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PubMedDate not supplied

Use of pharmaceuticals in noninvasive cardiovascular diagnosis.

A number of pharmaceuticals are employed as diagnostic agents for cardiovascular diseases. Four groups of agents are reviewed here: 1) vasoactive substances employed as adjuncts to physical maneuvers in diagnosis of structural heart disease; 2) vasodilators used to produce heterogeneity of coronary flow; 3) sympathomimetic agents simulating the effects of exercise on the heart for the purpose of detection of coronary artery stenosis; and 4) ultrasonic contrast agents used to enhance myocardial imaging for the assessment of segmental wall motion. In the first group are amyl nitrate, a vasodilator, and methoxamine and phenylephrine, both vasopressors. The vasodilators of the second group are dipyridamole and adenosine. When combined with scintigraphic perfusion imaging or with echocardiographic assessment of segmental wall motion, these agents can detect single- or multiple-vessel coronary artery disease with sensitivity and specificity comparable to submaximal exercise. They are especially useful for preoperative risk assessment before noncardiac surgery. The sympathomimetic agents of the third group, dobutamine and arbutamine, increase myocardial contractility and heart rate, and dilate the peripheral vasculature. As with the vasodilators, when combined with nuclear or echocardiographic techniques they are equivalent to exercise in detection of coronary disease. They are especially useful in patients with bronchospastic disease and for assessment of myocardial viability. Agents from groups 2 and 3 have acceptable side-effect and safety profiles. The last group reviewed includes echocardiographic contrast agents that, in this investigative setting, are employed to enhance detection of segmental wall motion when used with agents from groups 2 and 3.

Cardiovascular Diseases↗
PubMed1984

Timing of operation for chronic aortic regurgitation: influence of left ventricular function on clinical management.

Since symptomatic patients with aortic regurgitation and normal ventricular function (ejection fraction greater than or equal to 50%, fractional shortening greater than or equal to 29%, end-systolic diameter less than or equal to 55 mm) have a significantly higher three year survival postoperatively than patients with impaired left ventricular function (ejection fraction less than 50%, fractional shortening less than 29%, end-systolic diameter greater than 55 mm), the indication for surgery should be established prior to the onset of left ventricular functional impairment. In two-thirds or more of asymptomatic patients with left ventricular dysfunction, symptoms are incurred within two to three years. Additionally, in patients with impaired left ventricular function but with only slight or no symptoms or a normal exercise capacity, respectively, postoperatively there is a higher three year survival rate than in patients with marked symptoms or compromised exercise capacity. In patients in whom preoperative left ventricular dysfunction is present for only a relatively short duration (less than 14 months), the probability of postoperative regression of ventricular dilation and dysfunction is higher than in those whose left ventricular functional impairment is of longer duration (greater than 18 months). Thus, in asymptomatic patients with left ventricular dysfunction, the indication for surgery should be established before the onset of symptoms or compromise of exercise capacity. In asymptomatic patients with normal left ventricular function, symptoms or left ventricular dysfunction develop at a low incidence of 4% per year. Accordingly, with conservative, nonsurgical management, these patients have an excellent prognosis. Patients in whom the onset of symptoms or left ventricular dysfunction can be anticipated to develop, may be identified on the basis of an end-systolic diameter greater than 50 mm, a decrease in left ventricular ejection fraction during exercise, a progressive increase in the end-systolic as well as end-diastolic diameter or a rapid decrease in fractional shortening or ejection fraction seen during follow-up observation. The indication for surgery, however, should be established only at the onset of symptoms or left ventricular dysfunction since in all of these patients, regression of ventricular dilatation and normalization of left ventricular function can be expected postoperatively. The preoperative left ventricular function is a primary determinant of postoperative results even on employment of myocardial protection and a hemodynamically-favorable prosthesis.(ABSTRACT TRUNCATED AT 400 WORDS)

Aortic Valve↗
PubMed1995

Prominent uptake of Tl-201 by duodenal leiomyosarcoma after exercise myocardial perfusion study.

