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PubMed2003

Is the use of cardiopulmonary bypass for multivessel coronary artery bypass surgery an independent predictor of operative mortality in patients with ischemic left ventricular dysfunction?

BACKGROUND: l Coronary artery bypass grafting for patients with ischemic left ventricular dysfunction (ILVD) remains superior to medical therapy in terms of long-term survival. Recently, off-pump coronary artery bypass surgery has been shown to be very promising in achieving functional improvements with favorable operative mortality in this challenging group of patients. The aim of this study was to assess the risk factors responsible for operative mortality in this group of patients. METHODS: The records of 305 consecutive ILVD patients, who underwent primary isolated coronary artery bypass grafting for multivessel disease at The National Heart and Lung Institute, Imperial College, University of London, between January 1999 and January 2002, were reviewed retrospectively. Patients were considered to have ILVD if they had a left ventricular ejection fraction of 0.30 or less on preoperative coronary angiography. One hundred six patients were operated on using the off-pump coronary artery bypass surgery technique, and 199 patients were operated on using the conventional coronary artery bypass grafting technique with cardiopulmonary bypass. RESU;TS: Seven (6.6%) patients died in the off-pump coronary artery bypass surgery group, whereas 28 (14.1%) patients died in the cardiopulmonary bypass group (p = 0.05). Univariate analysis of all the preoperative characteristics was performed to identify the potential predictors of mortality in the whole group of ILVD patients. Potential predictors of mortality included symptom status (stable/unstable), chronic obstructive airway disease, dyspnea grade III and IV on the New York Heart Association classification, intravenous nitrates, preoperative use of intraaortic balloon pump, ventricular tachycardia or ventricular fibrillation, body surface area less than 2, and cardiopulmonary bypass. Only ventricular tachycardia or ventricular fibrillation was proved to act as an independent predictor of operative mortality in this group of ILVD patients, with an odds ratio of 29.6 (95% confidence interval, 8.9 to 98). CONCLUSIONS: This study showed that using cardiopulmonary bypass for multivessel coronary artery bypass grafting in patients with ILVD was not proved to act as an independent predictor of operative mortality.

Aged↗
PubMed2004

Usefulness of myocardial viability or ischemia in predicting long-term survival for patients with severe left ventricular dysfunction undergoing revascularization.

In 107 patients with coronary disease and severe left ventricular dysfunction, we examined the prognostic power of viability identified by dobutamine stress echocardiography. At a mean follow-up of 27 months, patients with viable myocardium who underwent revascularization had a significant survival advantage over all other patients (2-year survival 83.5% vs 57.2%, p = 0.0037).

Angioplasty, Balloon, Coronary↗
PubMed2003

Eplerenone, a selective aldosterone blocker, in patients with left ventricular dysfunction after myocardial infarction.

BACKGROUND: Aldosterone blockade reduces mortality and morbidity among patients with severe heart failure. We conducted a double-blind, placebo-controlled study evaluating the effect of eplerenone, a selective aldosterone blocker, on morbidity and mortality among patients with acute myocardial infarction complicated by left ventricular dysfunction and heart failure. METHODS: Patients were randomly assigned to eplerenone (25 mg per day initially, titrated to a maximum of 50 mg per day; 3319 patients) or placebo (3313 patients) [correction] in addition to optimal medical therapy. The study continued until 1012 deaths occurred. The primary end points were death from any cause and death from cardiovascular causes or hospitalization for heart failure, acute myocardial infarction, stroke, or ventricular arrhythmia. RESULTS: During a mean follow-up of 16 months, there were 478 deaths in the eplerenone group and 554 deaths in the placebo group (relative risk, 0.85; 95 percent confidence interval, 0.75 to 0.96; P=0.008). Of these deaths, 407 in the eplerenone group and 483 in the placebo group were attributed to cardiovascular causes (relative risk, 0.83; 95 percent confidence interval, 0.72 to 0.94; P=0.005). The rate of the other primary end point, death from cardiovascular causes or hospitalization for cardiovascular events, was reduced by eplerenone (relative risk, 0.87; 95 percent confidence interval, 0.79 to 0.95; P=0.002), as was the secondary end point of death from any cause or any hospitalization (relative risk, 0.92; 95 percent confidence interval, 0.86 to 0.98; P=0.02). There was also a reduction in the rate of sudden death from cardiac causes (relative risk, 0.79; 95 percent confidence interval, 0.64 to 0.97; P=0.03). The rate of serious hyperkalemia was 5.5 percent in the eplerenone group and 3.9 percent in the placebo group (P=0.002), whereas the rate of hypokalemia was 8.4 percent in the eplerenone group and 13.1 percent in the placebo group (P<0.001). CONCLUSIONS: The addition of eplerenone to optimal medical therapy reduces morbidity and mortality among patients with acute myocardial infarction complicated by left ventricular dysfunction and heart failure.

