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PubMed1993

Deciding when hemodynamic monitoring is appropriate. How will the data affect your diagnostic or therapeutic approach?

Hemodynamic data can be used to differentiate a variety of cardiopulmonary disorders, including right ventricular dysfunction, massive pulmonary embolism, and precapillary pulmonary hypertension. In patients with acute pulmonary edema, low-output states, or shock, hemodynamic measurements can help guide therapy; they also provide a precise estimate of a patient's response to vasoactive or inotropic drugs. Consider a flotation catheter for patients with complicated MIs, critically ill patients with multiorgan or major organ dysfunction, and high-risk cardiac patients undergoing surgery.

Cardiovascular Diseases↗
PubMed1999

[Effects of low dose pimobendan in patients with cor-pulmonale].

The acute and chronic efficacy of low dose pimobendan (1.25 mg x 2/day) was evluated in patients with cor-pulmonale. Fifteen patients (12 men, 3 women, mean age 73 +/- 5 yr) with right ventricular dysfunction judged by Tei's Doppler index (> or = 0.4) and poor working capacity (exercise tolerance: 2.2-6.6 MET) were studied. Mean pulmonary artery pressure, cardiac output, total pulmonary resistance using Swan-Ganz catheter, and arterial oxygen and carbon dioxide pressure (PaO2, PaCO2) were measured before and 24 hr after pimobendan administration. Maximal oxygen intake (MET), saturation of arterial blood oxygen at rest and desaturation by treadmill stress test were measured before and 1 month after pimobendan administration. Pulmonary artery pressure decreased (17.6 +/- 4.7 to 10.2 +/- 2.3 mmHg, p < 0.001) and cardiac output increased (3.5 +/- 0.6 to 5.1 +/- 0.9 l/min, p < 0.001), resulting in decreased total pulmonary resistance (5.0 +/- 1.3 to 2.1 +/- 0.7 U, p < 0.001), and a mild decrease in PaO2 (74 +/- 8 to 70 +/- 10 mmHg, p < 0.05). Exercise tolerance improved significantly (4.8 +/- 1.7 to 6.8 +/- 2.2 MET, p < 0.001), without deterioration of PaO2 and desaturation. These results indicate that low dose pimobendan is useful for the treatment of patients with cor-pulmonale.

Aged↗
PubMed1999

[Cardiology 1998].

In 1998, nitric oxide (NO) was extensively explored. First studies demonstrating a beneficial effect of inhaled NO in patients with pulmonary hypertension, right ventricular dysfunction and intractable heart failure were published. It was further shown, that, in patients with essential hypertension, impaired vasodilatation can be improved by vitamin C as an antioxidant, an effect that can be reversed by NO-synthase inhibition. Unlike arotinolol, which has no antioxidat effect, carvedilol is a beta- and alpha-blocker with antioxidative properties that may prevent the development of nitrate tolerance. In clinical cardiology, the main focus is on the prevention and therapy of coronary heart disease, heart failure and hypertension: a Task force report on the prevention of coronary heart disease in clinical practice. Proceedings on anticoagulant therapy and Guidelines for antithrombotic management were published in 1998. There is an agreement that in mild hypertension the decision how to treat should be based on the estimate of cardiovascular risk and not on an arbitrary blood pressure threshold. Diuretics and betablockers should be preferred unless they are contraindicated, or there are positive indications for other drug classes. Studies also strongly suggest that therapy with relatively small doses of two different classes of drugs is the effective way to treat the majority of patients and minimize side effects. In heart failure, the evidence for the current treatment with diuretics, ACE-inhibitors and digoxin, in selected patients, is well established.

Cardiovascular Diseases↗
PubMed1999

Optimizing anticoagulant therapy in the management of pulmonary embolism.

Pulmonary embolism (PE) continues to command a high price in terms of mortality and recurrence, despite full-dose initial anticoagulation and long-term warfarin therapy. Embolectomy, thrombolysis, and vena cava filters may be life saving in patients with massive PE and cardiogenic shock, but their use in other groups remains controversial. Recent progress has been made in identifying key markers of a poor prognosis; these markers may assist in tailoring treatment to patient risk. In particular, right ventricular dysfunction, detected using echocardiography, may portend an ominous prognosis for patients without hemodynamic instability. Thrombolysis may be beneficial in this group, although concerns about bleeding risk remain to be clarified. Low molecular weight heparins (LMWHs) have recently been shown to be as effective as unfractionated heparin in the initial treatment of PE. One agent has now received a limited approval from the United States Food and Drug Administration for use in certain low-risk patients, mostly those with asymptomatic PE in the presence of concomitant deep-vein thrombosis. Although enoxaparin for PE treatment is currently licensed for therapy exclusively in the hospital setting, brief hospitalization or home treatment for nonmassive PE may be possible in the future. Expert management of long-term warfarin therapy is also crucial to optimize clinical outcomes. Recognition of potential causes of excessive anticoagulation and the use of self-monitoring by patients may improve the efficacy and safety of long-term warfarin administration.