Thallium-201 SPECT performed preoperatively for the evaluation of myocardial ischemia in a 72-year-old man with duodenal leiomyosarcoma demonstrated prominent focal uptake in the abdomen. Comparing a transaxial slice of SPECT through the abdominal uptake to the CT scan, the uptake was confirmed to be corresponding to the tumor. The tumor was delineated clearly, in good contrast to the surrounding normal intestine, which showed far less Tl-201 uptake than the tumor. In the delayed SPECT performed 3 hours after injection, although the intestinal activity became perceptible, the tumor still could be differentiated from the surrounding normal intestine. In this case, the exercise might be attributable to the initial low Tl-201 uptake by the normal intestine, which might otherwise have been an obstacle to Tl-201 scintigraphy for abdominal tumor detection. This case suggests the use of exercise for avoiding unfavorable intestinal activity, and the possibility of Tl-201 SPECT for abdominal tumor imaging.

Aged↗
PubMed1978

Hemodynamic findings before and after surgery for atrial septal defect of the secundum type in middle-aged patients.

84 patients without concomitant pulmonary or cardiac disease, underwent surgery for atrial septal defect of the secundum type (ASD II) at the age of 40 years or more. Hemodynamics were studied preoperatively at rest, and postoperatively at rest and during exercise during a follow-up investigation which took place 74 months (range 22-174) after surgery. Preoperatively, the pulmonary artery mean pressure (PAMP) exceeded 20 mm Hg in 24 patients (30%). In the patients aged 50 years or more PAMP was significantly higher than in the younger patients, whereas the shunt ratio did not show any increase with age. After surgery, the pressures in right atrium, right ventricle and PA showed significant changes towards normalization. During exercise, a considerable increase of the PA pressures appeared, and this increase correlated significantly with the PA pressures obtained preoperatively at rest.

Adult↗
PubMed1981

[The left ventricular function in bicycle ergometric stress before and after aortocoronary bypass surgery].

Biplane left ventricular cineangiograms and pressure measurements were performed in 44 patients with coronary heart disease at rest and during submaximal or symptom-limited supine bicycle exercise before and 7 +/- 3 months after bypass surgery. Revascularization was complete in 12 (group 1) and incomplete in 32 patients (group II). Preoperative left ventricular ejection fraction (EF) was within normal limits at rest and declined during exercise in both groups (group I from 59 to 51%, p less than 0.01; group II from 61 to 48%, p less than 0.001). Postoperative EF at rest was nearly identical to preoperative EF in both groups and remained unchanged during exercise (group I from 65 to 63%; group II from 58 to 56%). Peak systolic pressure to end-systolic volume index ratio (LVSP/ESVI in mm Hg/ml . m-2) also decreased during exercise in both groups peroperatively (group I from 3.7 to 3.2 [n.s.]; group Ii from 3.4 to 2.6, p less than 0.005). Postoperative LVSP/ESVI at rest was again unchanged as compared to preoperative LVSP/ESVI. During exercise, however, it increased in both groups, reaching higher values in group I than in group II (5.1 vs. 3.7, p less than 0.05). Whereas both parameters indicate improvement of global left ventricular function following surgery, LVSP/ESVI also suggests more marked recovery of function in patients with complete revascularization than in those where revascularization is incomplete.

Adult↗
PubMedDate not supplied

Long-term changes in left ventricular mass, chamber size and function after valve replacement in patients with severe aortic stenosis and depressed ejection fraction.

We studied 21 patients undergoing valve replacement for severe aortic stenosis and marked left ventricular dysfunction (mean ejection fraction 27 +/- 7.9%) without significant coronary disease or other valve diseases. At 5-60 months (average 26 +/- 18) after surgery, the patients underwent a clinical history, physical examination and a complete M-mode, two-dimensional and Doppler transthoracic echocardiographic study. Thirteen patients were examined with cardiopulmonary exercise testing. Two patients with a low preoperative transvalvular pressure gradient (<50 mm Hg) died postoperatively. Nineteen patients were tested at follow-up. All patients showed an improvement in functional class, an increase in ejection fraction (EF), a normalization in left ventricular diameters, volumes and stress indices and a reduction in left ventricular mass which correlated with EF increase. Cardiopulmonary exercise testing showed a good exercise capacity. In conclusion, in patients affected by severe aortic stenosis and marked preoperative left ventricular dysfunction valve replacement induces a favorable remodeling of the left ventricle, as shown by a late postoperative examination. The regression of hypertrophy is a positive event which correlates with the improvement in EF.