Aged↗
PubMed1995

The vicious circle of ischemic left ventricular dysfunction.

Myocardial ischemia tends to be self-propagating, and minor events such as plaque rupture can lead to the catastrophic sequelae of myocardial infarction and death. The biology of the endothelium and the cardiac myocyte is crucial to the development of these vicious circles. The abnormal responses of the endothelial cell in atherosclerosis tend to provoke and propagate ischemia, and because of the limited metabolic reserve of the myocyte, even short periods of ischemia can lead to left ventricular dysfunction and arrhythmias. This article examines the clinical implications of the disordered biology of the endothelial cell and the myocyte that is the basis for ischemic left ventricular dysfunction.

Coronary Vessels↗
PubMed1980

Rest and exercise hemodynamic effects of oral hydralazine in patients with coronary artery disease and left ventricular dysfunction.

To determine the hemodynamic effects of afterload reduction at rest and during upright exercise in patients with coronary artery disease and left ventricular dysfunction, 12 patients were studied before and after taking 50-75 mg of oral hydralazine every 6 hours for 48 hours. Oxygen consumption and heart rate were unchanged from control both at rest and during two work loads on a bicycle ergometer. Cardiac output was significantly increased at rest and during both workloads. The arteriovenous oxygen difference was significantly reduced at rest and during exercise. Pulmonary capillary wedge pressure was also significantly lower at rest and during exercise. Systemic vascular resistance was reduced at rest, and exercise-induced vasodilation was augmented by the administration of hydralazine. Left ventricular end-diastolic volume and ejection fraction assessed by radionuclide angiocardiography were not significantly changed at rest or during exercise after hydralazine. Seven of the 12 patients have maintained clinical improvement during a follow-up of 6-12 months. Hemodynamic improvement provided by oral hydralazine at rest is maintained during moderate exertion in patients with coronary artery disease and left ventricular dysfunction. In selected patients, chronic afterload reduction with oral hydralazine may result in increased cardiac reserve, decreased pulmonary congestion or decreased myocardial oxygen demands, thereby improving or abolishing resting or exertional dyspnea or angina.

Aged↗
PubMed2003

'Tako-Tsubo cardiomyopathy' associated with syndrome malin: reversible left ventricular dysfunction.

A 66-year-old man developed a fever and had a syncopal attack during treatment with imipramine and amantadine for depression and Parkinson's disease. His muscular enzyme levels were very high, so he was diagnosed with incomplete syndrome malin and given hydration therapy. The electrocardiogram recorded an ST segment elevation like acute myocardial infarction in most leads, and the echocardiogram revealed left ventricular dysfunction with severe hypokinesis to dyskinesis of the anterior and apical wall regions, and hyperkinesis of the basal wall. One month from onset, the left ventricular contractility had not changed despite normal coronary arteries. Thallium-201((201)Tl) myocardial scintigraphy showed a perfusion defect and there was no accumulation of iodine-123((123)I) metaiodobenzylguanidine (MIBG) in the entire apex of the heart. Left ventricular function returned to normal and repeat (201)Tl scintigraphy showed recovery by the 4th month. However, there was still an absence of cardiac MIBG uptake. There are a number of reports from Japan of a syndrome demonstrating such reversible left ventricular dysfunction, called 'tako-tsubo cardiomyopathy', but the present case is the first to be associated with syndrome malin. A coronary microvascular abnormality and cardiac sympathetic denervation probably both play an important role in tako-tsubo cardiomyopathy.

3-Iodobenzylguanidine↗
PubMed1985

[Echocardiography in chronic aortic insufficiency. Prediction of the reversibility of left ventricular dysfunction following surgical correction].