Anticoagulants↗
PubMed1999

A comparison of esmolol & diltiazem for heart rate control during coronary revascularisation on beating heart.

This prospective study was done to compare the control of heart rate and haemodynamics during coronary artery revascularisation without cardiopulmonary bypass using either esmolol or diltiazem. Sixty adult patients with one or two vessel coronary artery disease, were randomly divided into 2 equal groups. Group A received a 500 micrograms/kg loading dose of esmolol followed by a 100 micrograms/kg/h infusion, for control of heart rate during surgical anastomosis of the coronary vessel. While Group B received 0.15 mg/kg diltiazem as a loading dose followed by a 5 mg/h infusion for heart rate control, during the anastomosis. It was seen that heart rate control was better in Group A, 51.4 (+/- 1.3) beats/min, than in Group B, 69.6 (+/- 3.9) beats/min but the decrease in heart rate was significant in both the groups at peak effect compared to respective predrug values. Group A patients had unchanged systemic resistance and pulmonary artery wedge pressure but mean pulmonary artery pressure and pulmonary vascular resistance were significantly raised. Group B patients had decreased systemic resistance, mean pulmonary artery pressure and pulmonary artery wedge pressure, and reduced right ventricular stroke work index. We concluded that although esmolol provided dramatically slower heart rates, during surgery, the resulting elevations in mean pulmonary artery pressure and pulmonary vascular resistance would require caution if used in patients with underlying right ventricular dysfunction from ischaemia or infarction. Diltiazem by virtue of its effects on systemic vascular resistance, cardiac output, and lowering of mean arterial pressure may be a better choice in hypertensive patients.

Adrenergic beta-Antagonists↗
PubMed2000

[Evolution after 5 years of percutaneous pulmonary valvulotomy: report of 47 cases].

47 patients aged from 2 to 59 years affected by valvular congenital or mixed pulmonary stenosis including three fallot trilogies and one patient with right congestive cardiac failure are treated by percutaneous pulmonary valvulotomy between october 1986 and december 1990. All patients have been controlled with a mean follow-up of 6.5 +/- 1.1 years. The total gradient rate between pulmonary artery and right ventricule decrease from 112 +/- 55 mm Hg to 20 +/- 8 mm Hg on the last control with disappearance of infundibular inflammation and inter auricular shunt in all the concerned cases. We observe the regression of right cardiac failure symptoms with disappearance of tricuspid insufficiency in the cases of advanced pulmonary stenosis with right ventricular dysfunction. Percutaneous pulmonary valvulotomy by its simplicity and harmlessness, its long term efficiency is a good method of treatment of pure valvular or mixed pulmonary stenosis.

Adolescent↗
PubMed2000

Aerosolized medications for altering lung surface active properties.

Surface active material is important in the function of both the infant and adult lung. In the premature infant, surfactant depletion results in the requirement for very high distending pressures to open alveoli. As a consequence, shunt, hypoxemia, and right ventricular dysfunction occur. Surfactant replacement, especially by the direct instillation approach, has been proven effective in improving clinical outcome under these circumstances. Problems with surfactant instillation include the "fluid bolus" effect and concerns about optimal distribution of the instilled material. Recent improvements in aerosol systems have created interest in using aerosol delivery to reduce the total dose of surfactant required to treat RDS. In adult acute lung injury, surfactant dysfunction, rather than depletion, is the problem. Simple phospholipid replacement strategies thus may not be effective. Instead, surfactant delivery strategies aimed at regional targeting with surfactants having the necessary associated proteins may be the goal in ARDS. In adults, several instillation trials are underway, but there is also a hope that an aerosol strategy might also be tried. The aerosol route may be particularly useful if a high-efficiency aerosol system (eg, one distal to an endotracheal tube) can be shown to be effective. Other surface active materials exist and there are small studies showing benefit when large instilled doses of these materials are given. These materials, however, have never been studied as aerosols.

