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PubMed1988

Diastolic filling in acute left ventricular dysfunction: role of the pericardium.

Patients with congestive heart failure and elevated left ventricular filling pressures demonstrate an abnormal pattern of diastolic filling that is characterized by a redistribution of diastolic filling to early diastole with reduced reliance on late diastolic filling. The diastolic filling pattern superficially resembles that which is seen with constrictive pericarditis. To examine potential mechanisms for these clinical findings, a model of ischemic left ventricular dysfunction was produced in seven dogs by repeated coronary microsphere embolization, producing a dilated left ventricle with reduced systolic function. Measurements of left ventricular systolic and end-diastolic pressures, rate of rise of left ventricular pressure (dP/dt) and echocardiographic end-diastolic and end-systolic areas were obtained at baseline, during intermediate embolization (moderate left ventricular systolic dysfunction, dilation and mild increases in left ventricular end-diastolic pressure), postembolization (further embolization resulting in severe left ventricular systolic dysfunction, dilation and marked increases in left ventricular end-diastolic pressure), after thoracotomy and after pericardiectomy. The filling fraction at 1/3 and 1/2 of diastole and the time constant of left ventricular pressure decline were also determined. Repetitive coronary microembolization caused progressive left ventricular dilation and decreasing systolic function, which did not change after opening the chest or pericardium. The filling fraction at 1/3 and 1/2 of diastole declined with intermediate embolization (12.0 +/- 5.6% and 23.1 +/- 10.8%, respectively) as compared with baseline values (29.0 +/- 11.9%, 42.9 +/- 15.6%, p less than 0.05). After embolization, there was an increase in the 1/3 and the 1/2 filling fraction (47.5 +/- 8.9%, 72.0 +/- 6.0%, respectively, p less than 0.01) as compared with baseline values.(ABSTRACT TRUNCATED AT 250 WORDS)

Acute Disease↗

PubMed1989

Left ventricular dysfunction in acute myocardial infarction due to isolated left circumflex coronary artery stenosis.

The characteristics of regional and global left ventricular dysfunction due to isolated left circumflex (LC) artery stenosis were determined from the contrast ventriculograms of 52 patients studied during acute myocardial infarction. In patients with a left dominant coronary circulation (35%), the severity, circumferential extent and location of hypokinesia resembled those of right coronary artery stenosis. However, in patients with a right dominant or balanced circulation (65%), the location of LC artery-related hypokinesia varied over the entire left ventricular contour, overlapping with the territories of the left anterior descending and right coronary arteries. The method for measuring the severity of hypokinesia was adjusted to take into account the wide territory of the LC artery. This enhanced the sensitivity of the method, particularly in the right anterior oblique view, as indicated by the greater severity of hypokinesia measured (-2.5 +/- 0.9 vs -1.8 +/- 1.1 standard deviations by our previously published method, p less than 0.001). However, the overlap of the artery territories may make it difficult to selectively measure the dysfunction due to stenosis of an artery of interest in patients with multiple infarctions. The circumferential extent of hypokinesia due to LC artery thrombosis was greater in the left than the right anterior oblique view. When averaged over both views, the size of the dysfunctional segment approached that due to left anterior descending coronary artery thrombosis, exceeding the size previously reported. These results suggest that current eligibility criteria for thrombolytic therapy select patients with extensive LC artery beds.

Cineradiography↗

PubMedDate not supplied

Prognostic value of coronary angiography in patients with chronic ischemic left ventricular dysfunction and evidence of viable myocardium on thallium reinjection imaging.

BACKGROUND: We evaluated the independent and incremental prognostic value of cardiac catheterization and coronary angiographic data over thallium reinjection after stress redistribution imaging in patients with myocardial infarction and left ventricular dysfunction. METHODS AND RESULTS: Sixty-nine patients with a first myocardial infarction (> 8 weeks) and left ventricular ejection fraction < or = 40% underwent thallium-201 reinjection after stress redistribution tomographic imaging and cardiac catheterization. During follow-up (mean 26 months) 11 cardiac events (8 cardiac deaths and 3 nonfatal myocardial infarctions) occurred. On Cox regression analysis independent predictors of cardiac events were the sum of reversible and moderately irreversible defects at thallium reinjection (chi 2, 16.4, p < 0.005) and the number of reversible defects at stress redistribution (chi 2, 5.1, p < 0.05). Moreover, thallium reinjection imaging improved the prognostic power of clinical, exercise, and stress redistribution data (p < 0.01). The inclusion of left ventricular ejection fraction produced a borderline improvement (p = 0.06), whereas the number of vessels with coronary disease did not. In contrast, in patients at high risk such as those with at least 25% of viable myocardium at reinjection, the number of diseased vessels provided additional prognostic information (p < 0.05). CONCLUSIONS: In patients with chronic ischemic left ventricular dysfunction, left ventricular ejection fraction, but not the number of diseased vessels, provides additional prognostic information to thallium imaging. Therefore coronary angiography seems unnecessary in these patients, unless a significative amount of viable myocardium is detectable.