UNLABELLED: The long term outcome of patients undergoing aortic valve replacement (AVR) for chronic aortic regurgitation (AR) is mainly determined by the reversibility or permanence of left ventricular dysfunction. We analysed the echocardiogram of 49 patients before and after surgery to identify the patients whose left ventricular dysfunction regressed completely after AVR. The patients were divided into 2 groups according to the results of the last postoperative echocardiogram: Group I: 25 patients whose left ventricular dimensions and wall motion reverted to normal; Group II: 24 patients with dilated and/or hypokinetic left ventricles. The two groups of patients were comparable for sex (Group I: 19 men, 6 women; Group II: 20 men, 4 women), age (Group I: 50,8 years, Group II: 53,9 years) and length of postoperative follow-up (Group I: 32 months, Group II: 34 months). The following parameters were measured and compared: diastolic and systolic left ventricular dimensions, myocardial mass and ventricular wall motion. RESULTS: Patients in Group I had less left ventricular dilatation than those in Group II (+35% vs +60%, p less than 0,001) and left ventricular contraction was better (FE: 62% vs 45%, p less than 0,001; %FS: 35% vs 23%, p less than 0,001). This study establishes that patients with chronic AR and % delta Dd less than 60%, an EF greater than 50% or %FS greater than 25%, have about a 90% probability of normalisation of LV function after AVR. If one of the indices exceeds these threshold values, the probability of permanent LV dilatation and/or hypokinesia after AVR is also about 90%.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗
PubMed2005

Brain natriuretic peptide based strategy to detect left ventricular dysfunction in Chagas disease: a comparison with the conventional approach.

BACKGROUND: Left ventricular dysfunction (LVd) is the main predictor of mortality in Chagas disease (ChD). AIMS: To compare the diagnostic performance of the conventional approach (ECG and chest X-ray) in the recognition of LVd in ChD, with a new strategy, in which BNP is measured in patients with an abnormal ECG. METHODS: Consecutive ChD patients recruited at an Outpatient Reference Center in Belo Horizonte, Brazil, without other systemic diseases, in 1998-99 (sample 1, n = 165) and in 2001-02 (sample 2, n = 62) underwent ECG, chest X-ray, BNP measurement and echocardiography. RESULTS: The prevalence of LVd (ejection fraction <or=0.40) was 9.1% in the sample 1. The conventional strategy recognized all patients with LVd (sensitivity: 100%, 95% CI: 79.6-100% and negative predictive value -PV 100%, 92.1-100%), but with low specificity (30%, 95% CI: 23.2-37.8) and +PV (12.5%, 95% IC: I7.7-19.6). The BNP/ECG strategy showed significantly better specificity (96.0%, 95% CI: 91.5-98.2, p < 0.001) and +PV (66.7%, 95% CI: 43.7-83.7, p < 0.001), and non-significantly lower sensitivity (80.0%, 95% CI: 54.8-93.0, p = 0.25) and -PV (98.0%,95% CI: 94.2-99.3, p = 0.08). Overall accuracy was improved with the new strategy. (94.5%,95% CI: 90.0-97.1 x 36.4%, 95% CI: 29.4-43.9, p < 0.001). Similar results were obtained for the sample 2. CONCLUSIONS: The BNP-based strategy was more accurate than the conventional approach in the detection of LVd in ChD patients and should be considered as a valid option.

Adult↗
PubMed2001

Increased circulating levels of ouabain-like factor in patients with asymptomatic left ventricular dysfunction.

BACKGROUND: Much evidence has been accumulated that human plasma contains digitalis-like factor(s) with Na/K ATPase inhibitor properties. Increased concentrations of ouabain-like factor (OLF) have been reported in patients with moderate to severe hypertension and in patients with overt congestive heart failure due to dilated cardiomyopathy. AIM: The presence of circulating OLF has not been investigated in borderline to mild hypertension or in the early stage of dilated cardiomyopathy. METHODS AND RESULTS: The study population consisted of 18 normal volunteers, 24 patients with borderline to mild hypertension, 47 patients with asymptomatic left ventricular dysfunction (ALVD) due to dilated cardiomyopathy and 26 patients with cardiac arrhythmias but normal left ventricular function. OLF values (pM ouabain equivalent) were assayed in extracted plasma, using a radioimmunoassay for ouabain. OLF was, respectively, 29.4+/-20.6 pM in normal controls, 39.1+/-23.8 pM in hypertensives, 35+/-18 pM in patients with cardiac arrhythmias, 52.3+/-25.8 pM in ALVD patients not treated with digoxin and 64.6+/-29.6 pM in ALVD patients treated with digoxin. Patients with ALVD, both treated and not treated with digoxin, had OLF significantly higher (P<0.05) than all the other groups. In patients with ALVD no correlation between OLF and left ventricular ejection fraction was observed. In the hypertensive group no correlation between OLF and both diastolic and systolic pressure was found. CONCLUSION: Increased concentrations of OLF were observed in patients with left ventricular dysfunction due to dilated cardiomyopathy, before the occurrence of overt heart failure, suggesting that OLF may be an early marker of the disease.

