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PubMed1993

Clinical evaluation with exercise performance in twenty patients who underwent coronary artery bypass grafting with both the gastroepiploic and internal thoracic arteries.

Postoperative exercise performance was evaluated in 20 patients who underwent complete coronary revascularization with simultaneous right gastroepiploic artery and internal thoracic artery grafts for ischemic heart disease and exhibited patency of all grafts on postoperative angiograms. Three patients received only arterial grafts, and 17 simultaneously received a saphenous vein graft. Forty five right gastroepiploic artery grafts were harvested during this study, but two were not used because of foci of severe calcification. The right gastroepiploic artery was grafted to the distal right coronary artery in 17 patients and to the distal obtuse marginal branches in three patients, accompanied by an internal thoracic artery graft to the left anterior descending artery in seventeen, to the diagonal branch in three, and to the proximal right coronary artery in one patient. A postoperative exercise test with a bicycle ergonometer was administered 6 to 12 weeks after the operation, and the results are reported after conversion into metabolic units. The preoperative exercise test resulted in 3.6 +/- 1.9 metabolic units for 18 patients tested, and the postoperative metabolic units were 7.8 +/- 1.3 for 20 patients. Left ventricular wall motion was analyzed by regional ejection fraction before and after coronary artery bypass grafting in 14 patients who received an right gastroepiploic artery graft for the right coronary system. The mean regional ejection fraction of the posterobasal or diaphragmatic wall was 28.0% or 28.2% before operation and improved to 43.1% or 43.2% after coronary artery bypass graft, respectively. The flow of right gastroepiploic artery seemed to distribute adequately to the revascularized area. Long-term results have not yet been proved; the use of simultaneous right gastroepiploic artery and internal thoracic artery grafts, however, thus produced excellent results, as seen from improvements in both left ventricular wall motion and early postoperative exercise performance.

Adult↗

PubMed1997

Exercise testing in the preoperative evaluation of patients with bronchogenic carcinoma.

The aim of this study was to evaluate which parameters of preoperative spirometry and cardiopulmonary exercise test are the best predictors of postoperative morbidity and mortality in patients with bronchogenic carcinoma. Ninety seven patients were prospectively and consecutively examined. All patients had preoperative maximal exercise test and dynamic spirometry. Postoperative complications and causes of death were registered. Logistic regression was used and models explaining the relationship between preoperative variables and postoperative complications and deaths were constructed. We found significant differences in preoperative maximal workload and carbon dioxide output between groups, with and without cardiopulmonary-related complications, but not in spirometry variables. Logistic regression showed maximal workload to be the only predictor of cardiopulmonary complications. Maximal oxygen uptake was predictive of cardiopulmonary deaths. Maximal oxygen uptake and forced expiratory volume were predictive of postoperative complications. A maximal oxygen uptake <50% predicted was associated with high risk of death from cardiopulmonary causes. Kaplan-Meier survival curves showed that maximal oxygen uptake was correlated to long-term survival, while spirometric variables were not. Exercise testing can be used in the preoperative evaluation of patients with nonmetastatic bronchogenic carcinoma. A combination of the results of variables from spirometry and exercise testing is proposed to be used as a preoperative criterion for operability.

Carcinoma, Bronchogenic↗

PubMed1999

Development of sinus node disease in patients with AV block: implications for single lead VDD pacing.

OBJECTIVE: To investigate the incidence of sinus node disease after pacemaker implantation for exclusive atrioventricular (AV) block. DESIGN: 441 patients were followed after VDD (n = 219) or DDD pacemaker (n = 222) implantation for AV block over a mean period of 37 months. Sinus node disease and atrial arrhythmias had been excluded by Holter monitoring and treadmill exercise preoperatively in 286 patients (group A). In 155 patients with complete AV block, a sinus rate above 70 beats/min was required for inclusion in the study (group B). Holter monitoring and treadmill exercise were performed two weeks, three months, and every six months after implantation. Sinus bradycardia below 40 beats/min, sinoatrial block, sinus arrest, or subnormal increase of heart rate during treadmill exercise were defined as sinus node dysfunction. RESULTS: Cumulative incidence of sinus node disease was 0.65% per year without differences between groups. Clinical indicators of sinus node dysfunction were sinus bradycardia below 40 beats/min in six patients (1.4%), intermittent sinoatrial block in two (0.5%), and chronotropic incompetence in five patients (1.1%). Only one of these patients (0.2%) was symptomatic. Cumulative incidence of atrial fibrillation was 2.0% per year, independent of the method used for the assessment of sinus node function and of the implanted device. CONCLUSIONS: In patients undergoing pacemaker implantation for isolated AV block, sinus node syndrome rarely occurs during follow up. Thus single lead VDD pacing can safely be performed in these patients.