Chronic Disease↗

PubMed1994

Late survival up to 20 years after isolated coronary by-pass surgery using internal mammary artery in patients with severe left ventricular dysfunction.

Coronary patients with left ventricular ejection fraction (LVEF) < 40% and abnormal motion of all left ventricular walls on cineangiography but without significant valve disease or left ventricular aneurysm were selected for this study. From January 1970 to December 1990, 155 patients meeting the above criteria consecutively underwent coronary by-pass surgery; preoperatively, 149 patients had angina class III or IV, and 49 patients had dyspnea class II or III. LVEF was 31 +/- 7%. During this 20-year period, two different surgical techniques have been used: from 1970 to 1981, 79 patients (group I) received internal mammary artery upon left anterior descending artery with associated simple saphenous grafts, under intermittent aortic cross clamping; from 1982 to 1990, 76 patients (group II) received internal mammary artery upon left anterior descending artery with associated sequential saphenous vein graft, under oxygenated cardioplegic myocardial protection. The mean number of by-pass was 1.6 in group I and 3.7 in group II (p = 0.001). Early mortality rate was lower in group II than in group I: 2.6% vs 7.6% (p = 0.01). After a follow-up of 79 +/- 14 months, there were 51 late deaths, 6 patients were lost to follow-up and 90 patients were still alive; 80% of all deaths were from cardiac causes, including 38% due to heart failure. Actuarial survival rate at 5, 10, 15 years was 79 +/- 7%, 63 +/- 10%, and 36 +/- 15% respectively. The 5-year survival rate was 71 +/- 10% in group I and 88 +/- 8% in group II (p = 0.02).(ABSTRACT TRUNCATED AT 250 WORDS)

Actuarial Analysis↗

PubMed1988

Surgical survival benefits for coronary disease patients with left ventricular dysfunction.

Controversy still exists about the proper selection of patients with coronary artery disease and left ventricular dysfunction for coronary bypass surgery. To examine this issue, we studied 710 patients with significant coronary artery disease and left ventricular dysfunction (ejection fraction less than or equal to 40%). Of 301 patients treated surgically, 232 had bypass grafts; 17, left ventricular surgery; and 52, both procedures. At 3 years after treatment, unadjusted survival was 84% for surgical patients and 64% for medical patients. At baseline, medical patients had more left ventricular dysfunction than surgical patients, but surgical patients had more coronary artery disease and angina than medical patients. In Cox survival models, two invasive factors (ejection fraction and extent of coronary artery disease) and three noninvasive indexes (assessment of myocardial infarction, angina, and conduction disturbances) were the five best predictors of survival (p less than 0.001). After adjustment for these factors between the two treatment groups, overall surgical survival at 3 years after treatment was 86%, and medical survival was 68%. Long-term surgical survival benefits appeared greatest in patients with the most severe left ventricular dysfunction, most extensive coronary artery disease, and most severe anginal symptoms. We conclude that surgery provides significant survival benefits for coronary disease patients with left ventricular dysfunction; in general, the sicker the patient, the greater the benefit.

Angina Pectoris↗

PubMed1978

Exercise-induced left ventricular dysfunction in symptomatic and asymptomatic patients with aortic regurgitation: assessment with radionuclide cineangiography.

In patients with aortic regurgitation,, left ventricular dysfunction at rest, which is associated with a poor long-term prognosis, often develops before severe symptoms. To determine whether evidence of left ventricular dysfunction could be detected before it appeared at rest, 43 patients with severe aortic regurgitation were studied using radionuclide cineangiography during exercise. In 30 normal subjects, left ventricular ejection fraction increased during exercise (57 +/- 1 percent [mean +/- standard error] at rest, 71 +/- 2 percent during exercise, P less than 0.001). In contrast, among 21 symptomatic patients, ejection fraction was normal at rest in 14 patients (average 47 +/- 2 percent) but normal during exercise in only one patient (average 38 +/- 2 percent, P less than 0.001). Ejection fraction was normal at rest in 21 of 22 asymptomatic patients (average 62 +/- 2 percent) but was normal during exercise in only 13 (average 57 +/- 3 percent, P less than 0.001). Thus, exericse-induced left ventricular dysfunction can precede symptoms and dysfunction at rest. Radionuclide assessment of left ventricular function during exercise may prove valuable in sequentially following the state of left ventricular function in patients before the onset of symptoms or of irreversible left ventricular failure.