Adult↗
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↗
PubMed2004

[Tako-tsubo-like transient left ventricular dysfunction with apical thrombus formation: a case report].

A 76-year-old woman with oppressive chest pain was admitted to our hospital. Initial electrocardiography revealed normal sinus rhythm with ST-segment elevation in leads V2-V5. The patient underwent emergent coronary angiography, which demonstrated no significant coronary stenosis. Left ventriculography revealed marked hypokinesis and akinesis of the mid and distal segments of all ventricular walls, with hyperkinesis of the base. Six days after admission, transthoracic echocardiography revealed immobile apical thrombus. The thrombus disappeared without any embolic episode after 2 weeks of anticoagulant therapy with heparin and warfarin. Left ventricular walls returned to normal 3 months after the attack. Tako-tsubo-like cardiomyopathy with apical thrombus has only been reported in three cases. Left ventricular function normalizes within several days or weeks in most cases of tako-tsubo-like transient left ventricular dysfunction. Therefore, if the thrombus remains within the left ventricle, the risk of embolism might be relatively high. Careful management must be required in patients with tako-tsubo-like transient left ventricular dysfunction.

Aged↗
PubMed1997

[A case of coronary artery bypass grafting without cardiopulmonary bypass in a patient with left ventricular dysfunction].

A 54-year-old man who had severe deterioration of left ventricular function (cardiac index ; 1.6 l/min/m2, left ventricular ejection fraction ; 26%) due to two myocardial infarcts underwent bypass of the left anterior descending artery using the left internal thoracic artery under IABP assist without extracorporeal circuration or cardiac arrest. Two hours postoperatively, he was extubated. Subsequent clinical course was uneventful with a satisfactory outcome. These findings suggest that coronary artery bypass without extracorporeal circulation or cardiac arrest is a safe and effective procedure in patients with left ventricular dysfunction.

Cardiopulmonary Bypass↗
PubMed2000

[Heart failure caused by severe systolic ventricular dysfunction of hypertensive origin. Long-term clinical and functional course].

AIMS: The aims of our study were to evaluate survival and evolution of functional class and ventricular function in patients with severe congestive heart failure due to dilated cardiomyopathy. METHODS: Inclusion criteria were: class III or IV heart failure, dilated left ventricle with ejection fraction < 40%, history of poor controlled hypertension, and exclusion of other etiologies for heart failure. We studied 17 patients with these features; mean age was 64 +/- 7 years and 70% were male. They were followed up during a mean period of 3.3 +/- 1 years (2 to 6; median 3 years). RESULTS: Baseline left ventricular ejection fraction was 30 +/- 5% (20 to 40); 35% of patients were in functional class III and 65% in class IV; 100% of patients received ACE inhibitors and diuretics, 53% betablockers, and 35% calcium-antagonists. Survival was 100%. Left ventricular ejection fraction increased from 30 +/- 5% to 44 +/- 11% at one year, to 50 +/- 11% at 3 years and 51 +/- 10% at the end of follow-up (p < 0.001). This improvement was mainly due to a reduction in systolic left ventricular diameter (from 51 +/- 4 mm to 42 +/- 11 mm, p < 0.01), since diastolic diameter did not significantly changed (63 +/- 4 to 59 +/- 11 mm). CONCLUSIONS: The evolution of severe systolic left ventricular dysfunction due to arterial hypertension is favourable at long-term, with null mortality and clinical ejection fraction and functional improvement. Nevertheless, the persistence of left ventricular dilatation suggests that myocardial damage caused by chronic pressure overload does not disappear.

Aged↗
PubMed1986

High-frequency ventilation versus conventional ventilation in dogs with right ventricular dysfunction.

