provides quantitative support for the impression that patients similar to the case scenario do better with surgery timed at the onset of ventricular dysfunction than with surgery delayed until symptoms develop. It thus supports the practice of following these patients noninvasively in order to time surgery.

Adult↗

PubMed2002

Tako-tsubo-like left ventricular dysfunction with ST-segment elevation: a novel cardiac syndrome mimicking acute myocardial infarction.

BACKGROUND: Peculiar asynergy, which consists of hypokinesis or akinesis from the mid portion to the apical area and hyperkinesis of the basal area on contrast left ventriculogram, is rare. Because the end-systolic left ventriculogram looks like a "tako-tsubo," which was used for trapping octopuses in Japan, we proposed the term "tako-tsubo-like left ventricular dysfunction." Our aim was to evaluate its clinical features and causes. METHODS: We studied 30 patients with tako-tsubo-like left ventricular dysfunction without significant coronary artery disease. We assessed its pathophysiologic mechanisms by coronary spasm provocation test, endomyocardial biopsy, measurement of virus titer, and measurement of circulating catecholamine levels. RESULTS: Patient age ranged from 55 to 83 years. Twenty-eight were women and 2 were men. Tako-tsubo-like left ventricular dysfunction was dramatically resolved on predischarge left ventriculogram at 11.3 +/- 4.3 days. Acute coronary angiography revealed spontaneous multivessel coronary spasm in 3 patients. Among 14 patients, ergonovine or acetylcholine induced epicardial single coronary spasm in 4 patients and multivessel coronary spasm in 6 patients. Spontaneous microvascular spasm occurred at predischarge in 1 patient. An endomyocardial biopsy specimen in 3 patients and measurement of virus titer in 7 patients did not show evidence of acute myocarditis. Circulating norepinephrine was normal or slightly elevated in 6 patients. CONCLUSIONS: We showed clinical features of a novel cardiac syndrome with tako-tsubo-like left ventricular dysfunction. Although the precise cause remains unclear, simultaneous multivessel coronary spasm at the epicardial artery or microvascular levels may contribute to the onset of tako-tsubo-like left ventricular dysfunction.

Acetylcholine↗

PubMed1993

Therapy of left ventricular dysfunction: implications of recent therapeutic trials and future directions for therapy.

The natural history of patients with heart failure has changed relatively little until recently. Several large randomized trials have however recently changed our approach to the patient with symptomatic as well as asymptomatic left ventricular dysfunction. Although the effect of digoxin on survival is still uncertain there is still good evidence from the Radiance study in which patients were randomly withdrawn from digoxin that patients who remain on digoxin have a significant improvement in exercise tolerance and well being. The Consensus trial in patients with class IV heart failure suggested that ACE inhibitors were effective in improving survival. This therapy has not however been widely adapted in patients with mild to moderate heart failure. The recent randomized SOLVD treatment trial in conjunction with the VHEFT II study clearly shows that ACE inhibitors should be the basis for therapy along with a diuretic and digoxin if necessary in all patients with symptomatic left ventricular dysfunction unless contraindicated or not tolerated. There is also evidence from the SOLVD prevention trial that ACE inhibitors can prevent the development of manifest heart failure and hospitalization for heart failure in patients with asymptomatic left ventricular dysfunction. The importance of ACE inhibitors in patients with asymptomatic left ventricular dysfunction is confirmed by data from the SAVE trial which examine both symptomatic and asymptomatic patients with left ventricular dysfunction 3-16 days post infarction. Of interest in both the SOLVD treatment and prevention trials as well as the SAVE trial was the finding that ACE inhibitors reduced the incidence of recurrent ischemic events.(ABSTRACT TRUNCATED AT 250 WORDS)

Adrenergic beta-Agonists↗

PubMed2006

Troponin T measurement can predict persistent left ventricular dysfunction in peripartum cardiomyopathy.

