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PubMed2000

Comparison between blood and crystalloid cardioplegia in patients with left ventricular dysfunction undergoing coronary surgery.

This study was done to compare the protective effect of blood and crystalloid cardioplegia in patients with left ventricular dysfunction undergoing coronary artery bypass grafting (CABG). Sixty consecutive patients with left ventricular ejection fraction < 35% scheduled for CABG with the use of cardiopulmonary bypass without additional procedures were randomly divided into two groups. In the first group we used cold blood cardioplegia, in the second group cold crystalloid cardioplegia, both delivered only ortogradely. We measured hemodynamic data in early hours after operation, enzyme release and we collected other clinical data which could be influenced by perioperative myocardial protection. There was no death in either group. We also didn't find any significant difference in incidence of perioperative myocardial infarction, arrhythmias and use of intraaortic balloon pumping between both groups. In an early hours after operation in the group with blood cardioplegia we found significantly better hemodynamic data (LVSWI, RVSWI) and significantly lower enzyme release. We conclude, that cold blood cardioplegia shows superior perioperative myocardial protection resulting in earlier restoration of myocardial function. This difference could be important in patients with high degree of left ventricular dysfunction.

Aged↗
PubMed2005

Diagnostic ability of B-type natriuretic peptide and impedance cardiography: testing to identify left ventricular dysfunction in hypertensive patients.

BACKGROUND: Patients with hypertension are at high risk for the development of left ventricular dysfunction (LVD). Echocardiography is considered to be the gold standard for diagnosis of LVD; but its cost, complexity, and availability prevents its use for frequent evaluation. Brain natriuretic peptide (BNP) and N-terminal BNP (NT-BNP) can identify heart failure in dyspneic patients. Impedance cardiography (ICG) is a noninvasive method of measuring hemodynamic and electromechanical timing parameters. The objective of this study was to determine the ability of BNP, NT-BNP, and ICG to detect the presence of LVD in patients with hypertension. METHODS: A convenience sample of subjects undergoing echocardiography who had a history of hypertension or current systolic blood pressure >/=140 mm Hg were enrolled and retrospectively evaluated. Patients with known LVD were excluded. Diagnosis of LVD was determined by the presence of systolic or diastolic dysfunction, valvular or wall motion abnormalities, or left ventricular hypertrophy. RESULTS: A total of 193 subjects were enrolled: 189 men and four women, age 68.8 +/- 11.7 years. Multivariate regression analysis of history and symptoms, BNP, and ICG parameters identified significant predictor variables for LVD including cardiac index (P = .005), left cardiac work index (P = .008), BNP (P = .017), arrhythmia (P = .023), angina (P = .034), and systemic vascular resistance (P = .048). Receiver operating characteristic (ROC) analysis determined the area under the ROC curve (AUC) of BNP (0.60), NT-BNP (0.67), ICG velocity index (0.66), composite ICG (0.66), ICG combined with BNP (0.70), and ICG combined with NT-BNP (0.73). CONCLUSIONS: In this high-risk hypertensive population, BNP, NT-BNP, and ICG were useful to identify the presence of LVD. The use of ICG with natriuretic peptide testing may improve the ability to detect LVD.

Aged↗
PubMed1997

[Myocardial revascularization in patients with ischemic cardiomyopathy and left ventricular dysfunction].

In this study we evaluated the outcome of coronary artery bypass grafting (CABG) in patients with coronary artery disease and left ventricular dysfunction. The aim of the study was to identify the risk factors for operative and medium-term mortality. We evaluated 117 consecutive patients (98 men, 19 women, aged 42 to 84 years, mean 65 +/- 9) with ejection fraction (EF) < 40%, operated on from January 1994 to December 1995. Patients who had previously undergone CABG, or who had other procedures associated with CABG, were excluded. Preoperatively, mean EF was 32 +/- 5%; 65 patients (56%) had angina and 62 (53%) had congestive heart failure in NYHA functional class III and IV. Hospital mortality rate was 5% (i.e. 6 deaths). At multivariate analysis significant risk factors were: NYHA functional class IV and moderate/ severe mitral regurgitation. All patients were evaluated at a mean follow-up time of 13 +/- 8 months (range 3 to 30); 9 deaths occurred, 7 due to cardiac causes. Actuarial survival rate at 24 months was 85 +/- 4%; freedom from death due to cardiac causes was 87 +/- 4%. Significant risk factors for medium-term mortality at multivariate analysis were age, moderate/severe mitral regurgitation and marked impairment of regional myocardial contractile function, evaluated by the wall motion score index (> or = 2.25). At follow-up the majority of patients showed improved clinical conditions: mean EF was 40 +/- 8%; 8 patients (8%) had angina and 12 (12%) were in NYHA functional class III and IV. Myocardial revascularization in patients with coronary artery disease and left ventricular dysfunction is characterized by low operative risk and good survival rate at 2 years, with improvement of both angina and congestive heart failure. The best results were obtained in those patients who preoperatively showed the best regional contractile function, even though the global EF was poor, and in those with signs of reversible left ventricular dysfunction, such as angina or documented myocardial viability.

