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PubMed2005

Effect of coronary artery bypass grafting and aneurysmectomy on QT dispersion in moderate or severe left ventricular dysfunction.

BACKGROUND: The aim of the study was to evaluate the effect that coronary artery bypass grafting (CABG) and aneurysmectomy in the same session have on QT dispersion (QTd) in moderate or severe left ventricular dysfunction. METHODS: Forty-four patients underwent QT interval analyses before and 1 month after aneurysmectomy and CABG. QT interval and QTd were corrected for heart rate using the square root formula of Bazett (QTCB), the cubic root formula of Fridericia (QTCF), and the linear formula of Sagie et al (QT CS ). RESULTS: The mean pre- and postsurgery QTd results were 65.29 +/- 29.25 and 51.76 +/- 18.49 milliseconds, respectively; the corresponding findings for QT CF were 68.06 +/- 31.26 and 55.16 +/- 24.56 milliseconds; and the corresponding findings for QT CS were 66.53 +/- 32.22 and 51.10 +/- 18.29 milliseconds. With these 3 methods, the postoperative findings were significantly lower than the preoperative findings ( P < .05 for all). In contrast, the opposite was true with the QT CB method (preoperative 71.1 +/- 65.80 vs postoperative 76.43 +/- 7.96 milliseconds, P < .05). CONCLUSION: The study showed that based on the methods of Fridericia (QT CF ) and Sagie et al (QT CS ), QT intervals are significantly decreased after CABG and aneurysmectomy.

Adult↗
PubMed2000

Exercise echocardiography predicts development of left ventricular dysfunction in medically and surgically treated patients with asymptomatic severe aortic regurgitation.

OBJECTIVE: To assess resting and exercise echocardiography for prediction of left ventricular dysfunction in patients with significant asymptomatic aortic regurgitation. DESIGN: Cohort study of patients with aortic regurgitation. SETTING: Tertiary referral centre specialising in valvar surgery. PATIENTS: 61 patients (38 men, 23 women; mean (SD) age 53 (14) years) with asymptomatic or minimally symptomatic aortic regurgitation and no known coronary artery disease; 35 were treated medically and 26 had aortic valve replacement. INTERVENTIONS: Exercise echocardiography was used to evaluate ejection fraction, which was measured on the resting and post-stress images using the modified Simpson method. Patients with an increment of ejection fraction after exercise were denoted as having contractile reserve (CR+); those without an increment were labelled CR-. MAIN OUTCOME MEASURES: Standard univariate and multivariate methods and receiver operating characteristic analyses were used to assess the ability of contractile reserve to predict follow up ejection fraction. RESULTS: In the 35 medically treated patients, 13 of 21 (62%) with CR+ (mean (SD) ejection fraction increment 7 (3)%) had preserved ejection fraction on follow up. In the 14 patients with CR- (ejection fraction decrement 8 (4)%), 13 (93%) had a decrement of ejection fraction on follow up from 60 (5)% at baseline to 54 (3)% on follow up (p = 0.005). Age, resting left ventricular dimensions, medical treatment, aortic regurgitation severity, exercise capacity, and rate-pressure product were similar in both CR+ and CR- groups. Among the 26 surgical patients, 13 showed CR+ (ejection fraction increase 9 (5)%), all of whom had an increase in ejection fraction on follow up (from 49% to 59%). Of 13 surgical patients with CR- (ejection fraction decrease 7 (5)%), 10 (77%) showed the same or worse ejection fraction on postoperative follow up. CONCLUSIONS: Contractile reserve on exercise echocardiography is a better predictor of left ventricular decompensation than resting indices in asymptomatic patients with aortic regurgitation. In patients undergoing aortic valve replacement, contractile reserve had a better correlation with resting ejection fraction on postoperative follow up. Measurement of contractile reserve may be useful to monitor the early development of myocardial dysfunction in asymptomatic patients with aortic regurgitation, and may help to optimise the timing of surgery.

Adult↗
PubMed2006

Correction of coronary arterial anomalies at surgical repair of common arterial trunk with ischaemic left ventricular dysfunction.

Common arterial trunk is frequently associated with anomalies of coronary arterial origin and distribution. We describe two infants in whom coronary intervention was performed during the repair of common arterial trunk, with reversal of ischaemic left ventricular dysfunction. We discuss the surgical implications of recognition of the coronary arterial anomalies during the repair of common arterial trunk.

Cardiac Catheterization↗
PubMed2006

Carcinoid crisis and reversible right ventricular dysfunction after embolization in untreated carcinoid syndrome.