Adolescent↗

PubMed1994

Frequency of development of acute global left ventricular dysfunction in human immunodeficiency virus infection.

OBJECTIVES: This study evaluated prospectively the frequency, clinical outcome and pathologic findings of acute global left ventricular dysfunction in human immunodeficiency virus (HIV) infection during the various stages of the disease. BACKGROUND: Acute global left ventricular dysfunction in the course of HIV infection is still a poorly defined clinical entity, and little is known about the outcome after the acute onset. METHODS: Between January 1988 and June 1992, 136 HIV-positive (HIV+) patients without clinical, electrocardiographic or echocardiographic evidence of cardiovascular dysfunction on admission were prospectively studied with serial echocardiograms. Patients were assigned to three groups: 1) anti-HIV+ asymptomatic (17 patients, 12.5%); 2) acquired immunodeficiency syndrome (AIDS)-related complex (26 patients, 19.1%); 3) AIDS (93 patients, 68.4%). RESULTS: During a mean follow-up period of 415 +/- 220 days, seven patients, all in the AIDS subgroup, developed clinical and echocardiographic findings of acute global left ventricular dysfunction; of these, six (85%) died of congestive heart failure. Mean survival time from symptom onset was 41 +/- 13 days. Necropsy findings in five patients revealed acute lymphocytic myocarditis in three, cryptococcal myocarditis in one and interstitial edema and fibrosis in one. In only one patient was left ventricular dysfunction reversible with treatment. CONCLUSIONS: Although infrequent, acute global left ventricular dysfunction is not rare in the course of HIV infection. It seems to occur exclusively during the AIDS stage. Acute global left ventricular dysfunction is often fatal but may be reversible and is mainly associated with the pathologic findings of acute myocarditis.

AIDS-Related Complex↗

PubMed1986

Left coronary artery spasm causing severe left ventricular dysfunction without myocardial infarction.

This report describes a patient with persistent, recurrent left anterior descending coronary artery spasm, which causes marked left ventricular dysfunction in a clinical course that is typical of acute myocardial infarction with hyperacute electrocardiographic changes. However, after emergency coronary artery bypass surgery, the patient had complete reversal of left ventricular dysfunction, with no residual evidence of acute myocardial infarction by electrocardiograph or gated blood pool imaging and no CPK enzyme rise. The patient therefore demonstrates that coronary spasm in some instances clearly precedes the sequence of pathophysiologic events leading to acute myocardial infarction. Our report also demonstrates for the first time in man that massive left ventricular dysfunction may occur in this intermediate coronary syndrome, presenting clinically as impending myocardial infarction. With aggressive surgical intervention and emergency bypass surgery, left ventricular function was restored to normal. Despite the semantic problems of categorizing such patients as having impending myocardial infarction, the severe left ventricular dysfunction and alarming course of this patient's illness was resolved by emergency surgery, suggesting that, in some instances, aggressive therapy is warranted.

Journal Article↗

PubMedDate not supplied

Safety and feasibility of dobutamine-atropine stress echocardiography in patients with ischemic left ventricular dysfunction.

The aim of this study was to analyze whether left ventricular dysfunction affects the safety and feasibility of high-dose dobutamine-atropine stress echocardiography. We examined the results of the test in 318 consecutive patients who were referred for high-dose dobutamine-atropine stress echocardiography and also underwent diagnostic cardiac catheterization. Forty-four patients had a left ventricular ejection fraction of 25% or less (mean, 21%; range, 15% to 25%). In the entire group of 318 patients, no serious complications (death, myocardial infarction, or ventricular fibrillation) occurred. The overall feasibility of completing the test was excellent (97%). A trial fibrillation occurred in four patients, nonsustained ventricular tachycardia in 12, and sustained ventricular tachycardia in one. A decrease in systolic blood pressure of greater than 40 mm Hg or a peak systolic pressure of less than 80 mm Hg was present in eight cases. In the group with an ejection fraction of 25% or less, there was a higher rate of significant tachyarrhythmias (14% versus 5%; p = 0.03), whereas the feasibility of the test was slightly lower (89%; p < 0.01), but no difference for hypotension was found. By multivariate analysis, a history of tachyarrhythmias was the only predictor of stress-induced arrhythmias. Advanced left ventricular dysfunction does not represent a contraindication for dobutamine-atropine stress testing.