Adult↗
PubMed2000

Diffuse and severe left ventricular dysfunction induced by epicardial coronary artery spasm.

Endothelial dysfunction and effectiveness of treatment of calcium antagonists are suggestive of coronary artery spasm as an underlying disorder in dilated cardiomyopathy (DCM). The aim of this study is to determine whether or not the epicardial coronary artery spasm can induce severe cardiac dysfunction like DCM. Thirty-four consecutive patients with angiographically normal coronary arteries and diffuse left ventricular hypokinesis whose causes had been unknown underwent acetylcholine provocation test and left ventricular biopsy. Eight patients were excluded according to the clinical and laboratory data and biopsy findings suggesting myocarditis or other systemic diseases. According to the results of the acetylcholine provocation test, 17 patients were finally diagnosed as having DCM, and nine patients (35% of the study patients), who had acetylcholine-induced diffuse and multivessel coronary spasm, were diagnosed as having DCM-like vasospastic angina pectoris (VSA). Clinical and cardiac catheterization data including hemodynamics and biopsy findings were similar between the two groups except that left ventricular end-systolic volume was significantly greater in DCM than in DCM-like VSA. After the acetylcholine provocation test, DCM patients received both a beta blocker and an angiotensin-converting enzyme inhibitor, and DCM-like VSA patients received antianginal drugs. In echocardiographic findings at predischarge and those after 6-month drug treatment, both DCM-lke VSA and DCM showed significant reduction in end-diastolic and end-systolic diameters and significant increase in fractional shortening and ejection fraction, whereas changes in ejection fraction and fractional shortening were significantly greater in DCM-like VSA than those in DCM. Epicardial coronary artery spasm can induce diffuse and severe left ventricular dysfunction like DCM in VSA. Although antianginal drugs markedly improve left ventricular function of these patients, only the acetylcholine provocation test can identify DCM-like VSA.

Acetylcholine↗
PubMed1996

How well can the chest radiograph diagnose left ventricular dysfunction?

OBJECTIVES: To review the diagnostic utility of the chest radiograph for left ventricular dysfunction. DATA SOURCES: Structured MEDLINE searches, citation reviews of relevant primary research, review articles, and textbooks, personal files, and data from experts. STUDY SELECTION: Studies of patients without valvular disease that allowed calculation of the sensitivity and specificity of selected radiographic signs compared with a criterion standard of increased left ventricular preload or reduced ejection fraction. DATA EXTRACTION: Two independent readers reviewed 29 studies. Studies were pooled after stratification by radiographic finding, criterion standard, and clinical setting. MAIN RESULTS: Redistribution best diagnosed increased preload with a sensitivity of 65% (95% confidence interval [CI] 55%, 75%) and specificity 67% (95% CI 53%, 79%). Cardiomegaly best diagnosed decreased ejection fraction with a sensitivity of of 51% (95% CI 43%, 60%) and specificity of 79% (95% CI 71%, 85%). Interrater reliability was fair to moderate for redistribution and moderate for cardiomegaly. The clinical setting affected results by decreasing the specificity of cardiomegaly to 8% in detecting increased preload in patients with severe systolic dysfunction. The absence of redistribution could only exclude increased preload in situations in which the suspicion (pretest probability) of disease was less than 9%, whereas redistribution could confirm increased preload when the pretest probability was greater than 91%. The absence of cardiomegaly could only exclude a reduced ejection fraction if the pretest probability was less than 8%, whereas cardiomegaly could confirm a reduced ejection fraction if the pretest probability was greater than 87%. CONCLUSIONS: Redistribution and cardiomegaly are the best chest radiographic findings for diagnosing increased preload and reduced ejection fraction, respectively. Unfortunately, neither finding alone can adequately exclude or confirm left ventricular dysfunction in usual clinical settings. Redistribution is not always reliably interpreted.