A 59-year-old white male with carcinoid tumor and hepatic metastases underwent hepatic artery embolization. The patient developed carcinoid crisis and a subsequent transthoracic echocardiogram showed classic findings of carcinoid heart disease along with a dilated hypertrophied right ventricle and severely depressed right ventricular ejection fraction. After treatment with octreotide the patient's clinical condition improved and a repeat transthoracic echocardiogram showed a significant improvement and normalization of right ventricular systolic function. Serotonin levels showed a progressive decline that correlated well with the patient's improved clinical condition. These findings suggest that the acute right ventricular dysfunction was secondary to acute carcinoid crisis and resolution resulted in a significant improvement of both right ventricular systolic function and clinical condition.

Acute Disease↗
PubMed2005

The imbalance between coronary reserve and wall stress explains the severity of ventricular dysfunction in hypertension.

BACKGROUND: The pathophysiologic role of coronary reserve impairment in hypertensive cardiac dysfunction is still debated. Previously, we demonstrated that satisfactory coronary vasodilatation may coexist with ventricular systolic dysfunction. It is conceivable that coronary reserve might otherwise be inappropriate for enhanced myocardial oxygen demand and may thus affect cardiac performance negatively. HYPOTHESIS: Myocardial supply-demand imbalance contributes to the severity of ventricular dysfunction in hypertension (HTN). METHODS: Fractional shortening (%) and end-systolic stress (10(3) x dyn x cm(-2)) were determined using echocardiography, and coronary reserve was calculated using transesophageal Doppler echocardiography. Coronary reserve/stress (cm2 x dyn(-1)) was utilized as a measure of supply-demand. Groups NL (20 healthy subjects), HTN1 (15 patients, fractional shortening > or = 30), HTN2 (19 patients, 20 < or = fractional shortening < 30), and HTN3 (21 patients, fractional shortening < 20) were constituted. RESULTS: Compared with NL and HTN1, groups HTN2 and HTN3 had significantly (p < 0.05) greater end-systolic stress (NL = 72 +/- 16, HTN1 = 72 +/- 23, HTN2 = 143 +/- 32, HTN3 = 186 +/- 70). Coronary reserve was impaired in HTN3 alone (NL = 3.5 +/- 0.6, HTN1 = 3.4 +/- 1.0, HTN2 = 3.1 +/- 1.0, HTN3 = 2.6 +/- 1.1), but coronary reserve/stress was reduced in both HTN2 and HTN3 (NL = 50 +/- 12, HTN1 = 53 +/- 21, HTN2 = 22 +/- 7, HTN3 = 15 +/- 7). Stepwise regression analysis identified diastolic internal dimension, end-systolic stress, and coronary reserve/stress as independently associated with fractional shortening. CONCLUSION: The imbalance between supply-demand explains the severity of hypertensive cardiac dysfunction and adds information to cardiac enlargement and elevated wall stress.

Adult↗
PubMedDate not supplied

[The use of angiotensin-converting enzyme inhibitors in left ventricular dysfunction (the generalization of the experience of multicenter studies)].

The lecture highlights the results of a 10-yr experience gained with the clinical trial of the angiotensin-converting enzyme inhibitors (ACEI) in patients presenting with left ventricular dysfunction (LVD) on an international multicentre basis. The results obtained and conclusions drawn from the above megatrial were employed in giving guidelines on ACEI use in a clinical setting in different categories of LVD patients.

Acute Disease↗
PubMed2002

Epidemiology and screening of asymptomatic left ventricular dysfunction.

The traditional approach to estimating heart failure prevalence has been based on signs and symptoms of heart failure; such prevalence estimates have been in the range of 2% of persons <or= 75 years of age. Newer approaches have focused on objective (echocardiographic) evaluation of systolic and diastolic function as well as on signs and symptoms. It is estimated that 4-5% of the population has depressed systolic function and approximately 5% has moderate to severe diastolic dysfunction. Since over half of these persons are asymptomatic, efforts are underway to determine whether simple techniques, such as measurement of plasma brain natriuretic peptide, will aid in early diagnosis of ventricular dysfunction.

Aged↗
PubMed1988

Right ventricular dysfunction in patients with septic shock.