Aged↗

PubMed2005

Cardiopulmonary exercise tests and lung cancer surgical outcome.

STUDY OBJECTIVES: Surgical resection remains the treatment of choice for anatomically resectable non-small cell lung cancer. However, the presence of associated comorbid conditions increases the risk of death and surgical complications. Several studies have evaluated the usefulness of preoperative exercise testing for predicting postoperative morbidity and mortality. The aim of this study was to establish whether exercise testing could predict poor surgical outcome in lung cancer surgery and whether the absolute value or percentage of predicted value is the better predictor of the surgical outcome. DESIGN: The study was designed as a prospective study. PATIENTS AND SETTING: One hundred thirty patients with potentially operable lung cancer at Papworth Hospital over 2 years were recruited; of these, 101 underwent curative surgery. INTERVENTIONS: Spirometry and cardiopulmonary exercise tests were performed for every patient (n = 99), except for two patients with back problems. We also recorded the outcome of surgery, in particular, complications and mortality. MEASUREMENTS AND RESULTS: Mean maximum oxygen transport at peak exercise (Vo(2)peak) was 18.3 mL/kg/min (SD, 4.7 mL/kg/min), and mean percentage of predicted Vo(2)peak value was 84.4% (SD, 30%). Poor surgical outcome was significantly related to Vo(2)peak percentage of predicted (p < 0.01) but not to the actual oxygen uptake value. CONCLUSIONS: The use of the percentage of predicted Vo(2)peak value would be a better indicator of surgical outcome, since it predicts the surgical outcome better, and corrects for normal physiologic ranges. The threshold of Vo(2)peak for surgical intervention could be set between 50% and 60% of predicted without excess surgical mortality.

Adult↗

PubMed1990

Postoperative myocardial infarction and cardiac death. Predictive value of dipyridamole-thallium imaging and five clinical scoring systems based on multifactorial analysis.

Sixty-six patients unable to complete a standard preoperative exercise test because of physical limitations were studied to determine the predictive value of individual clinical parameters, of clinical scoring systems based on multifactorial analysis, and of dipyridamole-thallium imaging before major general and vascular surgery. Study endpoints were limited to postoperative myocardial infarction or cardiac death before hospital discharge. There were nine postoperative cardiac events (seven deaths and two nonfatal infarctions). There was no statistical correlation between cardiac events and preoperative clinical descriptors, including individual clinical parameters, the Dripps-American Surgical Association score, the Goldman Cardiac Risk Index score, the Detsky Modified Cardiac Risk Index score, Eagle's clinical markers of low surgical risk, and the probability of postoperative events as determined by Cooperman's equation. There were no cardiac events in 30 patients with normal dipyridamole-thallium scans or in nine patients with fixed myocardial perfusion defects. Of 21 patients with reversible perfusion defects who underwent surgery, nine had a postoperative cardiac event (sensitivity, 100%; specificity, 43%). In the six other patients with reversible defects, preoperative angiography showed severe coronary disease or cardiomyopathy. Thus in patients unable to complete a standard exercise stress test, postoperative outcome cannot be predicted clinically before major general and vascular surgery, whereas dipyridamole-thallium imaging successfully identified all patients who sustained a postoperative cardiac event.

Aged↗

PubMed1984

Exercise capacity as a predictor of post-thoracotomy morbidity.