OBJECTIVE: To determine whether measurement of cardiac troponin T (cTnT) concentration in newly diagnosed peripartum cardiomyopathy (PPCM) can be used to predict persistent left ventricular dysfunction after a 6-month follow-up. PATIENTS AND METHODS: This was a prospective, multiple-centre clinical trial that studied 106 patients with newly diagnosed PPCM surviving over 6 months. cTnT concentration was measured within 2 weeks of the onset of PPCM. RESULTS: Serum cTnT concentration was negatively correlated with left ventricular ejection fraction (LVEF) at follow-up (LVEF, r = -0.518, p = 0.0001). Analysis by receiver operator characteristic curve yielded an area under the curve of 0.764 (95% CI 0.669 to 0.860, p = 0.0001, vs null hypothesis value 0.5) for cTnT, and a cTnT concentration cut off of >0.04 ng/ml, predicting persistent left ventricular dysfunction with a sensitivity of 54.9% and a specificity of 90.9%. Among 106 recruited patients, there were 33 patients with cTnT concentrations >0.04 ng/ml and 73 patients with cTnT concentrations < or =0.04 ng/ml. After a 6-month follow-up, there was significantly smaller LVEF (35.42% (13.04% vs 50.16% (10.48%, p = 0.0001) and more persistent left ventricular dysfunction (84.8% vs 31.5%, OR = 12.17 (95% CI 4.17 to 35.57), p = 0.001) in patients with cTnT >0.04 ng/ml than in patients with cTnT < or =0.04 ng/ml. CONCLUSION: Serum cTnT concentration measured within 2 weeks of the onset of PPCM was correlated negatively with LVEF at follow-up. This marker offers a simple, quick, inexpensive, non-invasive method for predicting a persistent LVEF of < or =50%. A cTnT concentration of >0.04 ng/ml predicted persistent left ventricular dysfunction with a sensitivity of 54.9% and a specificity of 90.9%.

Adult↗

PubMed1996

Transplant candidates with severe left ventricular dysfunction managed with medical treatment: characteristics and survival.

OBJECTIVES: This study sought to assess the clinical characteristics and survival of patients with symptomatic heart failure who were referred as potential heart transplant candidates, but were selected for medical management. BACKGROUND: Patients with severe left ventricular dysfunction referred for heart transplantation may be considered too well to be placed immediately on an active waiting transplant list. The clinical characteristics of this patient group and their survival have not been well defined. These patients represent a unique group that are characterized by comparatively low age and freedom from significant comorbid conditions. METHODS: We studied 116 consecutive patients with symptomatic heart failure, severe left ventricular dysfunction (left ventricular ejection fraction 20 +/- 7% [mean +/- SD]) and duration of symptoms >1 month referred for heart transplantation, who were acceptable candidates for the procedure but who were not listed for transplantation because of relative clinical stability. These patients were followed up closely on optimal medical therapy. A variety of baseline clinical, hemodynamic and exercise variables were assessed to define this patient group and used to predict cardiac death and requirement later for heart transplantation. RESULTS: During a mean follow-up period of 25.0 +/- 14.8 months (follow-up 99% complete), there were eight cardiac deaths (7%) (seven sudden, one acute myocardial infarction). Only nine patients (8%) were listed for heart transplantation. Actuarial 1- and 4-year cardiac survival rates were 98 +/- 1% and 84 +/- 7% (mean +/- SE), respectively, and freedom from listing for transplantation was 95 +/- 2% and 84 +/- 7% (mean +/- SE), respectively. Patients were mainly in New York Heart Association functional class II or III and had a preserved cardiac index (2.4 liters/min.m2), pulmonary capillary wedge pressure of 16 +/- 9 mm Hg (mean +/- SD) and maximal oxygen consumption of 17.4 +/- 4.3 ml/min per kg (mean +/- SD). By logistic regression analysis, there was no predictor for cardiac death. Longer duration of heart failure (p = 0.013) and mean pulmonary artery (p < 0.05) and pulmonary systolic (p = 0.014) and diastolic (p < 0.05) pressures correlated significantly with listing for heart transplantation by univariate logistic regression. By multivariate logistic regression, only pulmonary artery systolic pressure (p < 0.004) and duration of heart failure (p < 0.015) remained as predictors for need for later transplantation. CONCLUSIONS: In the current treatment era, prognosis is favorable in a definable group of transplant candidates despite severe left ventricular dysfunction. This patient group can be identified after intensive medical therapy by stable symptoms, a relatively high maximal oxygen uptake at peak exercise and a preserved cardiac output.