Confidence Intervals↗
PubMed2006

Pre-operative use of levosimendan in two patients with severe aortic stenosis and left ventricular dysfunction.

We describe two patients with severe aortic stenosis, coronary artery disease, severe left ventricular dysfunction and heart failure in which the calcium-sensitising agent, levosimendan was administered prior to aortic valve replacement and coronary artery bypass graft surgery. In both cases, drug infusion was well tolerated at the doses used, heart failure improved significantly prior to surgery and peri-operative management was relatively uncomplicated in cases that would traditionally be considered high risk. Further investigation of the use of levosimendan both for treating heart failure in the presence of severe aortic stenosis and as pre-operative therapy is warranted.

Aged↗
PubMed1997

Adjustable model of chronic left ventricular dysfunction.

BACKGROUND: As an adjunct to the development of skeletal muscle-powered left ventricular assist devices, an adjustable model of chronic left ventricular failure was developed. METHODS: Implantation of a left ventricular balloon to induce heart failure was accomplished via left thoracotomy. Upon recovery, left ventricular failure was simulated by manipulation of left ventricular balloon volume to chronically raise left atrial pressure. RESULTS: Left atrial pressure increased from a baseline of 9.3 +/- 0.7 mm Hg to 18.5 +/- 1.2 mm Hg, 20.2 +/- 1.8 mm Hg, and 26.0 +/- 1.2 mm Hg by the 2nd, 6th, and 10th postoperative week, respectively. Cardiac index declined from a baseline of 4.4 +/- 0.3 L x min(-1) x m(-2), reaching stability by the 8th postoperative week at 3.0 +/- 0.4 L x min(-1) x m(-2). Stroke volume index declined from 1.12 +/- 0.1 mL x kg(-1) x beat(-1) to 0.60 +/- 0.1 mL x kg(-1) x beat(-1) by the 10th postoperative week. Mean survival was 75 +/- 7 days. Causes of death included left ventricular failure, thromboembolism, and euthanasia. CONCLUSIONS: This method of simulating chronic left ventricular dysfunction proved to be stable and adjustable and has been useful in the development of ventricular assist systems.

Animals↗
PubMed2001

Improved survival of patients with acute myocardial infarction with significant left ventricular dysfunction undergoing invasive coronary procedures.

BACKGROUND: Acute myocardial infarction (AMI) associated with significant left ventricular dysfunction (LVD) indicates a poor prognosis. Previous studies suggested that revascularization improves survival of patients with AMI complicated by cardiogenic shock. However, other studies that suggested that revascularization improves survival of stable patients with significant LVD did not specifically address patients who had recently had an AMI. OBJECTIVES: Our purpose was to determine whether patients with thrombolysis-treated AMI associated with significant LVD are likely to incur a survival advantage from catheterization and coronary revascularization performed within 30 days after AMI. METHODS: The study population was drawn from the Argatroban in Acute Myocardial Infarction-2 (ARGAMI-2) trial, which included 1200 patients with AMI, all of whom received thrombolytic therapy. Our analysis included 737 patients for whom LV function was estimated by echocardiography. Two hundred two patients had significant LVD; of them, 117 (58%) underwent cardiac catheterization and 85 were treated noninvasively. Among 535 patients without significant LVD, 291 (54%) underwent cardiac catheterization and 244 were treated noninvasively. RESULTS: Compared with a noninvasive approach, an invasive approach resulted in reduced 30-day and 6-month mortality rates in patients with significant LVD: 4.3% versus 10.6%, adjusted odds ratio (OR) 0.26, 95% confidence interval (CI) 0.04 to 1.18, and 6.1% versus 15.5%, OR 0.27, 95% CI 0.06 to 0.98, respectively. A similar comparison in patients without significant LVD resulted in comparable 30-day and 6-month mortality rates for both patient groups: invasively versus noninvasively treated, 0.7% versus 0.8%, OR 1.04, 95% CI 0.04 to 12.7, and 1.4% versus 1.7%, adjusted OR 1.60, 95% CI 0.20 to 9.87. CONCLUSIONS: The current study suggests that AMI patients with significant LVD may benefit from cardiac catheterization and revascularization performed early after AMI, whereas in patients without significant LVD the outcome of those treated invasively or conservatively was similar.

Cardiac Catheterization↗
PubMed2000

Neurohormones in an ovine model of compensated postinfarction left ventricular dysfunction.