Adrenergic beta-Agonists↗

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↗

PubMed1996

Myocardial revascularization for severe left ventricular dysfunction. Factors influencing early and late survival.

The results of coronary bypass surgery have been assessed in 102 patients with severe left ventricular dysfunction who had a preoperative left ventricular ejection fraction of < or = 0.35 (mean (s.e.m.) 0.29 (0.01)). Independent risk factors influencing operative mortality were obesity (P = 0.0290) and the need for preoperative intra-aortic balloon counterpulsation (P = 0.0010). Cox regression analysis using as its end-point 'cardiac-related death' demonstrated three variables; the need for preoperative intra-aortic balloon counterpulsation (P < 0.001), advanced age (P = 0.011), and obesity (P = 0.36). In a subset of 43 patients who did not have these risk factors, the 4-year cardiac-related death rate was 95.1 (3.4)%. The operative mortality and long-term survival can be expected to be satisfactory in patients with severe left ventricular dysfunction, provided they have a viable myocardium rather than myocardial fibrosis.

Aged↗

PubMed1997

Lack of left ventricular dysfunction associated with sustained exposure to hyperlipidemia following lung transplantation.

OBJECTIVES: Hyperlipidemia due to standard immunosuppressive agents occurs commonly following solid organ transplantation. A decision to treat hyperlipidemias would be based on the assumption that such disorders lead to accelerated atherogenesis and ultimately to cardiac dysfunction. We therefore sought to examine whether hyperlipidemias following lung transplantation were associated with a decline in left ventricular (LV) function. STUDY DESIGN: We retrospectively reviewed serial echocardiograms, radionucleotide angiograms (RNAs), and serum lipid levels following lung transplantation. Results of cardiac studies were defined as abnormal if a decline in LV grade occurred from the best result at any time postoperatively to the most recent study. PATIENTS: A total of 184 patients with transplants between November 1983 and June 1995 were reviewed. Eighty patients were excluded owing to incomplete data. One patient was excluded because of severe perioperative myocardial dysfunction. RESULTS: Approximately 80% of patients had elevated cholesterol levels and 60% had elevated low-density lipoprotein levels. Triglyceride levels were raised in 34% of patients while only 4% had an abnormal serum high-density lipoprotein level. More than 80% of patients had no evidence of LV abnormalities in either RNA or echocardiographic studies (group 1). One patient had a change in echocardiographic LV function but no change in grade of RNA (group 2). Twenty patients had a decline in grade based on RNA but no change in the echocardiogram (group 3). There were no patients with changes in both RNA and echocardiogram (group 4). All changes in LV function were from grade I to II. The mean period of follow-up exceeded 30 months for patients in groups 1 to 3. Follow-up data at 3, 4, and 5 years were available on 47, 23, and 12 patients, respectively. There were no differences between the proportions of subjects with normal and abnormal serum lipid levels in each group. CONCLUSIONS: In the initial 5 years after lung transplantation, dyslipidemias affect the majority of patients but are not associated with evidence of deteriorating LV function.

Anticholesteremic Agents↗

PubMed2006

Comparison of N-terminal pro-B-type natriuretic peptide levels in critically ill children with sepsis versus acute left ventricular dysfunction.