Aerosols↗
PubMed2001

[Plasma brain natriuretic peptide as a prognostic indicator in patients with primary pulmonary hypertension].

BACKGROUND: Plasma brain natriuretic peptide (BNP) level increases in proportion to the degree of right ventricular dysfunction in pulmonary hypertension. We sought to assess the prognostic significance of plasma BNP in patients with primary pulmonary hypertension. METHODS AND RESULTS: Plasma BNP was measured in 60 patients with primary pulmonary hypertension at diagnostic catheterization, together with atrial natriuretic peptide, norepinephrine, and epinephrine. Measurements were repeated in 53 patients after a mean follow-up period of 3 months. Forty-nine of the patients received intravenous or oral prostacyclin. During a mean follow-up period of 24 months, 18 patients died of cardiopulmonary causes. According to multivariate analysis, baseline plasma BNP was an independent predictor of mortality. Patients with a supramedian level of baseline BNP (> or = 150 pg/ml) had a significantly lower survival rate than those with an inframedian level, according to Kaplan-Meier survival curves (p < 0.05). Plasma BNP in survivors decreased significantly during the follow-up (217 +/- 38 to 149 +/- 30 pg/ml, p < 0.05), whereas that in nonsurvivors increased (365 +/- 77 to 544 +/- 68 pg/ml, p < 0.05). Thus, survival was strikingly worse for patients with a supramedian value of follow-up BNP (> or = 180 pg/ml) than for those with an inframedian value (p < 0.0001). CONCLUSIONS: A high level of plasma BNP, and in particular, a further increase in plasma BNP during follow-up, may have a strong, independent association with increased mortality in patients with primary pulmonary hypertension.

Biomarkers↗
PubMedDate not supplied

[Atrioventricular discordance. Clinico-surgical experience 1990-2000].

OBJECTIVE: To know the incidence of ventriculoarterial connections combined with atrioventricular discordance, associated lesions and surgical results, including the first case with anatomical correction. METHOD: All patients with atrioventricular discordance by echocardiography from 1990 to March 2000 were analyzed. RESULTS: Thirty six patients with atrioventricular discordance were found. Ages ranged from 0.1 to 46 years, with a mean 9.2 years (SD 5.9 years). Atrial chambers were situs solitus in 88.9%, inversus in 11.2%. The ventriculoarterial connections were discordant in 28 (77.7%), double outlet right ventricle in 4 (11.1%) (one of them was a "criss cross" heart), single outlet (pulmonary atresia) in 4 (11.1%), and double outlet left ventricle in 1 (2.7%). Associated lesions: Ventricular septal defect with pulmonary stenosis or atresia was present in 21 (58%), ventricular septal defect with no pulmonary obstruction was observed in 10 (28%). Five had tricuspid regurgitation with right ventricular disfunction, (two adults). Surgical results: 22 (61%) required 28 surgical procedures: 8 (36%) were palliative and 19 (86%) were corrective, one of them was our first anatomical correction. Operative mortality in all was 40.1%, postoperative atrioventricular block was observed in 9 (40.1%). CONCLUSION: Right ventricular dysfunction is not uncommon. Surgical results revealed high mortality and high pacemaker requirement for atrioventricular block.

Adolescent↗
PubMed2001

[Aspects of diastolic function of the heart in vibration disease].

AIM: To study effects of occupational vibrations on the myocardium, to elucidate early alterations in cardiac performance and to introduce approaches to their correction. MATERIALS AND METHODS: Doppler echocardiography was made to evaluate diastolic function of the heart ventricles in 54 men with vibration disease. Mean exposure to local vibration was 22.4 years. The examinees were divided into two groups: 42 men (mean age 46.8 years) with vibration disease of the first degree--group 1; 12 men (mean age 51.2 years) of the first-second and second degree--group 2. RESULTS: In group 2 compared to group 1 there was a decrease of maximal velocity of early filling (MVEF) by 24.2%, early filling phase (EFP) by 27%, ratio MVEF/MVLF 1.17-fold, increase of isometric relation phase by 15.9%. For the right ventricle there was a decrease in MVEF by 15.4%, MVEF/MVLF 1.51-fold, prolongation of EFP by 20%. By these indices, the groups differed significantly in the diseases severity. Trimetasidine had a corrective effect on diastolic function of both left and right ventricles of the heart. CONCLUSION: Patients with vibration disease were diagnosed to have left and right ventricular diastolic dysfunction.