Clinical heart failure, often the result of myocardial infarction, may be preceded by a period of compensated left ventricular impairment. There is substantial need for an experimental model that reflects this human condition. In sheep, coronary artery ligation produced consistent left ventricular anteroapical myocardial infarctions resulting in chronic (5 wk), stable hemodynamic changes compared with sham controls, including reductions in ejection fraction (51 +/- 2 vs. 30 +/- 5%, P < 0.001), cardiac output (6.3 +/- 0.2 vs. 5.1 +/- 0.2 l/min, P < 0.01), and arterial pressure (93 +/- 2 vs. 79 +/- 3 mmHg, P < 0.001), and increases in cardiac preload (left atrial pressure, 3.3 +/- 0.1 vs. 8.3 +/- 1.3 mmHg, P < 0.001). These changes were associated with acute and sustained increases in plasma concentrations of atrial natriuretic peptide (ANP; 5 wk, 11 +/- 2 vs. 27 +/- 5 pmol/l, P < 0.001), brain natriuretic peptide (BNP; 3 +/- 0.2 vs. 11 +/- 2 pmol/l, P < 0.001), and amino-terminal pro-brain natriuretic peptide (NT-BNP; 17 +/- 3 vs. 42 +/- 12 pmol/l, P < 0.001). Significant correlations were observed between plasma levels of the natriuretic peptides (ANP, day 7 to week 5 samples; BNP and NT-BNP, day 1 to week 5 samples) and changes in left ventricular volumes and ejection fraction. In contrast, renin activity, aldosterone, catecholamines, and endothelin were not chronically elevated postinfarction and were not related to indexes of ventricular function. Coronary artery ligation in sheep produces the pathological, hemodynamic, and neurohormonal characteristics of compensated left ventricular impairment secondary to myocardial infarction. Plasma concentrations of the cardiac natriuretic peptides are sensitive markers of left ventricular dysfunction. This is a reproducible model that reflects the clinical condition and should prove suitable for investigating the pathophysiology of, and experimental therapies in, early left ventricular dysfunction.

Aldosterone↗
PubMed2005

[Head to head comparison of dobutamine alone and combined with nitrate stress echocardiography and 99mTc-MIBI/18FDG myocardial SPECT image for diagnosis of viable myocardium in patients with severe left ventricular dysfunction].

OBJECTIVE: This study was sought to compare the sensitivity, specificity and accuracy of (1) dual isotope simultaneous acquisition single-photon emission computed tomography (DISA SPECT) myocardial image with (99m)Tc-sestamibi/(18)F-fluorodeoxyglucose ((99m)Tc-MIBI/(18)FDG); (2) low dose dobutamine alone and combined with Isosorbide Dinitrate (ISDN: Isoket) stress two dimensional echocardiography (2DE) to predict regional movement recovery after revascularization (CRV) in patients with old myocardial infarction (OMI) and severe left ventricular dysfunction. METHODS: Twenty-six patients (mean age 51 +/- 8 years, male 25, female 1) with OMI and severe left ventricular dysfunction (mean left ventricular ejection fraction, LVEF (38.6% +/- 4.9%) underwent low dose dobutamine 10 microg x kg(-1) x min(-1) (Dob10 microg) and ISDN (286 +/- 31 microg/min) combined with Dob5 microg (ISDN-Dob 5 microg) 2DE and DISA SPECT within one week. In echocardiogram and DISA SPECT images: the left ventricle (LV) was divided into 16 segments. The semi-quantitative scoring system was used for both images. Myocardial viability was defined as an improvement of at least >or= 1 grade in at least two contiguous segments at rest 2DE after CRV. The viable segments detecting rate with stress 2DE and DISA SPECT were compared. Compared with the results of post-CRV, the sensitivity, specificity and accuracy of detecting viable segments of two methods were calculated. RESULTS: Among 272 abnormal segments in 26 patients, 156 (57.4%) segments showed contractile improvement after CRV. The viable segments detecting rate with DISA SPECT was 72.4% (134/254), which was significantly higher than the contractile improved rate after CRV (P < 0.001). During Dob10 microg 2DE and ISDN-Dob5 microg 2DE, the detecting rates were 65.5% (163/249) and 65.7% (176/268), respectively, which were both comparable to the improved rate after CRV (both P > 0.05). With DISA SPECT, the sensitivity, specificity and accuracy were 93.7%, 55% and 76.8%, respectively. Compared with DISA SPECT, Dob10 microg 2DE showed similar sensitivity (88.6%), specificity (64.2%) and the accuracy (77.9%). When ISDN combined with Dob5 microg, the sensitivity (91.4%), specificity (68.1%) and accuracy (81.4%)were comparable to those of Dob10 microg 2DE and DISA SPECT (all P > 0.05), while the specificity was even higher than DISA SPECT (P < 0.05). CONCLUSION: In identifying myocardial viability in patients with OMI and severe left ventricular dysfunction, DISA SPECT has higher sensitivity, lower specificity and better accuracy. Dob10 microg and ISDN-Dob5 microg 2DE are both equivalent to DISA SPECT in sensitivities, specificities and accuracies, and even higher in specificity in ISDN-Dob5 microg 2DE.