Adult↗

PubMed1981

Aortic regurgitation. Detection of left ventricular dysfunction by exercise echocardiography.

Left ventricular performance was assessed in 20 symptom free patients and 10 with symptoms, all with isolated aortic regurgitation, by measuring the echocardiographic peak velocity of circumferential fibre shortening (echo peak Vcf) at rest and during graded bicycle ergometer exercise in the supine position. The normal left ventricular response during such exercise was first determined in 20 healthy controls. On the basis of their resting and exercise echo peak Vcf, the 30 patients with aortic regurgitation could be separated into three groups: Group 1 comprised 11 symptom free patients with a normal resting echo peak Vcf which increased normally with exercise; group 2 comprised nine symptom free patients with a normal resting echo peak Vcf but with a subnormal response to exercise; group 3 consisted of 10 patients with symptoms with a depressed resting echo peak Vcf which remained subnormal with exercise. Subsequent cardiac catheterisation disclosed normal ejection fractions in patients in group 1, borderline ejection fractions in those in group 2, and reduced ejection fractions in those in group 3. Echocardiographic assessment of left ventricular performance during supine isotonic exercise may provide a simple noninvasive method for the early detection of left ventricular dysfunction in symptom free patients with aortic regurgitation.

Adolescent↗

PubMed2006

Surgical management of right ventricular dysfunction late after repair of tetralogy of fallot: right ventricular remodeling surgery.

With the increasing number of late survivors of repair of tetralogy of Fallot, surgical management of patients with right ventricular (RV) dysfunction and limited exercise capacity has become a more frequent problem. The wide variability in clinical status, extent of RV dilatation, and dysfunction at the time of presentation for surgical intervention has resulted in disparate surgical results after pulmonary valve insertion. With increasing use of magnetic resonance imaging, quantitative measures of RV volumes, function, and pulmonary regurgitant fraction have enabled a more systematic analysis of results. While there is a group of patients that responds favorably to pulmonary valve insertion, there is also a large subgroup that does not; this requires further analysis of the mechanisms responsible. We have developed a surgical approach to this latter group of patients, which incorporates the concepts of ventricular remodeling or restoration developed for the left ventricle following myocardial infarction. Preliminary results indicate that this procedure is equally safe to pulmonary valve insertion alone, and may result in improved RV function.

Adolescent↗

PubMed2002

Normal fluctuations in pulmonary artery pressures and cardiac output in patients with severe left ventricular dysfunction.

BACKGROUND: One barrier to accurate interpretation of changes in hemodynamic pressures and cardiac output is lack of data about what constitutes a normal fluctuation. Few investigators have examined normal fluctuations in these parameters and none have done so in patients with left ventricular dysfunction. AIMS: To describe normal fluctuations in pulmonary artery pressures and cardiac output in patients with left ventricular dysfunction. METHODS: Hemodynamically stable advanced heart failure patients (N=39; 55+/-6 years old; 62% male) with left ventricular dysfunction (mean ejection fraction 22+/-5%) were studied. Cardiac output and pulmonary artery pressures were measured every 15 min for 2 h. RESULTS: Mean+/-standard deviation fluctuations were as follows: pulmonary artery systolic pressure=7+/-4 mmHg; pulmonary artery diastolic pressure=6+/-3 mmHg; pulmonary capillary wedge pressure=5+/-3 mmHg; cardiac output=0.7+/-0.3 l/min. The coefficient of variation for fluctuations in pulmonary artery systolic pressure was 6.7%, in pulmonary artery diastolic pressure was 9.3%, in pulmonary capillary wedge pressure was 9.2%, and in cardiac output was 7.2%. CONCLUSIONS: Values that vary <8% for pulmonary artery systolic pressure, <11% for pulmonary artery diastolic pressure, <12% for pulmonary capillary wedge pressure, and <9% for cardiac output from baseline represent normal fluctuations in these parameters in patients with left ventricular dysfunction.