Using a rapid computerized thermodilution method, we examined the evolution of right ventricular performance in 23 patients with septic shock. Nine survived the episode of septic shock. The other 14 patients died of refractory circulatory shock. Significant right ventricular systolic dysfunction, defined as decreased ejection fraction (-39%) and right ventricular dilation (+38%) was observed in all patients with septic shock. However, in the survivors, increased right ventricular preload may prevent hemodynamic evidence of right ventricular pump failure by utilizing the Frank-Starling mechanism to maintain stroke volume. Conversely, in the nonsurvivors, right ventricular dysfunction was more prononced two days after the onset of septic shock, leading to a fall in stroke. In the last patients, a decrease in contractility appears to be the major factor accounting for decreased right ventricular performance, as evidenced by the marked increase in end-systolic volume (+27%) without significant change in pulmonary artery pressure, during the later stage of septic shock. The observed right ventricular pump failure then appears associated with an alteration in diastolic mechanical properties of this ventricle, as suggested by a leftward displacement of the individual pressure-volume curves.

Adult↗
PubMed1999

Estimation of left ventricular function in right ventricular volume and pressure overload. Detection of early left ventricular dysfunction by Tei index.

Although the effects of right ventricular (RV) volume and pressure overload (RVVO and RVPO) on ventricular septal motion are different, the differential effect on left ventricular (LV) function is still controversial. The Doppler-derived index (Tei index) combining systolic and diastolic ventricular function, defined as the sum of isovolumetric contraction time (ICT) and isovolumetric relaxation time (IRT) divided by ejection time (ET), has been demonstrated to be a useful index to estimate LV function and to predict the prognosis of patients with congestive heart failure. This study was designed to evaluate the differential effects of RVVO and RVPO on LV function using the Tei index. Study patients consisted of 26 age-matched normal subjects, 22 patients with atrial septal defect (ASD) with normal or borderline RV pressure and 25 with primary pulmonary hypertension (PPH). All subjects had normal LV ejection fractions measured with 2-dimensional echocardiogram using biplane Simpson's method (61 +/- 4 vs 61 +/- 4 vs 63 +/- 8%, normal vs ASD vs PPH). Tei index was easily obtained in all subjects from transthoracic Doppler echocardiogram of LV inflow and outflow. Patients with ASD had normal ICT, IRT and ET, resulting in normal Tei index, however, patients with PPH had significantly prolonged ICT and IRT with shortened ET, resulting in a significant increase in Tei index (0.38 +/- 0.04 vs 0.36 +/- 0.03 vs 0.61 +/- 0.22, p < 0.001). Although RVVO due to ASD has no significant effects on LV function, RVPO due to PPH can adversely affect LV function. The Tei index is a simple and sensitive measure to assess LV function caused by RVVO or RVPO.

Adult↗
PubMed2002

Predictors of outcome after coronary bypass surgery in patients with left ventricular dysfunction.

OBJECTIVE: The aim of this study was to determine the risk factors affecting the mortality and morbidity after coronary artery bypass grafting (CABG) in patients with LV dysfunction and without any viability assessment. METHODS: The preoperative, perioperative, and postoperative early and mid-term follow-up data of 252 patients with left ventricular ejection fraction (LVEF) of < or = 30% who underwent isolated CABG from 1995 through 2000, were evaluated. No preoperative viability study was performed for patient selection. Preoperative echocardiography and cardiac catheterization, and postoperative control echocardiography were performed in all patients. Follow-up data after the discharge of these patients were obtained via monthly periodical examinations in the first 6 months, and thereafter via telephone interviews. As preoperatively, 229 (90.87%) patients were in NYHA class III or IV, and the mean LVEF was 26.58 +/- 3.66%. RESULTS: Overall mortality and late mortality rates were 16.27% and 5.16%, respectively. Postoperative complications were observed in 61 (24.21%) patients. During 49.06 +/- 15.17 months of follow-up, 185 (93.43%) of 198 (78.57%) survived patients were in NYHA class I or II and the mean LVEF was 39.64% +/- 5.68%. Advanced age, diabetes, hypertension, cross-clamp time > 60 min, bypass time > 120 min, severity of angina and functional classes (class III-IV of NYHA and CCS) were found to be the determinants of mortality. However, by multivariate analysis only older age and class III-IV of NYHA and CCS were detected as predictors of mortality. CONCLUSION: The low mortality and morbidity rates as well as postoperative improvements in functional capacity and in LVEF support the use of CABG without the need of any viability assessment in patients with left ventricular dysfunction. Advanced age, severe angina and functional symptom status seem to be the predictors of poor prognosis in these patients after CABG.

Adult↗
PubMed2004

The long-term impact of the angiotensin-converting enzyme inhibitor trandolapril on mortality and hospital admissions in patients with left ventricular dysfunction after a myocardial infarction: follow-up to 12 years.