OBJECTIVE: N-terminal pro-B-type natriuretic peptide has been shown to be a marker for cardiac dysfunction. The peptide level is also elevated in patients with sepsis. The purpose of this study was to assess whether N-terminal pro-B-type natriuretic peptide levels can differentiate pediatric patients with sepsis from patients with acute left ventricular dysfunction. PATIENTS AND METHODS: Pediatric patients admitted to an ICU with sepsis or acute left ventricular dysfunction were evaluated clinically, and the grade of systemic inflammatory-response syndrome was determined. Echocardiography was performed, and their levels of N-terminal pro-B-type natriuretic peptide were measured. The N-terminal pro-B-type natriuretic peptide level was also measured in patients with simple febrile illness. RESULTS: There were 10 patients with sepsis and 10 with acute left ventricular dysfunction. The age of the patients was similar, and systemic inflammatory-response syndrome grading was not different (sepsis: 2.8 +/- 0.4; acute left ventricular dysfunction: 2.6 +/- 0.7). N-terminal pro-B-type natriuretic peptide levels were elevated in patients with sepsis (median: 6064 pg/mL; range: 495-60,417 pg/mL) but were significantly higher in patients with acute left ventricular dysfunction (median: 65,630 pg/mL; range: 15,125-288,000). The area under the receiver operating characteristics curve for the diagnosis of acute left ventricular dysfunction was 0.9. N-terminal pro-B-type natriuretic peptide levels of patients with sepsis and impaired systolic function were not different from those of patients with sepsis and normal systolic function. The N-terminal pro-B-type natriuretic peptide levels of 20 patients with simple febrile illness were significantly lower. CONCLUSIONS: N-terminal pro-B-type natriuretic peptide levels are elevated in pediatric patients with sepsis but are higher in some, but not all, patients with acute left ventricular dysfunction. The overlap between N-terminal pro-B-type natriuretic peptide levels in sepsis and acute left ventricular dysfunction precludes the use of the peptide's level as a sole means to differentiate between these conditions. Excessive elevation in N-terminal pro-B-type natriuretic peptide levels, however, suggests cardiac etiology for acute hemodynamic deterioration in infants and children.

Acute Disease↗

PubMed2004

Alterations in myofilament function contribute to left ventricular dysfunction in pigs early after myocardial infarction.

Myocardial infarction (MI) initiates cardiac remodeling, depresses pump function, and predisposes to heart failure. This study was designed to identify early alterations in Ca2+ handling and myofilament proteins, which may contribute to contractile dysfunction and reduced beta-adrenergic responsiveness in postinfarct remodeled myocardium. Protein composition and contractile function of skinned cardiomyocytes were studied in remote, noninfarcted left ventricular (LV) subendocardium from pigs 3 weeks after MI caused by permanent left circumflex artery (LCx) ligation and in sham-operated pigs. LCx ligation induced a 19% increase in LV weight, a 69% increase in LV end-diastolic area, and a decrease in ejection fraction from 54+/-5% to 35+/-4% (all P<0.05), whereas cardiac responsiveness to exercise-induced increases in circulating noradrenaline levels was blunted. Endogenous protein kinase A (PKA) was significantly reduced in remote myocardium of MI animals, and a negative correlation (R=0.62; P<0.05) was found between cAMP levels and LV weight-to-body weight ratio. Furthermore, SERCA2a expression was 23% lower after MI compared with sham. Maximal isometric force generated by isolated skinned myocytes was significantly lower after MI than in sham (15.4+/-1.5 versus 19.2+/-0.9 kN/m2; P<0.05), which might be attributable to a small degree of troponin I (TnI) degradation observed in remodeled postinfarct myocardium. An increase in Ca2+ sensitivity of force (pCa50) was observed after MI compared with sham (DeltapCa50=0.17), which was abolished by incubating myocytes with exogenous PKA, indicating that the increased Ca2+ sensitivity resulted from reduced TnI phosphorylation. In conclusion, remodeling of noninfarcted pig myocardium is associated with decreased SERCA2a and myofilament function, which may contribute to depressed LV function. The full text of this article is available online at http://circres.ahajournals.org.

Actin Cytoskeleton↗

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↗

PubMed1994

Identification and revascularization of hibernating myocardium in angina-free patients with left ventricular dysfunction.

We examined 17 angina-free patients with left ventricular dysfunction, referred for surgical decision-making, who presented with no or few signs and symptoms of myocardial ischemia according to treadmill stress test. On cardiac catheterization they were affected by severe multi-vessel coronary artery disease; the mean left end-diastolic pressure of this population was 26.3 +/- 5.5 mm Hg (mean +/- SD) and their mean ejection fraction was 27.6 +/- 4.9% (mean +/- SD). They all were investigated for the presence of viable myocardium by the combined assessment of cardiac perfusion and metabolism using single photon emission tomography with [99mTc] labelled hexakis-2-methoxy-isobutyl-isonitrile [99mTc]MIBI/SPET) and positron emission tomography with [18F]-2-fluoro-2-deoxy-D-glucose ([18F]FDG/PET), respectively. Patients were considered for coronary surgery when [18F]FDG was detectable in at least two cardiac segments with wall motion abnormalities and perfusion defects. Nine patients were operated on, six were medically treated and two were scheduled for heart transplantation. We recorded no in-hospital mortality. At a mean follow-up of 28.4 +/- 9.8 (mean +/- SD) months all surgical patients were alive and their NYHA functional classes have improved, except in one case. Among the patients refused for bypass surgery, three are in stable conditions, three have worsened clinical statuses and two died while waiting for heart transplantation. In conclusion, for patients with bypassable coronaries, left ventricular dysfunction and lack of angina, successful coronary revascularization may be predicted by the presence of viable myocardium demonstrated with positron emission tomography.