Blood Pressure↗

PubMed1994

[What is the appropriate treatment for myocardial infarction with left ventricular dysfunction?].

The essential goal of medical treatment following myocardial infarction with left ventricular dysfunction must be the prevention of secondary cardiac failure. The existence of left ventricular dysfunction, in particular when it is not accompanied by clinical cardiac failure, is a virtually formal indication for beta-blocker treatment after an infarction. Beta-blockers with intrinsic sympathomimetic activity (ISA) are possibly better tolerated in this context. However, experience shows that cardiologists and general practitioners often remain reluctant to prescribe beta-blockers whenever left ventricular function is impaired. Converting enzyme inhibitors decrease the risk of onset of secondary cardiac failure, reduce sudden deaths by ventricular arrhythmias, reduce recurrences of myocardial infarction or unstable coronary insufficiency, and more generally reduce overall and cardiovascular mortality. This is a class effect. While there is no urgency to prescribe them during the acute phase, it is generally considered that it is extremely useful to give them fairly quickly, i.e. during the first 72 hours. At the end of the hospital phase, around two weeks, it is desirable, whenever possible, to prescribe a dose of the order of 75 mg/day of captopril or 2.5 mg/day of ramipril. The administration of aspirin can be considered virtually routine. Oral anticoagulants are desirable in the presence of a large akinetic pocket, a frequent starting point of thrombosis and/or systemic emboli, or in the presence of atrial fibrillation. Digitalis/diuretic treatment does not appear to be indicated at this stage. Other types of anti-ischemic treatment are not theoretically indicated as a matter of principle at this stage in the absence of residual ischemia.(ABSTRACT TRUNCATED AT 250 WORDS)

Adrenergic beta-Antagonists↗

PubMed2000

Angiotensin-converting enzyme inhibitor therapy for ventricular dysfunction in infants, children and adolescents: a review.

Angiotensin-converting enzyme (ACE) inhibitors have become an important part of the pharmacologic armamentarium in the battle against treatment of ventricular dysfunction. There have been a number of large controlled, randomized trials in adults with both asymptomatic and symptomatic ventricular dysfunction, which confirm the safety and efficacy of this category of drugs for the treatment of this potentially lethal condition. ACE inhibitors may be used to treat infants, children and adolescents with asymptomatic and symptomatic ventricular dysfunction as well. The data supporting their use in children is less complete than that concerning the treatment of adults. We review here the various causes of ventricular dysfunction and congestive heart failure (CHF) in infants, children, and adolescents; the data available regarding treatment of these conditions with ACE inhibitors, and the safety and efficacy of these drugs for the various conditions. The pharmacokinetics and proposed mechanisms of action of ACE inhibitors in children are reviewed, as are speculated long-term results of ACE inhibitor use in cohorts of growing children. Recommendations are made for future studies.

Journal Article↗

PubMed1998

The cost and cardioprotective effects of enalapril in hypertensive patients with left ventricular dysfunction.