A randomized crossover protocol was used to compare conventional mechanical ventilation (CMV) and high-frequency ventilation (HFV) in mongrel dogs experiencing right ventricular dysfunction after right ventriculotomy. When inspired oxygen, pH, PCO2, core temperature, and preload were held constant, cardiac output increased significantly (p less than .05) from 1.16 +/- 0.24 to 1.38 +/- 0.25 L/min and pulmonary vascular resistance decreased significantly (p less than .05) from 734 +/- 257 to 554 +/- 169 dyne X sec/cm5 during HFV relative to CMV. We also noted a significant (p less than .05) increase in mean arterial pressure from 116 +/- 27 to 124 +/- 23 mm Hg and a significant (p less than .05) increase in left ventricular stroke work from 10.2 +/- 3.5 to 12.3 +/- 2.6 g X m during HFV. During the inspiratory phase of CMV there were increases in CVP, pulmonary artery pressure, and systemic arterial pressure, and decreases in pulmonary artery flow which did not occur during HFV. HFV may be preferable to CMV in the presence of right ventricular dysfunction.

Animals↗
PubMed1993

Coronary artery bypass grafting in severe left ventricular dysfunction: excellent survival with improved ejection fraction and functional state.

OBJECTIVES: The present study evaluated our experience with coronary artery bypass grafting in patients with severe left ventricular dysfunction. BACKGROUND: Despite the ominous prognosis of advanced ischemic cardiomyopathy, coronary artery bypass grafting in this setting remains controversial because of concerns over operative risk and lack of functional or survival benefit. METHODS: We analyzed the data of 83 consecutive patients (69 men, 14 women, aged 42 to 83 years [mean 66.8]) with a left ventricular ejection fraction < or = 30% who underwent isolated coronary artery bypass grafting (without aneurysmectomy, valve replacement or other open heart procedures) performed by one surgeon during a 6-year period. The ejection fraction ranged from 10% to 30% (mean 24.6%). Preoperatively, 49% of patients had angina, 52% had congestive heart failure (17% with pulmonary edema) and 30% manifested significant ventricular arrhythmia. The mean number of grafts was 2.7/patient. The internal mammary artery was used in 82% of grafts to the left anterior descending coronary artery. The intraaortic balloon pump was required therapeutically (for angina or pump failure) in 19% of patients and was prophylactically placed preoperatively in another 43% of patients. RESULTS: The hospital mortality rate was 8.4% (7 of 83). The mortality rate was 3.3% (2 of 61) in those patients who did not require admission to an intensive care unit immediately before operation. Canadian Cardiovascular Society angina class improved postoperatively by 1.9 categories and New York Heart Association congestive heart failure class by 1 category. Left ventricular ejection fraction (assessed postoperatively in 68 of 76 hospital survivors) improved from 24.6% preoperatively to 33.2% postoperatively (36% increase) (p < 0.001). At 1 and 3 years, respectively, all-cause survival was 87% and 80% and freedom from cardiac death was 89.8% and 84.5%. CONCLUSIONS: In patients with coronary artery disease and advanced ventricular dysfunction: 1) coronary artery bypass grafting can be performed relatively safely, 2) good medium-term survival is attained, 3) improvement in left ventricular function can be documented objectively after bypass grafting, 4) quality of life is improved (as reflected by improvement in anginal and congestive heart failure status), and 5) the internal mammary artery can safely be used as a conduit. The use of coronary artery bypass grafting is encouraged for this group of patients and may provide a viable alternative to transplantation in selected patients.

Actuarial Analysis↗
PubMed2004

Selecting patients with mitral regurgitation and left ventricular dysfunction for isolated mitral valve surgery.