Adult↗

PubMed2003

Radial artery use is safe in patients with moderate to severe left ventricular dysfunction.

BACKGROUND: Using radial artery grafts in patients with moderate to severe left ventricular dysfunction (LVD; ejection fraction < 35%) has been discouraged for the fear that postoperative vasopressor support may cause graft spasm and lead to ischemic complications. We, therefore, examined the safety of radial grafts in aortocoronary bypass (ACB) patients with LVD. METHODS: Data were collected from 5,455 patients who underwent isolated ACB between January 1995 and September 2001. One thousand eight hundred three patients received a radial artery graft (RadACB), and 3,652 patients did not (NoRadACB). Three hundred seven RadACB, and 819 NoRadACB operations were performed in LVD patients. A matched (age, sex, urgency of operation, diabetes, and renal insufficiency) cohort analysis was performed in LVD patients. Univariate and logistic regression analyses were performed in the entire population and the unmatched RadACB and NoRadACB patient subgroups to examine the effect of radial artery use on postoperative death or myocardial infarction rate. RESULTS: The matched cohort analysis revealed a similar rate of death or myocardial infarction (RadACB, 11 of 242 patients; NoRadACB, 16 of 242 patients; p = 0.32). Left ventricular dysfunction was associated with a higher rate of death or myocardial infarction in both unmatched groups (RadACB, odds ratio, 2.36; 95% confidence interval, 1.38 to 4.58; p = 0.004; NoRadACB, odds ratio, 1.62; 95% confidence interval, 1.18 to 2.24; p < 0.001) and in the entire population (odds ratio, 1.77; 95% confidence interval, 1.32 to 2.35; p = 0.003). An interaction term for patients with LVD and a radial artery graft, which was forced into the logistic regression model for the entire population, was not predictive of death or myocardial infarction (odds ratio, 1.52; 95% confidence interval, 0.75 to 3.10; p = 0.25). CONCLUSIONS: Left ventricular dysfunction carries similar risk for postoperative death or myocardial infarction in RadACB and NoRadACB patients. The presence of LVD in isolation is not a contraindication to the use of radial grafting.

Aged↗

PubMed2000

Usefulness of the ejection fraction response to dobutamine infusion in predicting functional recovery after coronary artery bypass grafting in patients with left ventricular dysfunction.

Quantification of dysfunctional but viable myocardium has high prognostic value for improvement of left ventricular (LV) function after coronary artery bypass grafting (CABG). Dobutamine stress echocardiography (DSE) can assess viable myocardium by segmental wall motion changes during stress. However, analysis of wall motion is subjective with only moderate interinstitutional agreement (70%) and frequently overestimates functional improvement after CABG. In contrast, calculation of ejection fraction (EF) is less subjective and allows a more precise quantification of global contractile reserve. The aim of the study was to compare the prognostic value of EF response and segmental wall motion changes during DSE for the prediction of LV functional recovery after CABG. Forty patients underwent DSE before CABG. EF responses were assessed at rest, low-dose dobutamine, and at peak stress using the biplane disk method. Wall motion was scored using a 16-segment 5-point model. Resting radionuclide ventriculography (RNV-LVEF), performed before and 8 +/- 2 months after CABG, was used as an independent reference. Five patients were excluded because of perioperative infarction or poor echo images. In 11 of 35 patients, RNV-LVEF recovered >5%. Improvement in EF during dobutamine infusion predicted RNV-LVEF recovery after CABG significantly better than segmental wall motion changes (72% vs 53%, p = 0.03). A biphasic EF response (i.e., improvement in > or =10% at low dose and subsequent worsening at peak stress) had the highest predictive value (80%) for late functional recovery. In conclusion, EF response to dobutamine infusion was superior to segmental wall motion changes in predicting RNV-LVEF recovery after CABG.

Coronary Artery Bypass↗