Aged↗
PubMed1994

[Cardiopulmonary capacity in patients before and after prosthetic valve replacement].

In this study we wanted to investigate if noninvasive cardiopulmonary exercise testing can be securely, accurately applied in patients with acquired cardiac valve disease pre- and postoperatively with any convenience. Furthermore, we looked if the cardiopulmonary exercise capacity (anaerobic threshold, etc.) was improved postoperatively (3 and 6 months) in 15 patients suffering from severe mitral valve disease as compared to the preoperative condition. The symptom-limited cardiopulmonary exercise testing was performed on a bike in a semi-supine position using a ramp program (+20 W/min). The following parameters were continuously monitored, and the breath-by-breath gas exchange values documented: cardiocirculatory parameters (heart rate; blood pressure; surface ECG; exercise capacity in Watts); gas-exchange parameters (O2-uptake VO2; CO2-production VCO2; respiratory anaerobic threshold VO2 AT; gas-exchange ratio VCO2/VO2; O2-pulse VO2/HR; aerobic capacity delta VO2/delta WR) and ventilatory parameters (respiratory rate; tidal volume Vt; minute ventilation VE; equivalent for O2: VE/VO2 and CO2: VE/VCO2). The 155 cardio-pulmonary exercise tests in 115 patients were practicable, safe (no emergency case) and accurate. In 100 patients late postoperatively (68.3 +/- 53.0 -102.9 +/- 41.2 months) after aortic or mitral valve replacement or both without signs of significant hemolysis or prosthetic valve dysfunction the NYHA classification was too imprecise to characterize the actual exercise capacity of the patients (e.g., NYHA class II: Weber class B to E). Patients with aortic valve prosthesis had a significantly better anaerobic threshold (57.4 +/- 19.1% pred. value max. VO2) as compared to those with mitral valve replacement (mean: 35.9% pred. value max. VO2).(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed1984

A summary of preoperative and postoperative cardiorespiratory performance in patients undergoing pectus excavatum and carinatum repair.

Preoperative and postoperative pulmonary function tests and progressive work exercise performances were compared for fourteen pectus excavatum and five pectus carinatum patients who underwent operative repair. No changes could be documented in the pectus carinatum patients. The excavatum patients demonstrated a small improvement in total lung capacity (P less than .02) and a significant improvement in maximal voluntary ventilation (P less than .001). In addition, the exercise performances were improved for the excavatum patients postoperatively as quantitated both by the total exercise time and the maximal oxygen consumption (P less than .01). In addition, at any given work rate, the excavatum patient demonstrated a lower heart rate and higher minute ventilation after operation. These findings support the hypothesis that both the restricted cardiac stroke volume and the increased work of breathing that have been described in pectus excavatum patients can be ameliorated by operative intervention.

Adolescent↗
PubMed1985

Left ventricular function after elective aneurysmectomy.

Employing rest and exercise first-pass radionuclide angiography before and 3 months after surgery, we studied patients with hemodynamically stable left ventricular aneurysm (LVA) undergoing both coronary artery bypass surgery to relieve angina pectoris and elective aneurysmectomy. There were 15 patients, 14 men and 1 woman with a mean age of 54 +/- 7 years. All patients had anterior and/or apical LVA. After surgery the postexercise mean left ventricular ejection fraction (LVEF) for the whole group improved significantly (p less than 0.004) compared with the preoperative value, but the resting LVEF did not change. The duration of exercise improved (p less than 0.01) after surgery, but not the double product. However, based upon the preoperative LVEF response to exercise, two groups were seen: Group A (n = 5) had greater than or equal to 5% increase in their LVEF with exercise versus Group B (n = 10), who had less than 5% increase or a decrease in their LVEF. Postoperatively, Group A decreased their LVEF with exercise and failed to improve exercise capacity or double product. Postoperatively, Group B increased the LVEF by greater than or equal to 5% as well as increasing exercise capacity (p less than 0.01), and double product (p less than 0.03). Group A had lower preoperative LVEF than Group B (p less than 0.01) and larger LVA. Patients with hemodynamically stable LVA who require coronary artery bypass surgery for angina should not have aneurysmectomy. The presence of hemodynamically stable LVA is not a contraindication to deriving benefit from myocardial revascularization.