Adult↗
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↗
PubMed1999

Functional recovery after coronary artery bypass grafting in patients with severe left ventricular dysfunction and preserved myocardial viability in the left anterior descending arterial territory as assessed by thallium-201 myocardial perfusion imaging.

To evaluate the functional recovery after coronary bypass surgery in patients with severe left ventricular (LV) dysfunction (ejection fraction (EF) < or = 35%), 100 consecutive patients with viable myocardium in the territory supplied by the left anterior descending artery (LAD) underwent coronary bypass grafting. In addition, cardiac catheterization and single-photon emission computed tomography (SPECT) perfusion imaging with thallium-201 were repeated 1-year postoperatively. Although 12 patients with severe LV dysfunction were preoperatively in a worse New York Heart Association functional class (3.1+/-0.7 vs 2.4+/-0.8; p<0.01), had a higher incidence of heart failure (10/12 vs 14/88; p<0.001) and had a worse LVEF (29+/-5 vs 61+/-14%; p<0.001) compared with 88 patients without severe LV dysfunction, the operative mortality was similar in the 2 groups (1/12 vs 2/88; p=NS). The postoperative NYHA functional class in the patients with severe LV dysfunction was similar to that in the patients without such dysfunction (1.6+/-0.7 vs 1.3+/-0.6; p=NS). In addition, the 1-year postoperative study revealed a significant improvement in the thallium defect score in both the LAD territory (1.7+/-1.2 to 0.7+/-1.0, p=0.01) and all the territories (5.2+/-2.2 to 3.2+/-1.9, p=0.002) in patients with severe LV dysfunction, whereas no improvement in defect score was found in either of these territories in those without severe LV dysfunction (LAD: 0.6+/-1.4 to 0.4+/-1.2, p=NS; All: 1.9+/-2.2 to 1.8+/-2.0, p=NS). Furthermore, a marked 1-year postoperative improvement (15-24%; 95% confidence interval) in LVEF (29+/-5 to 48+/-10%, p<0.001) was demonstrated in patients with severe LV dysfunction, but not in those without such dysfunction (60+/-13 to 61+/-11%, p=NS). These results indicate that myocardial viability in the LAD territory, as demonstrated by thallium-201 SPECT perfusion imaging, predicts a significant improvement in functional class and LVEF of at least 10% or more after coronary artery bypass grafting in patients with severe LV dysfunction.

Adult↗
PubMed2003

Transient left ventricular dysfunction in ischaemic myocardium after stress: comparative study with exercise and pharmacological stress gated myocardial single photon emission computed tomography.

In ischaemic heart disease patients, transient left ventricular dysfunction is observed due to post-exercise stunning. The aim of this study was to determine whether transient left ventricular dysfunction could also be seen after short-acting pharmacological stress (adenosine triphosphate). A 1 day rest/stress gated myocardial single photon emission computed tomography was performed on 362 patients suspected of having ischaemic heart disease by exercise (n=199) or short-acting pharmacological stress (n=163). Left ventricular ejection fraction were estimated both at rest and stress. Based on perfusion findings, patients were subdivided into ischaemia, fixed defect and normal group. For the ischaemia and fixed defect group, left ventricular ejection fraction after stress was significantly decreased compared with the resting value by exercise stress (ischaemia group, 57.5+/-11.0 vs 60.4+/-10.4; fixed defect group, 47.7+/-16.7 vs 49.6+/-16.8; P<0.01), but not by pharmacological stress (ischaemia group, 55.8+/-13.4 vs 57.1+/-13.8; fixed defect group, 50.8+/-13.5 vs 50.6+/-13.1; P=NS). In the normal group, left ventricular ejection fraction after stress was not significantly changed by either exercise (65.7+/-10.4 vs 66.8+/-10.2; P=NS) or pharmacological stress (63.0+/-11.7 vs 64.0+/-12.1; P=NS). It is concluded that a transient decrease in left ventricular ejection fraction after stress was observed following post-exercise, not following a short-acting pharmacological stress in patients showing perfusion abnormalities. Transient left ventricular dysfunction may be the result of post-exercise stunning, not from subendocardial hypoperfusion induced by short-acting pharmacological stress.