Although severe impairment on routine pulmonary function tests will identify patients with a high post-thoracotomy morbidity, cardiopulmonary complications often develop in patients with only a mild-to-moderate impairment in pulmonary function. To determine whether the preoperative exercise capacity can prospectively identify those at risk of developing complications, 22 patients scheduled for thoracotomy (mean age, 55.7 +/- 2 yr) underwent an incremental exercise test on a cycle ergometer to determine their maximal O2 uptake (VO2max) prior to thoracotomy. Routine pulmonary function tests were performed and postoperative forced expiratory volume in one second (FEV1) was predicted from split function perfusion lung scan in all subjects. Eleven of the 22 patients had no cardiopulmonary complications postoperatively. The age, history of prior cardiovascular disease, degree of impairment on routine pulmonary function tests, and predicted postoperative FEV1 were similar in those who did and those who did not experience complications. However, those without complications had a significantly higher VO2max than did those who experienced complications (22.4 +/- 1.4 versus 14.9 +/- 0.9 ml/kg/min, p less than 0.001). Only 1 of 10 patients with a VO2max greater than 20 ml/kg/min had a complication, whereas all 6 patients with a VO2max less than 15 ml/kg/min had a complication. We conclude that exercise testing is a useful adjunct in the evaluation of operative risk for thoracotomy.

Adult↗

PubMed1990

[The current aspects of the preoperative preparation of cancer patients at the polyclinic stage].

Two hundred and one candidates for surgical treatment of cancer underwent ergokinetic examination on an outpatient basis to evaluate functional status of the body. Patients were distributed into three groups according to results of complex evaluation of indexes of tolerance to dosed physical exercise. Preoperative preparation was determined by functional-somatic status. Preparation on an outpatient basis allowed to shorten hospital stay by 1.1-2.3 days.

Ambulatory Care↗

PubMed1987

Predictive value of exercise renography for presurgical evaluation of nephrogenic hypertension.

Functional omicron-iodohippurate scintigrams were obtained in 18 hypertensive patients. Each patient was examined in the prone position and during exercise. An exercise-induced transient, bilateral, hippurate transport disturbance was sought as an expression of an exercise-mediated cortical perfusion abnormality. The study sought to test the hypothesis that patients who present evidence for an exercise-induced renal perfusion disturbance would have stabilized hypertension that was no longer surgically curable because of morphological changes of the peripheral vasculature. All 18 patients continued on to therapy: 13 proceeded to renovascular reconstructive surgery, 2 had a unilateral nephrectomy, and 3 were treated with percutaneous transluminal renal angioplasty. During preoperative exercise renography, evidence of bilateral renal dysfunction developed in 10 of 18 hypertensive patients during ergometric stress (abnormal exercise response). Following surgical therapy nine of these patients with abnormal exercise scintigrams continued to have hypertensive disease, while one patient was cured. The exercise renograms of eight hypertensive patients were not influenced by the exercise protocol, and operation cured seven of these eight patients. The results suggest that an accentuated vascular response to exercise occurs in the maintenance phase of renovascular hypertension, a disturbance not observed while the hypertension is curable by surgical therapy.

Antihypertensive Agents↗

PubMed1981

The role of intra-aortic balloon pump in the management of patients with main left coronary artery disease.

Seventy-five patients with greater than or equal to 70% stenosis of the left main coronary artery (LMCA) were treated surgically between January 1974 and February 1980. The group consisted of 57 men and 18 women with a mean age of 62.8 years. All patients were symptomatic with angina pectoris, and 64 (85%) had unstable angina. Twenty-nine patients (38.6%) had electrocardiographic evidence (ECG) of old myocardial infarction (MI) and only six (8%) had a normal resting ECG. Preoperative exercise testing was done in 22 of the 75 patients. The stress test was positive in all patients, 17 (77%) of whom had greater than 2 mm ST depression; 90.6% (68/75) had significant right coronary artery disease. The intra-aortic balloon pump (IABP) was inserted preoperatively in only four patients (5%) and was required in two additional patients postoperatively. The IABP was inserted preoperatively in four patients because of medically refractory angina and not on the basis of coronary anatomy alone. An average of three grafts per patient were inserted. There were three (4%) postoperative myocardial infarctions and two (2.6%) deaths. During the follow-up period, which comprised 105 patient-years, there was one myocardial infarction and one death. These data indicate that successful surgical treatment of left main coronary artery disease can be achieved with low mortality and that routine preoperative insertion of IABP is unnecessary.