This study examined the effect of enalapril on survival, resource use, and cost of care in patients with left ventricular dysfunction and hypertension using a retrospective analysis of patients who participated in the Studies of Left Ventricular Dysfunction (SOLVD). Among the 6797 SOLVD participants, 1917 patients had either elevated systolic (> or = 140 mm Hg) or diastolic (> or = 90 mm Hg) blood pressure. Therapy with enalapril was associated with a significant relative risk reduction for mortality (RR = 0.819, 95% CI: 0.68 to 0.98; P = .03). This resulted in a gain of 0.11 years (95% CI: 0.00 to 0.20 years) of survival during the average 2.8 year follow-up for this subgroup and was projected to result in a gain of 2.14 years (95% CI: 0.05 to 4.21 years) during the patient's lifetime. Enalapril significantly reduced the risk of first hospitalization for heart failure by 37%. For all types of hospitalizations, there was an average reduction of 32 hospitalizations per 100 patients treated with enalapril during the trial period (95% CI: 11.8 to 52.2 hospitalizations avoided per 100 patients), resulting in an estimated net savings of $1656 per patient during the trial period (95% CI: increased cost of $191 to savings of $3502). Although the projected lifetime net savings of $1456 was not significant (95% CI: increased cost of $9243 to saving of $12,527), evaluation of the cost per life year saved indicated that enalapril represented a cost-effective strategy. The estimated clinical benefit of enalapril among the hypertensive subgroup in SOLVD supports the recommendation that angiotensin converting enzyme (ACE) inhibitors should be considered as first line pharmacologic therapy for hypertensive patients with left ventricular dysfunction. From both the clinical and economic viewpoints, ACE inhibitors provide important clinical benefits and are cost-effective.

Angiotensin-Converting Enzyme Inhibitors↗

PubMed1992

Studies of Left Ventricular Dysfunction (SOLVD) Registry: rationale, design, methods and description of baseline characteristics.

The Studies of Left Ventricular Dysfunction (SOLVD) comprises 2 double-blind, randomized clinical trials to test improved survival by angiotensin-converting enzyme inhibitor in patients with left ventricular dysfunction, with or without congestive heart failure. Patients entering the trials may be a highly selected subset of the population of such patients; those with the worst and best prognosis are likely to be excluded. To obtain the clinical history of a broader group, a registry of 6,273 patients included a relatively unselected cohort of patients with heart failure or left ventricular dysfunction, or both, from SOLVD hospitals. Registry data were obtained from hospital records. Because data collection from medical records may lead to incomplete data and more investigations in "sicker" patients, 898 randomly chosen subjects from different disease strata were seen in clinic where neurohumoral measures, echocardiograms, x-rays and electrocardiograms were obtained, and a 6-minute walking test was performed. The design and methodologic features, and the baseline characteristics of the participants in this 2-tiered registry are described, and its use in complementing the results and interpretation of the SOLVD trials is discussed.

Adult↗

PubMed1999

[Arterial hypertension and systolic left ventricular dysfunction: therapeutic approach].

Arterial hypertension is a cardinal precursor of congestive heart failure, and diastolic dysfunction is the most frequent mechanism for it. Systolic left ventricular dysfunction, although less frequent, has a worse prognosis. Most cases of systolic dysfunction in patients with hypertension is due to acute myocardial infarction, although other mechanisms can be involved. In some studies, non-ischemic hypertensive systolic dysfunction is the etiology of chronic heart failure in up to 10% of patients with dilated cardiomyopathy. Diastolic dysfunction and left ventricular hypertrophy are also associated with a higher risk of heart failure and systolic dysfunction. Given the poor prognosis of patients with congestive heart failure and dilated cardiomyopathy, it is fundamental to try to prevent the development of left ventricular dysfunction by means of a correct control of blood pressure, regression of left ventricular hypertrophy and prevention of coronary artery disease. When systolic dysfunction is established, angiotensin converting enzyme inhibitors are the treatment of choice; diuretics and digoxin can be added in patients with overt congestive heart failure. Recent studies suggest that other drugs, such as carvedilol and losartan, can be beneficial, but current evidence is still scarce.

Amlodipine↗

PubMed2003

Pulmonary autografts in patients with severe left ventricular dysfunction.