AIMS: To investigate the long-term benefits of treatment with angiotensin-converting enzyme (ACE)-inhibitors in patients with myocardial infarction (MI) and left ventricular dysfunction (LVD). METHODS AND RESULTS: In the trandolapril cardiac evaluation (TRACE) study, 1749 patients with LVD (ejection fraction< or =35%) were randomized to trandolapril (n=876) or placebo (n=873) 3-7 days post-MI. Enrolment lasted from 1990 to 1994; on-treatment follow-up ranged from 2 to 4 years. At study closure, all patients were recommended continued ACE-inhibitor use. National registries were used to track deaths and hospitalizations until 2002. Mortality was analysed with Cox proportional hazard models and hospitalization with Poisson regression models (models adjusted for observation time). Over 10-12 years of follow-up, a total of 1283 deaths and 9220 hospitalizations were registered. Compared with the placebo group, the trandolapril group had a significantly reduced risk of all-cause mortality (relative risk 0.89, 95% CI 0.80-0.99, P=0.03), all-cause hospitalizations (rate ratio 0.92, 95% CI 0.88-0.96, P<0.001), and cardiovascular hospitalizations (rate ratio 0.95, 95% CI 0.91-1.00, P=0.047), including congestive heart failure hospitalizations (rate ratio 0.85, 95% CI 0.77-0.93, P<0.001). CONCLUSION: In patients with LVD, use of trandolapril shortly after an MI for 2-4 years has long-term benefits. The beneficial effect on mortality and hospitalization rates is maintained for at least 10-12 years.

Aged↗
PubMed2001

[Apical ballooning by transient left ventricular dysfunction (so-called "ampulla" cardiomyopathy) associated with therapy for acute pulmonary thromboembolism: a case report].

An 86-year-old-woman presented with apical ballooning left ventricular dysfunction associated with therapy for acute pulmonary thromboembolism. She was referred to our hospital for advanced treatment for her shock state due to acute pulmonary embolism with normal left ventricular(LV) function. Her condition was stabilized using a percutaneous cardiopulmonary support system. Suction embolectomy was successfully carried out after pulmonary arteriography. After the therapy, echocardiography revealed apical ballooning and hyperkinesis of the base(LV ejection fraction = 28%), although coronary arteriography showed no fixed stenosis. LV wall motion significantly improved on day 3(LV ejection fraction = 45%). Pulmonary embolism relapsed on day 5 in spite of anticoagulation treatment. She died of multiple organ failure on day 9. Autopsy findings indicated no sign of myocardial infarction or myocarditis, patchy appearance of myocardial contraction band necrosis and few migrated lymphocytes. The mechanism for the flow mis-matched LV dysfunction remains unknown. The probable explanations include non-ischemic stress such as catecholamine or neurogenic stress, and possibly ischemic stress or ischemia/reperfusion injury.

Aged↗
PubMed1987

Cardiac rehabilitation in patients with severe ischemic left ventricular dysfunction.

Twenty patients who had had a myocardial infarction and who had a resting left ventricular ejection fraction of 25% or less participated in an 8-week outpatient supervised exercise and education program. No morbidity or mortality occurred during the program, and most patients achieved a substantial improvement in exercise capacity. During a follow-up interval of a mean of 29.7 +/- 13.0 months, four patients died, an annualized mortality of 8 +/- 4%. The outcome of cardiac rehabilitation was assessed 19.1 +/- 4.4 months after completion of the supervised program. Of the 16 survivors, all of whom had been fully employed before their most recent myocardial infarction, 9 (56%) had returned to full-time work, 6 (38%) were medically disabled, and 1 was retired (age 73 years) but fully active. Of the 16 survivors, 13 (81%) completed a questionnaire about their perceptions of their current quality of life. Of the 13 patients, 12 (92%) had continued to exercise regularly. Four patients (31%) reported the ability to perform all desired activities without symptoms, whereas nine patients (69%) noted some impairment in their functional capacity. Thus, in this group of patients with profound left ventricular dysfunction, the rehabilitation potential, as evidenced by return to productive employment and the ability to perform desired activities-including exercise training-was generally favorable.

Electrocardiography↗
PubMed1998

Warfarin anticoagulation and survival: a cohort analysis from the Studies of Left Ventricular Dysfunction.