Aged↗

PubMed1993

Hemodynamic findings in patients with left bundle branch block after myectomy in hypertrophic obstructive cardiomyopathy (HOCM)

To determine the hemodynamic effects of postoperative left bundle branch block (LBBB) in patients with hypertrophic obstructive cardiomyopathy (HOCM), we investigated 28 patients using Swan-Ganz pulmonary artery catheterization at rest and on exercise. Fourteen patients had postoperative LBBB (group A) and 14 had undisturbed intraventricular conduction (group B). All patients were examined by clinical investigation, electrocardiogram and bicycle ergometer exercise preoperatively and postoperatively (mean 6 months). Pulmonary artery pressure and pulmonary capillary wedge pressure were continuously measured, stroke volume index and cardiac index were obtained by the thermodilution method. All patients showed an improvement of their clinical symptoms (NYHA class: 2.8 +/- 0.45 before and 1.7 +/- 0.22 after operation) (P < 0.05). The postoperative exercise capacity (Watt) increased significantly (P < 0.05) in group A by 38% and in group B by 30%. The maximum mean pulmonary artery pressure on physical exercise decreased in group A from 40.7 +/- 9.1 to 32.5 +/- 8.7 mmHg and in group B from 42.8 +/- 12.4 to 32.4 +/- 9.2 mmHg (P < 0.05). The maximal stroke volume index and cardiac index improved significantly in 9 of 14 patients in each group. Thus, patients with HOCM and LBBB after myectomy have a marked improvement in postoperative hemodynamics, the results equaling those of patients with undisturbed intraventricular conduction.

Adolescent↗

PubMed1995

Pattern of coronary artery disease in patients with ventricular tachycardia and fibrillation exposed by exercise-induced ischemia.

The majority of patients with serious exercise-induced ventricular arrhythmias have extensive coronary artery disease. These arrhythmias develop, however, only in a minority of patients with angina pectoris. The purpose of the present study was therefore to investigate whether these arrhythmia patients are characterized by any specific "arrhythmogenic" pattern of coronary artery disease. Among 1100 consecutive patients undergoing coronary artery bypass grafting, 30 (2.7%) patients had ventricular tachycardia or fibrillation during preoperative exercise testing. For each of these patients, two matched controls with angina pectoris but no ventricular arrhythmia were selected. All patients underwent angiocardiography by standard techniques. The recordings were blinded and interpreted in random order by an experienced invasive cardiologist. Significant stenosis (> or = 50%) of the main left coronary artery was found in 27% of the case patients compared to 12% of the matched controls (p = 0.069, two-tailed t test); proximal left anterior descending artery stenoses were more frequent in the arrhythmia patients. Although stenosis > or = 75% was only moderately more frequent in the case patients, the difference was highly significant for stenosis > or = 95%, which was seen in 47% of the case patients compared to 22% of the controls (p = 0.015). The difference was even more pronounced for the combination of main left coronary artery stenosis and/or high-grade stenosis (> or = 95%) of the left anterior descending artery. This pattern was seen in 60% of the case patients compared to 28% of the matched controls (p = 0.004).(ABSTRACT TRUNCATED AT 250 WORDS)

Angiocardiography↗

PubMed1992

Cardiac arrhythmias and myocardial ischemia after thoracotomy for lung cancer.

The records of 598 patients undergoing a thoracic surgical procedure for lung cancer from 1975 through 1989 were reviewed for occurrence of cardiac arrhythmias and myocardial ischemic events. Atrial tachycardias occurred in 16% (94/598); atrial fibrillation was preponderant (87%), followed by supraventricular tachycardia and atrial flutter. Patients with recurrent episodes of dysrhythmias had a significantly higher mortality rate than those without episodes or with a single episode only (17% versus 2.4%; p less than 0.01). Transient ischemic electrocardiographic changes were documented in 23 patients (3.8%) and myocardial infarction in 7 (1.2%). An abnormal preoperative exercise test result and intraoperative hypotension were strongly associated with both dysrhythmia and ischemia (p less than 0.01). Pneumonectomy, ischemic changes on the electrocardiogram, and cardiac enlargement were also associated with arrhythmias (p less than 0.01). A weaker association (p less than 0.05) was found between postoperative arrhythmias and old myocardial infarction (greater than 6 months), arterial hypertension, and heart failure. Pulmonary function had no predictive value in this respect. A history of angina or old myocardial infarction was predictive of transient postoperative myocardial ischemia but not myocardial infarction. Despite improved anesthetic and monitoring techniques and more frequent use of the intensive care unit postoperatively in the last decade, the incidence of arrhythmias after thoracotomy has not decreased. More effective prevention is needed, particularly for patients with defined preoperative and perioperative risk factors.