Adult↗
PubMedDate not supplied

Oversizing of donor hearts: beneficial or detrimental?

To determine the effects of donor/recipient weight mismatch on allograft function and survival after orthotopic heart transplantation, we retrospectively compared the clinical and the hemodynamic characteristics of recipients weighing more than their donor ("undersized") with those of recipients weighing less than their donor ("oversized"). The median follow-up period was 24 months (range, 0 to 67 months). In 88 patients (59%) donor weight was 1% to 46% less than recipient weight (13.5 +/- 8.9 means +/- SD). In 61 patients (41%) donor weight exceeded recipient weight by 0% to 139% (20% +/- 23%). When recipient ideal body weight was used in the analysis, 75 patients (51%) were undersized by 1% to 59% (13% +/- 10%), and 72 patients (49%) were oversized by 0% to 67% (19% +/- 18%). Preoperative transpulmonary gradient, ventricular function, and exercise tolerance were similar in the two groups. The number and severity of episodes of rejection and infection after transplantation were also similar in the two groups 1, 6, and 12 months after transplantation. When recipient ideal weight was used in the analysis, right ventricular (RV) and left ventricular (LV) ejection fractions (EFs) were within normal limits (RVEF greater than 40%; LVEF greater than or equal to 45%) and similar in the two groups. When recipient actual weight was used in the analysis, the LVEF measured at 12 months after heart transplantation was higher in the oversized than in the undersized group (52 +/- 11 vs 46 +/- 10; p less than 0.05). Postoperative hemodynamic values and exercise tolerance were similar in the two groups regardless of whether recipient weight or ideal body weight were used in the analysis. Forty-six recipients died 0 to 46 months (median, 7 months) after orthotopic heart transplantation. In a Cox regression model, recipients with donor weight greater than recipient ideal weight had a significantly greater risk of death within the follow-up period than did recipients with donor weight less than recipient ideal weight (relative risk = 2.19; p less than 0.05). When percent donor weight/recipient ideal weight mismatch was used as a continuous variable, donor heart oversizing was negatively related to survival, independent of preoperative transpulmonary gradient values (p less than 0.05). In contrast to common belief, oversizing of donor hearts does not improve the outcome of orthotopic heart transplant recipients who have reversible preoperative pulmonary hypertension. Acceptance of undersized donor hearts is not detrimental to allograft function and recipient survival. Use of undersized donor hearts may maximize the use of critically scarce donor organs.

Adult↗
PubMedDate not supplied

An estimate of the prevalence of reversible left ventricular dysfunction in patients referred for coronary artery bypass surgery.

BACKGROUND: The prevalence of reversible left ventricular function through revascularization has been difficult to assess because of the referral bias inherent in patients undergoing viability-targeted preoperative testing. METHODS AND RESULTS: Rest and exercise gated equilibrium radionuclide angiography was performed in 86 patients within 6 months before and any time after coronary artery bypass. Clinical characteristics were recorded for each patient before each of the two radionuclide ventriculograms. Global left ventricular ejection fraction (LVEF) was calculated for each patient at rest. A definite change in LVEF was defined as 0.08 or more points and a probable change as 0.04 or more points. Only patients with a resting LVEF of 0.50 or less were eligible for the study. There was no significant group change in LVEF (0.39 +/- 0.08 before surgery vs 0.38 +/- 0.11 after surgery; difference not significant). However, a definite improvement in LVEF was seen in 18 patients (21%) and a probable change in an additional 10 (12%). Consequently, one third of the patients had at least a probable improvement in resting left ventricular function. These prevalences were not related to any change in medical therapy. CONCLUSION: According to a test not specifically designed to evaluate myocardial viability, the prevalence of reversible left ventricular dysfunction is not uncommon, occurring in up to one third of patients referred for coronary revascularization.

Confounding Factors, Epidemiologic↗
PubMed1994

[The simultaneous evaluation of preoperative cardiopulmonary functions of esophageal cancer patients in the analysis of expired gas with exercise testing].