BACKGROUND: American College of Cardiology/American Heart Association (ACC/AHA) Guidelines state that patients with an ejection fraction (EF) of 30% or less should not undergo mitral valve replacement for mitral regurgitation (MR). We sought to establish, using a national cardiac surgery database, whether patients with left ventricular dysfunction may safely undergo mitral valve surgery for MR, and if so, which ones. METHODS: We queried the Society of Thoracic Surgeons (STS) National Database to identify patients who had isolated mitral valve replacement or repair for MR between 1998 and 2001. Mortality and morbidity outcomes were compared by EF category (< or = 30% vs > 30%), and observed mortality compared by EF group, stratified by predicted risk for mortality. A classification and regression tree (CART) model was then used to determine which patient characteristics contributed most to designate the high-risk patient. RESULTS: Of the 14,582 patients who had mitral valve surgery, 727 had an EF of 30% or less and 13,855 had an EF of more than 30%. Observed mortality rates were higher for patients with an EF of 30% or less (5.4% vs 3.1%). However, for low-risk to medium-risk patients, mortality rates remained fairly constant across levels of EF. Mortality is notably increased in the high-risk patients (predicted risk > 10%). A classification tree identifies three key characteristics for high risk: age more than 75 years, renal failure, and emergent or salvage procedure. CONCLUSIONS: When the predicted mortality risk is less than 10%, EF has minimal impact on operative mortality for mitral regurgitation. In contrast to the ACC/AHA Guidelines, our data show that operative risk for mitral valve surgery is not prohibitive for most patients with ventricular dysfunction.

Aged↗
PubMed1998

Stability of the defibrillation probability curve with the development of ventricular dysfunction in the canine rapid paced model.

Most patients with implantable defibrillators have diminished cardiac function. Progressive heart failure might impair defibrillation efficacy, leading to interpreted device failure. This study sought to determine the effect of ventricular dysfunction on defibrillation energy using a biphasic endocardial system. Eleven dogs were ventricularly paced at 225 pulses/min for 2 weeks to induce ventricular dysfunction, and five control dogs remained unpaced. Dose response defibrillation probability curves were generated for each animal at baseline, after 2 weeks (at which time the pacemakers were turned off in the paced group), and then 1 week later. The defibrillation thresholds, ED20, ED50, and ED80 (the 20%, 50%, and 80% effective defibrillation energies, respectively) were determined for each dog at each study. In the paced dogs, the mean ejection fraction fell from 55% to 25% after pacing (P < 0.0001), and rose to 46% after its discontinuation (P = 0.0002). The defibrillation threshold, ED20, ED50, and ED80 remained unchanged in both the control and paced groups for all three studies, even after adjustment for dog weight or left ventricular mass. Rapid pacing produced no change in left ventricular mass. It induced ventricular cavity dilatation and wall thinning, which had opposing effects on defibrillation energy requirements, resulting in no net change of the ED50 in heart failure. In conclusion, the defibrillation efficacy of a biphasic transvenous system is not changed by the development of heart failure using the rapid paced canine model.

Analysis of Variance↗
PubMed2004

Long-term results of left ventricular reconditioning and anatomic correction for systemic right ventricular dysfunction after atrial switch procedures.

OBJECTIVES: Systemic right ventricular failure after atrial switch procedures for transposition of the great arteries has been addressed at Melbourne's Royal Children's Hospital (1981-1993) and the Cleveland Clinic Foundation (1993-2001) with reconditioning of the morphologically left ventricle by means of pulmonary artery banding followed by an arterial switch operation and an atrial reseptation. METHODS: Thirty-nine patients (Royal Children's Hospital, 19; Cleveland Clinic Foundation, 20) with a median age of 10.8 years (range, 13 months-24 years) entered this protocol a median of 10.3 years (range, 0.5-24 years) after an atrial switch procedure. RESULTS: The median duration of pulmonary artery banding was 13 months (range, 0.5-5.4 years). Ten (28%) patients responded unfavorably to morphologically left ventricular reconditioning (5 mortalities: 4 transplantations and 1 PAB still in place). Twenty-four (83%) of the 29 patients who underwent an atrial switch operation and atrial reseptation survived. During a median follow-up period of 8.2 years (range, 1-16 years), 3 patients had cardiac-related deaths. All 18 long-term survivors are asymptomatic. At last echocardiographic evaluation, the morphologically left ventricular function was normal or mildly decreased in 16 (89%) patients, and all had normal or mildly decreased systemic right ventricular function with no or mild tricuspid regurgitation. Age greater than 12 years was associated with a greater probability of morphologically left ventricular failure and not completing the protocol (P =.02) and a higher operative mortality at anatomic correction (P =.02). CONCLUSIONS: Morphologically left ventricular reconditioning and an anatomic correction protocol should be integrated into a cardiac transplantation program when treating patients with morphologically right ventricular failure after Mustard and Senning procedures. It is an alternative to cardiac transplantation in selected patients, with good long-term results. The response to morphologically left ventricular reconditioning past adolescence is inconsistent.

Adolescent↗