Aged↗

PubMed2005

Impact of pectus excavatum on pulmonary function before and after repair with the Nuss procedure.

BACKGROUND/PURPOSE: Patient reports of preoperative exercise intolerance and improvement after surgical repair of pectus excavatum (Pex) have been documented but not substantiated in laboratory studies. This may be because no study has been large enough to determine if pulmonary function tests (PFTs) in the Pex population are significantly different from the normal population, and none has assessed improvement in pulmonary function after Nuss bar removal. METHODS: The authors studied PFT results in 408 Pex patients before repair and in a subset of 45 patients after Nuss procedure and bar removal. Significance of differences in percent predicted (using Knudson's equations) was tested using t tests (parametric) or sign tests (nonparametric). Normal was defined as 100% of predicted for forced vital capacity (FVC), forced expired volume in 1 second (FEV1), and forced expiratory flow (FEF25%-75%). RESULTS: Preoperatively, FVC and FEV1 medians were lower than the normal by 13%, whereas the FEF 25-75 median was lower than normal by 20% (all P < .01). The postoperative group had statistically significant improvement after surgery for all parameters. Patients older than 11 years at the time of surgery had lower preoperative values and larger mean post-bar removal improvement than the younger patients. An older patient with a preoperative FEF25-75 score of 80% of normal would be predicted by these data to have a postoperative FEF25-75 of 97%, indicating almost complete normalization for this function. CONCLUSIONS: These results demonstrate that preoperatively Pex patients as a group have decreased lung function relative to normal patients. After Nuss procedure and bar removal, we show a small but significant improvement in pulmonary function. These results are consistent with patient reports of clinical improvement and indicate the need for more in-depth tests of cardiopulmonary function under exercise conditions to elucidate the mechanism.

Adolescent↗

PubMed1989

Efficacy of coronary artery bypass surgery with gastroepiploic artery. Assessment with thallium 201 myocardial scintigraphy.

This study describes the efficacy of the right gastroepiploic artery (GEA) as graft material for coronary artery bypass grafting (CABG) as assessed by exercise thallium 201 myocardial scintigraphy in eight patients (age, 59.4 +/- 9.35 years [mean +/- SD]) who underwent CABG with the GEA graft in the past 2 years. Planar and single-photon-emission computed tomographic (SPECT) images were obtained during and 3 hours after exercise. Planar images were evaluated quantitatively with the percentile-washout method, and SPECT images were evaluated qualitatively with a bull's-eye, polar-coordinate map. All patients had triple-vessel disease, and in situ GEAs were anastomosed to the right coronary artery in seven patients and to the left anterior descending coronary artery in one. The internal mammary artery graft was concomitantly used in all patients. The mean number of grafts per patient was 3.0 (range, 2-4). Preoperative exercise testing could not be performed in two patients because of emergency operation. By qualitative assessment with the polar-coordinate map, four patients showed improvement, one did not show any change, and one became worse due to perioperative myocardial infarction.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗

PubMed1992

Exercise testing, 6-min walk, and stair climb in the evaluation of patients at high risk for pulmonary resection.

To evaluate three types of exercise testing in prediction of death or prolonged mechanical ventilation after lung resection in high-risk patients, 16 patients underwent evaluation prior to resection. Eleven patients (group 1) had minor or no complications (arrhythmia, atelectasis, pneumonia) and five patients (group 2) died within 90 days of surgery. Exercise testing showed that group 1 had a longer 6-min walk distance and a higher stair climb than group 2. The maximum oxygen uptake on a cycle ergometer was not significantly different between groups, although only ten patients completed this test. Group 1 had a significantly greater calculated oxygen uptake with stair climbing than group 2. A 6-min walk distance of greater than 1,000 feet and a stair climb of greater than 44 steps were predictive of successful surgical outcome. Preoperative exercise testing is a useful adjunct to traditional spirometric testing in evaluation of the high-risk surgical patients.