OBJECTIVES: We sought to evaluate the relation between warfarin anticoagulation and survival and morbidity from cardiac disease in patients with left ventricular (LV) dysfunction. BACKGROUND: Warfarin anticoagulation plays a major role in the management of patients who have had a large myocardial infarction and in those with atrial fibrillation. However, its use in patients with LV systolic dysfunction has been controversial. METHODS: We reviewed data on warfarin use in 6,797 patients enrolled in the Studies of Left Ventricular Dysfunction (SOLVD) trial and analyzed the relation between warfarin use and all-cause mortality, as well as the combined end point of death or hospital admission for heart failure. We used Cox regression to adjust for differences in baseline characteristics and to test for the interaction between warfarin use and selected patient variables in relation to outcome. RESULTS: On multivariate analysis, use of warfarin was associated with a significant reduction in all-cause mortality (adjusted hazard ratio [HR] 0.76, 95% confidence interval [CI] 0.65 to 0.89, p = 0.0006) and in the risk of death or hospital admission for heart failure (HR 0.82, 95% CI 0.72 to 0.93, p = 0.0002). Risk reduction was observed when each trial or randomization arm was analyzed separately, as well as in both genders. It was not significantly influenced by the presence of atrial fibrillation, age, ejection fraction, New York Heart Association functional class or etiology. CONCLUSIONS: In patients with LV systolic dysfunction, warfarin use is associated with improved survival and reduced morbidity. This association is primarily due to a reduction in cardiac events and does not appear to be limited to any particular subgroup.

Angina, Unstable↗
PubMed2006

Giant extracardiac unruptured sinus of Valsalva aneurysm in a patient with left ventricular dysfunction.

Extracardiac unruptured sinus of Valsalva aneurysm (SVA) is an infrequent cardiac anomaly. Unruptured SVAs are typically symptom-free until rupture occurs. We describe a case of an unruptured extracardiac SVA originating from noncoronary sinus with left ventricular dysfunction. The patient was asymptomatic. The diagnosis was made by transthoracic echocardiography, computed tomography, and cardiac catheterization. The aneurysm was surgically resected and the sinus was successfully reconstructed with a patch. The patient remained asymptomatic throughout the postoperative follow-up period. Early surgical repair should be the choice of treatment for extracardiac SVAs in order to prevent sudden death.

Adult↗
PubMed2006

Pharmacokinetic profile of controlled-release carvedilol in patients with left ventricular dysfunction associated with chronic heart failure or after myocardial infarction.

We compared the pharmacokinetic (PK) profiles of repeated dosing with the currently available immediate-release (IR) carvedilol (given twice daily) and a newly developed controlled-release (CR) formulation (given once daily) in patients with left ventricular dysfunction (LVD). We enrolled 188 patients with stable mild, moderate, or severe heart failure as well as survivors of a recent acute myocardial infarction (MI) with asymptomatic LVD (left ventricular ejection fraction </=0.40) in a crossover study. PK variables were initially assessed after patients had received carvedilol IR 3.125, 6.25, 12.5, or 25 mg twice daily for >/=2 weeks. Patients were then switched to the corresponding dose of carvedilol CR (10, 20, 40, or 80 mg once daily), and PK variables were reassessed after an additional 2 weeks. The primary measures included trough plasma concentration (C(tau)), maximum plasma concentration (C(max)), and area under the concentration-time curve (AUC([0-t])) for both enantiomers of carvedilol of each formulation of the drug. The AUC((0-t)) and the trough and maximum carvedilol concentrations for both the R(+) and S(-) enantiomers were similar when carvedilol IR was compared with carvedilol CR as follows: 3.125 mg twice daily versus 10 mg once daily, 6.25 mg twice daily versus 20 mg once daily, 12.5 mg twice daily versus 40 mg once daily, and 25 mg twice daily versus 80 mg once daily, respectively. Based on a pooled analysis, the AUC((0-t)), C(max), and C(tau) for both R(+) and S(-) were equivalent for the CR and IR formulations, with point estimates and 90% confidence intervals within the bioequivalence limits of 80%-125%. The fluctuation index (the CR-IR ratio for [C(max) - C(min)]/C(ss) where C(min) is the minimum observed concentration over the dosing interval and C(ss) is the concentration at steady state) for both R(+)- and S(-)-carvedilol was approximately 1, indicating that the peak-to-trough fluctuation in plasma concentration for carvedilol after use of carvedilol CR once daily was similar to that for carvedilol IR given twice daily. The median time to maximum observed plasma concentration (t(max)) was approximately 3 hours longer for both enantiomers after administration of carvedilol CR as compared with carvedilol IR. These data demonstrate that the new carvedilol CR formulation given once daily is equivalent to the currently available carvedilol IR formulation given twice daily in patients with heart failure and asymptomatic post-MI LVD.

Adolescent↗