BACKGROUND: Performing a Ross operation in patients with severe left ventricular dysfunction is controversial. The objective in this retrospective study was to determine the outcome of 15 patients with aortic valve disease (11 had aortic insufficiency and 4 had aortic insufficiency and aortic stenosis) associated with reduced left ventricular function (ejection fraction < 40%) treated with a pulmonary autograft. METHODS: We identified 15 patients with severe left ventricular dysfunction from 226 consecutive pulmonary autograft procedures done between age 18 and 50 years from 1986 to 2001. Patients had documented preoperative ejection fraction less than 40% and were in New York Heart Association class III or IV. Preoperative ejection fraction ranged from 18% to 37% (mean, 31% +/- 6.5%). Transthoracic echocardiograms obtained preoperatively and at 1-week, 6-month, and 1- and 2-year intervals were reviewed. Records were evaluated for survival, clinical status, left ventricular function, and valve function. RESULTS: There were no operative deaths, late deaths, or reoperations. All patients had follow-up examinations within the past year and are clinically well (67% > 2 years follow-up). Ten of 15 patients (67%) had substantially improved ventricular function (> 20% increase). The average ejection fraction increased from 31% +/- 7% preoperatively to 51% +/- 11% at 2 years, and the increase is significant from 1 week on (p < 0.02). Average left ventricular mass index decreased by 41% at 6 months (n = 10; p = 0.009) and by 44% at 2 years (n = 9; p = 0.02). Mean Z values for left ventricular mass decreased from 7.6 to 3.6 after more than 2 years (p = 0.007). CONCLUSIONS: The Ross operation is an appropriate option in adults age 50 or younger in the presence of decreased left ventricular ejection fraction. Neither operative mortality nor postoperative sequelae were identified in our subset of patients. Excellent survival and ventricular recovery are predicted.

Adult↗

PubMed1995

Right ventricular dysfunction after acute pulmonary embolism: pathophysiologic factors, detection, and therapeutic implications.

Acute PE may lead to right ventricular dilatation and failure. Through ventricular interdependence and decreased left ventricular filling, cardiac output and systemic circulation also may be compromised. The associated decrease in coronary perfusion pressure to the acutely overloaded right ventricle may produce ischemia and worsening right heart failure. This downward cycle of right ventricular failure and ischemia may ultimately progress to right ventricular infarction, circulatory arrest, and death. Certain clinical findings, hemodynamic values, and, particularly, echocardiographic signs can identify right ventricular dysfunction after PE. Detection of right ventricular hypokinesis helps to stratify patients' risk, because right ventricular dysfunction confers a worse prognosis than does normal right ventricular function after PE. The concept of "hemodynamic instability" after PE should be expanded to include right ventricular dilatation and wall motion abnormalities, even among normotensive patients. Aggressive intervention with thrombolytic therapy, vasoactive agents, or mechanical embolectomy may improve right ventricular function and clinical outcome.

Electrocardiography↗

PubMed1998

Plasma brain natriuretic peptide as a biochemical marker of high left ventricular end-diastolic pressure in patients with symptomatic left ventricular dysfunction.

BACKGROUND: Plasma atrial natriuretic peptide (ANP), mainly from the atrium, brain natriuretic peptide (BNP), mainly from the ventricle, norepinephrine (NE), and endothelin-1 (ET-1) levels are increased with the severity of congestive heart failure (CHF). Although a close correlation between the left ventricular end-diastolic pressure (LVEDP) and plasma ANP in patients with left ventricular dysfunction has been reported, it is not yet known which cardiac natriuretic peptide is a better predictor of high LVEDP in patients with CHF. METHODS: To investigate the biochemical predictors of the high LVEDP in patients with left ventricular dysfunction, we measured plasma ANP, BNP, NE, and ET-1 levels and the hemodynamic parameters in 72 patients with symptomatic left ventricular dysfunction. Stepwise multivariate regression analyses were also used to determine whether the plasma levels of ANP, BNP, NE, and ET-1 could predict high LVEDP. RESULTS: Although significant positive correlations were found among the plasma levels of ANP, BNP, ET-1, and NE and the LVEDP, only BNP (p = 0.0001) was an independent and significant predictor of high LVEDP in patients with CHF. In all eight patients with severe CHF measured for hemodynamics before and after the treatments, the plasma BNP levels decreased in association with the decrease of LVEDP, whereas other factors increased in some patients despite the decrease of LVEDP. CONCLUSIONS: These findings suggest that plasma BNP is superior to ANP as a predictor of high LVEDP in patients with symptomatic left ventricular dysfunction.

Adult↗