Aged↗

PubMed1983

Cardiac risks and complications of noncardiac surgery.

When internists are consulted to assess risks and to aid in the perioperative management of surgical patients, they often can rely on substantial clinical data to guide the consultation. Perioperative cardiac risk can be estimated based on the severity of underlying heart failure, the occurrence of a recent myocardial infarction or various arrhythmias, the presence of aortic stenosis, the patient's age, the type of planned surgery (including whether it is an emergency or elective procedure), and the patient's general medical condition. Preoperative exercise testing or cardiac catheterization to assess risk are not routinely indicated, but perioperative hemodynamic monitoring to improve management is recommended in patients at high risk. Postoperative hypertension, arrhythmias, and heart failure commonly occur in the first 2 days after surgery, but the risk of myocardial infarction persists for at least 5 or 6 days after surgery. Effective perioperative consultation must include careful postoperative observation to detect cardiac complications at an early stage and to assist in their management.

Adult↗

PubMed1982

Timing of operation for chronic aortic regurgitation.

Left ventricular systolic function is an important determinant of long-term prognosis in patients with chronic aortic regurgitation. Data from several centers, using invasive and noninvasive assessment of left ventricular function, indicate that long-term postoperative survival is excellent, even in symptomatic patients, if preoperative left ventricular systolic function is normal. The long-term postoperative results are significantly worse in symptomatic patients with preoperative left ventricular systolic dysfunction, many of whom appear to have irreversible left ventricular failure before the onset of symptoms and are at a risk of late postoperative death from congestive heart failure. However, within this high risk subgroup long-term prognosis is excellent for patients, despite left ventricular dysfunction, if preoperative exercise capacity is preserved. In these patients, left ventricular dysfunction is likely to be reversible after operation. Hence, all patients with left ventricular dysfunction at rest should undergo aortic valve replacement, even if severe symptoms and deterioration in exercise tolerance have not developed. Once exercise tolerance becomes limited in such patients, the likelihood of irreversible left ventricular dysfunction is increased, and long-term postoperative survival is threatened.

Aortic Valve↗

PubMed1977

Ventricular buckling: a factor in the abnormal ventriculogram and peculiar hemodynamics associated with mitral valve prolapse.

Because of intractable ventricualr arrhythmias after a near-fatal episode of ventricular fibrillation, a patient with idiopathic mitral valve prolapse was subjected to mitral valve replacement. Vector analysis and intraoperative epicardial mapping localized the ectopic focus to the region of the posterior papillary muscle. The patient is alive and well two years after surgery; chronically inverted T waves have become upright. But propranolol and diphenylhydantoin are needed to prevent arrhythmias and T wave abnormalities during standing and exercise. Preoperatively, with the onset of mitral regurgitation and a second rapid phase of prolapse, the ventriculogram was deformed by abnormal midsystolic hyperkinesis at both sites of papillary muscle insertion. Postoperatively, focal hypokinesis appeared in the same areas, implying that they had been retracted by the prolapsing valve. Preoperatively, a papillary tip could be seen entering the mitral ring while coronary arteriography showed late systolic elongation of a small vessel feeding the anterior papillary muscle, suggesting that the papillary apparatus was indeed subject to damaging stress during the abnormal basal movement. Three other persons with severe mitral prolapse (but intact chordae) have had valve repacement and developed qualitatively similar changes in the ventriculogram. Papillary speciments in two showed significant fibrosis. Indication for operation in one of these was edpisodic ventricular fibrillation, which has not recurred. A spectrum of ventriculographic abnormality associated with mitral prolapse could be partly explained by hypokinesis of the papillary loops, variably disguised by retraction stress tansmitted from the billowing leaflets, translocation of blood into the expanding valve sail, and various degrees of unloading into the left atrium. Abnormal intraventicular flow may probably result from associated prolapse of the anterior leaflet and from buckling of the papillary sties toward the mitral annulus. Unusual physical findings in the operated cases and in eight other patients define a clinically recognizable syndrome in which severe prolapse abbreviates left ventricular ejection. Liability to symptoms and to progression of disease seems high in this group.

Adolescent↗