Adenosine Triphosphate↗
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↗
PubMed1999

Dobutamine-induced hypotension is an independent predictor for mortality in patients with left ventricular dysfunction following myocardial infarction.

Dobutamine echocardiography was performed on 297 patients after acute myocardial infarction to assess the prognostic value of dobutamine-induced hypotension in patients with left ventricular dysfunction. Patients were divided into two groups according to ejection fraction (group I, ejection fraction <0.45, n = 123; group II, ejection fraction > or =0.45, n = 174) and were followed for 20+/-8 months. Hypotension was defined as a decrease in systolic blood pressure > or =20 mm Hg, compared with baseline values. The incidence of hypotension was similar in groups I and II (23.6% vs. 18.4%, P = 0.28), and the hypotension was not related to positive dobutamine echocardiography. Univariate analysis showed that the development of hypotension was associated with a higher incidence of cardiac death in group I but not in group II. Multivariate analysis showed that dobutamine-induced hypotension was an independent predictor only for cardiac death in group I and was not related to any other cardiac events in either group. In conclusion, the development of hypotension during dobutamine stress can identify a subgroup with poor ventricular functional reserve and at high risk for cardiac death among patients complicated with left ventricular dysfunction.

Adrenergic beta-Agonists↗
PubMed2002

Off-pump coronary artery bypass grafting in patients with left ventricular dysfunction.

BACKGROUND: Coronary artery bypass grafting in patients with severe left ventricular (LV) dysfunction still remains a high risk procedure due to its high mortality and morbidity. Off-pump surgery can be an alternative technique in these patients. We analyzed our results of off-pump coronary surgery in patients with left ventricular dysfunction and compared them with patients operated on-pump. METHODS: Between January 1997 and December 2000, 355 patients with LV dysfunction (EF equal to or less than 30%) underwent off-pump coronary artery bypass (OPCAB) surgery. During the same period, 959 patients with LV dysfunction underwent coronary artery surgery on cardiopulmonary bypass. Octopus was used as mechanical stabilizer and intracoronary shunts were used in most patients. The mean age of the patients was 57.7 +/- 9.2 in patients operated on-pump and 58.4 +/- 9.8 in patients operated off-pump. RESULTS: The preoperative variables were comparable in two groups, except that there were more patients with triple vessel disease in on-pump group. Average number of grafts was 2.8 +/- 0.7 and 3.3 +/- 0.7 (p<0.001) in off-pump and on-pump groups respectively. The mortality was 3.9% and 6.0% (p = 0.176) in off-pump and on-pump groups respectively. Postoperative morbidity was less in off-pump group but it was statistically significant in incidence of atrial fibrillation and prolonged ventilation which were low in off-pump group. The hospital stay was significantly less in patients operated off-pump. CONCLUSION: OPCAB surgery can be safely performed in patients with LV dysfunction. The postoperative morbidity and length of stay is less as compared to patients operated on-pump.

Cardiopulmonary Bypass↗
PubMed2006

Transient left ventricular dysfunction (tako-tsubo phenomenon): Findings and potential pathophysiological mechanisms.

Tako-tsubo-like left ventricular dysfunction phenomenon (TTP) is characterized by transient left ventricular apical ballooning associated with symptoms, electrocardiographic changes and minimal cardiac enzyme release in the absence of coronary artery disease. Initially described in Japan, TTP occurs worldwide, predominantly in women and frequently after emotional or physical stress. Symptoms include anginal chest pain, dyspnea and syncope. Electrocardiographic ST elevations may be present only for several hours, and are followed by negative T waves that persist for months. Arterial hypertension is found in up to 76% of TTP patients, hyperlipidemia in up to 57% and diabetes mellitus in up to 12%. Potential pathophysiological mechanisms for TTP include catecholamine-induced myocardial stunning or hyperkinesis of the basal left ventricular segments, coronary vasospasm, plaque rupture, myocarditis and genetic factors. TTP patients should be monitored similarly to myocardial infarction patients because organ failure, cardiogenic shock, ventricular fibrillation or rupture may occur. Beta-blockers are indicated, whereas catecholamines and nitrates should be avoided. The long-term prognosis is unknown.

Chest Pain↗