Data Interpretation, Statistical↗
PubMed2001

[Reoperation for late postoperative right ventricular outflow tract obstruction].

Between February 1993 and July 2000, 18 patients with a mean age of 7.9 years underwent re-operation for critical stenosis of the right ventricular outflow tract. Their diagnoses of these patients included tetralogy of Fallot (n = 7), transposition of the great arteries (n = 6), truncus arteriosus communis (n = 3), and double outlet right ventricle with pulmonary stenosis (n = 2). The first operations were extracardiac conduit operations (n = 9), arterial switch operations (n = 6) and patch reconstruction of the right ventricular outflow tract (n = 3). At re-operation, the right ventricular outflow tract obstruction was released completely and reconstructed using a monocusp ventricular outflow patch (n = 14), valved pericardial roll (n = 2), or bovine pericardial patch sparing the native pulmonary valve annulus (n = 2). There were no early deaths, although one patient died of arrhythmia 2.6 years after re-operation. The pressure gradient across the right ventricular outflow tract, right ventricular systolic pressure, and right ventricle to systemic systolic pressure ratio were satisfactorily relieved (84.3 +/- 19.0 vs. 16.7 +/- 19.7 mmHg, 109.2 +/- 20.5 vs. 48.7 +/- 16.7 mmHg, 0.92 +/- 0.25 vs. 0.43 +/- 0.16; p < 0.001, p < 0.001, p < 0.001, respectively). The right ventricular end-diastolic volume index and right ventricular ejection fraction were also improved (166.3 +/- 85.2 vs. 105.6 +/- 28.8% of normal, 38.3 +/- 12.6 vs. 50.9 +/- 8.8%; p < 0.05, p < 0.005, respectively). Re-operation should be done before the development of marked right ventricular dysfunction, while it can still be performed at a low risk with satisfactory results.

Child↗
PubMed2001

BNP in decompensated heart failure: diagnostic, prognostic and therapeutic potential.

B-type or brain natriuretic peptide (BNP) is a balanced vasodilator with no inotropic nor chronotropic properties. Plasma levels can be used in diagnosis and prognosis of patients with heart failure, hypertension, myocardial infarction, right ventricular dysfunction and cor pulmonale. Intravenous therapy with BNP (nesiritide) in nearly 1000 patients demonstrated significant dose-dependent reductions in pulmonary capillary wedge pressure and systemic vascular resistance, as well as increased cardiac index. Compared to dobutamine, it is not pro-arrhythmic and has no effect on heart rate. Compared to standard therapy, it improves dyspnea by 3 h of therapy and leads to fewer headaches and arrhythmias than the commonly used intravenous agents nitroglycerin and dobutamine, respectively. Current research suggests an important role for use of nesiritide in the treatment of decompensated heart failure.

Biomarkers↗
PubMed2002

Acute myocardial infarction late after Mustard procedure for dextrotransposition of the great arteries.

Systemic right ventricular dysfunction has been closely linked to late mortality and sudden cardiac death in patients with Mustard procedure for dextrotransposition of the great arteries. Two young patients with dextrotransposition of the great arteries late after Mustard procedure who presented with acute transmural myocardial infarction and sudden cardiac death (one patient) without prior exertional angina or causative coronary abnormalities are reported. It is surmised that acute coronary emboli originating from a severely dilated, hypocontractile systemic ventricle were the cause of transmural myocardial infarction. This phenomenon may be an important and as yet unrecognized factor in late morbidity and mortality in such patients.

Adolescent↗
PubMed2002

[Outcome of operated Fallot's tetralogy].

Fifty years after the beginning of cardiac surgery, a large percentage of operated congenital heart disease patients attain adulthood. The tetralogy of Fallot is one of the malformations in which the natural outcome was unfortunately nearly fatal in the long-term. Open heart surgery has radically transformed the prognosis of this, the most common of all cyanotic congenital cardiac malformations. Nowadays, most operated patients lead normal professional and family lives. Lonf-term survival after correction is between 90-95% after 30-35 years. Although surgical repair is satisfactory, the operated heart is not anatomically normal. The patients have a variable degree of devalvulation of the pulmonary outflow tract, a scar on the right ventricle, a patch repairing the ventricular septal defect and scars on the atrium (cannulation for cardiopulmonary bypass). These sequellae expose the patients to a number of complications, notably arrhythmic and sometimes haemodynamic, affecting the right ventricle. The late mortality rate varies from 5 to 13% in the literature. The main causes of death are sudden death and reoperation. Sudden death is the most severe long-term complication but it is uncommon, affecting less than 5% of the population. It is mainly due to ventricular arrhythmias. Certain predisposing factors should be identified during long-term follow-up, among them the presence of haemodynamic abnormalities: systolic overload (residual pulmonary stenosis) or diastolic overload of the right ventricle (pulmonary regurgitation), infundibular aneurysm, right ventricular dysfunction. It would appear to be important to prevent pulmonary regurgitation by preserving the pulmonary valve even if it means persistence of a mild transvalvular pressure gradient. When pulmonary regurgitation is inevitable, follow-up is essential to evaluate the timing of valvulation of the pulmonary orifice. Despite these different complications which must be understood for proper follow-up of these patients, the long-term outcome of operated tetralogy of Fallot remains very good.