By analyzing expired gas with exercise testing, we examined the relationship between test results and postoperative cardiopulmonary complications. The analysis was evaluated for its accuracy and reliability in comparison with general pulmonary function tests including spirometry, flow volume curves, diffusing capacity and arterial blood gas analysis. Enrolled were 52 of patients admitted between a period from 1991 to 1993 for thoracic esophageal cancer, who underwent a radical operation of right thoracolaparotomy. Patients were divided into two groups according to postoperative cardiopulmonary complications; one with complications (group C, n = 11) and the other without complication (group NC = 41). The two groups were compared in maximum oxygen consumption (VO2 max)/m2, anaerobic threshold (AT)/m2, VC/m2, %VC, FEV1.0/m2, V25/m, V50/V25, %DLCO and PaO2. In the results, there were significant differences between the two groups only in VO2 max/m2 (p < 0.001), AT/m2 (p < 0.001), and V50/V25 (p < 0.05), while there were no significant differences between the two groups in VC/m2, %VC, FEV1.0/m2, FEV1.0%, V25/m, %DLCO or PaO2. The above results suggest that analysis of expired gas with exercise testing is able to measure easily both cardiac and pulmonary reserve forces, which conventional pulmonary function tests are unable to do, and is evaluating surgical indications for esophageal cancer patients and predicting postoperative cardiopulmonary complications.

Adult↗
PubMed1987

Planned simple carotid resection in surgery of paraganglioma fixed to the carotid artery.

Of 25 surgically treated cases (1956-1986) of paraganglioma, eleven underwent simple carotid resection. The collateral cerebral crossflow was promoted preoperatively with the use of compressing exercises of the carotid artery and controlled by rheoencephalography. There was no operative mortality. One died with a malignant lesion, and nine survived 3 months to 21 years without cerebrovascular complications. It appears that this procedure is worthwhile in selected cases.

Acupuncture Therapy↗
PubMed1990

[Early prognosis of work capacity in patients with ischemic heart disease after direct myocardial revascularization].

The study was designed to estimate the clinical status and exercise tolerance in 25 patients in the preoperative and early postoperative periods, as well as at weeks 6-8 of direct myocardial revascularization performed by applying microsurgical techniques. The clinical status improved in all the patients. Their exercise tolerance was increased by 67 and 106% 2-3 and 6-8 weeks after the surgery, respectively. Thus, with uncomplicated coronary artery reconstruction, the patients can perform graded physical exercise in the early postoperative period, which provides evidence for reduction of a patient's stay in hospital.

Adult↗
PubMed1986

Late postoperative ventricular function after blood and crystalloid cardioplegia.

Although blood cardioplegia preserves perioperative ventricular function better than crystalloid cardioplegia, late results are uncertain. Nuclear ventriculograms were used to assess ventricular function in 47 patients undergoing coronary bypass surgery who were randomly assigned to receive blood (23 patients) or crystalloid cardioplegia (24 patients). Data were acquired at rest and during maximal exercise (bicycle ergometer) 1 month before surgery (PRE), 5 months after surgery (POST), and perioperatively at rest 3 to 5 hr after operation (PERI). Perioperatively, blood cardioplegia decreased ischemic injury (less elevation in creatine kinase-MB fraction and aspartate aminotransferase; p less than .05), preserved ventricular performance (lower stroke work index at higher left ventricular end-diastolic volume index after crystalloid than blood cardioplegia; p = .02 by analysis of covariance [ANOCOVA]) and preserved systolic function (higher left ventricular end-systolic volume index [LVESVI] at similar systolic blood pressure after crystalloid than blood cardioplegia; p = .02 by ANOCOVA). Postoperatively, resting ventricular performance and systolic function were not different with blood and crystalloid cardioplegia and were similar to preoperative measurements. Postoperatively, the response to exercise was similar between the two groups and was improved compared with that at PRE. Postoperative systolic function at exercise was similar between the two groups but was better than that at PRE (higher systolic blood pressure at similar LVESVI; p = .01 by ANOCOVA). The type of cardioplegic solution influenced perioperative but not late postoperative function after elective coronary artery bypass surgery.

Blood↗