Adult↗
PubMed2003

[The best of vascular medicine in 2002].

During this year, cellular therapy with bone mononuclear cells of critical leg ischemia was demonstrated to be a new therapeutic approach in critical leg ischemia. This treatment, as well as gene therapy, is an important step forward in this pathology when there is no other therapeutic option. In venous thromboembolism, the usefulness of fibrinolytic therapy in severe pulmonary embolism associated with right ventricular dysfunction or pulmonary-artery hypertension was demonstrated. Fondaparinux appears also to be a promising agent for prophylaxis of deep vein thrombosis. Finally, the publication of the WHI trial (Women Health Initiative) confirms the absence of any benefit of hormone replacement therapy in primary cardiovascular prevention.

Bone Marrow Transplantation↗
PubMed2003

Gender mediated cardiac protection from adverse ventricular remodeling is abolished by ovariectomy.

Gender differences in the prevalence of cardiovascular disease have been observed both clinically and experimentally. These cardioprotective effects have frequently been attributed to female hormones, however, the underlying mechanisms responsible for this cardioprotection are still poorly understood. Accordingly, this study sought to determine the contribution of ovarian hormones to the prevention of adverse ventricular remodeling and congestive heart failure in chronic volume overload (i.e. aortocaval fistula in intact or ovariectomized female rats). Ovariectomized rats developed more extensive cardiac remodeling than intact females at 21 weeks post-fistula, characterized by significantly greater left ventricular (LV) hypertrophy (167 vs. 86%, respectively, p < 0.05) and a substantial increase in LV dilatation (71%, p < 0.05) relative to control. In contrast to the eccentric hypertrophy in ovariectomized females post-fistula, the hypertrophic response in the intact female hearts was essentially concentric. While neither fistula group suffered significant mortality, there was a marked increase in the lung weight of ovariectomized rats (87%, p < 0.05) consistent with the development of pulmonary edema. Overall, the extent of myocardial remodeling and decrease in LV function in the ovariectomized females was comparable to those changes reported for males with symptomatic heart failure, while intact females maintained chronic compensated ventricular function similar to that of controls. The marked ventricular dilatation and symptoms of congestive heart failure seen at 21 weeks post-fistula in the ovariectomized females clearly demonstrate the influence of circulating ovarian hormones on the pattern of myocardial remodeling resulting from a chronic volume overload.

Animals↗
PubMed2004

Acute hypoxemia after repositioning of patient: a case report.

Hypoxemia occurred after induction of anesthesia and repositioning in a patient undergoing hip pinning. The patient had previously presented to the emergency department with multiple fractures and hemodynamic instability sustained in a motor vehicle accident. Three days after admission to the intensive care unit the patient remained intubated with respiratory insufficiency and had developed acute respiratory distress syndrome with marginal oxygen saturation. The patient was transported to the operating room for hip pinning, and anesthesia was induced with midazolam, fentanyl, vecuronium, and isoflurane. When the patient was turned to the left lateral position, oxygen saturation suddenly worsened from 94% to 78%, with Pao2 from arterial blood gas measured at 54 mm Hg. The patient was returned to the supine position, but despite maneuvers to improve oxygen saturation, the patient's saturation remained below 87% and pulmonary thromboembolism was suspected. However, other signs of pulmonary embolus such as hemodynamic deterioration and right ventricular dysfunction were not present. Chest radiographs demonstrated severe left lung atelectasis, and surgery was postponed. Upon return to the intensive care unit, fiberoptic bronchoscopy was performed, and a large mucous plug was removed from his left upper and lower lobes, with subsequent improvement of Pao2 to 77 mm Hg with an oxygen saturation of 94%.

Acute Disease↗