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PubMedDate not supplied

Pharmacologic reduction of pretransplantation pulmonary vascular resistance predicts outcome after pediatric heart transplantation.

Pulmonary hypertension leading to donor right ventricular dysfunction remains a major risk factor associated with poor outcome after heart transplantation. This study evaluated a pretransplantation protocol to assess pulmonary vascular resistance index and its response to pharmacologic modulation. Cardiac catheterization was performed in 25 patients (mean age, 8.6 years [range, 1 to 17 years]; mean weight, 27.3 kg [range, 8.1 to 54 kg]) with end-stage heart failure. Mean pulmonary artery and capillary wedge pressures and cardiac index were measured in the baseline state and during administration of 100% oxygen, dobutamine at 10 micrograms/kg/min, and nitroprusside at 1 to 4 micrograms/kg/min. Transpulmonary pressure gradient and pulmonary vascular resistance index were calculated. In 22 survivors, hemodynamics were reassessed 1 and 4 weeks after transplantation. The mean cardiac index significantly increased (2.2 to 3.2 L/min/m2); transpulmonary pressure gradient (12.7 to 9.6 mm Hg) and pulmonary vascular resistance index (6.2 to 3.0 units/m2) decreased during the drug study. In 12 patients with a baseline pulmonary vascular resistance index of more than 6 units/m2, 10 survived heart transplantation. This study shows that pharmacologic reduction of the pulmonary vascular resistance index in the pretransplantation protocol predicts reduced pulmonary vascular resistance index and a favorable outcome after heart transplantation.

Adolescent↗
PubMed1996

Congenitally corrected transposition of the great arteries and exercise-induced ventricular tachycardia.

Congenitally corrected transposition of the great arteries (CCTGA) is an uncommon condition. Few patients survive past 50 years of age, because of associated congenital defects, systemic (morphological right) ventricular dysfunction, atrioventricular valvular insufficiency or complete heart block. A unique case is presented of exercise-induced ventricular tachycardia, which led to the diagnosis of CCTGA, without atrioventricular block or other cardiac anomalies.

Age Factors↗
PubMed1996

[Inhaled nitric oxide test for patients with stable chronic obstructive pulmonary disease: value and feasibility].

Patients suffering from chronic lung disease (CLDP) often develop secondary pulmonary hypertension (HP), which contributes to right ventricular dysfunction and worsens their prognosis. In order to evaluate the severity of this HP, pharmacodynamics tests are periodically proposed to these patients. Therefore, the administration of vasodilators is limited by systemic and pulmonary side-effects. Inhaling nitric oxide gas (NO) has been reported to induce a selective pulmonary vasodilation. The purpose of this study was to evaluate the safety and efficacy of an inhaled NO test perfected in our service. Sixteen CLDP were investigated in the absence of acute pulmonary failure. All had severe pre-capillary HP, confirmed after placement of a thermodilution pulmonary-artery catheter (mean pulmonary artery pressure >20 mmHg, pulmonary capillary wedge pressure >12 mmHg). Each subject breathed spontaneously NO in a concentration of 10 ppm for 15 minutes. They were connected through a facial mask and a one-way valve put on the inspiratory connection of a ventilator (Drager-Evita), to a tank of nitrogen with a NO concentration of 900 ppm. Hemodynamic variables and gas exchange were measured before, during and after gas inhalation. The inspired fractions of NO and NO2 were determined using a Polytron analyser (Drager). The methemoglobin levels were measured with spectrophotometry (OSM3). Inhaled NO acts as a selective pulmonary arterial vasodilator, without systemic effect. The action on the shunt is variable. Methemoglobin levels are remained <0.01%. All the patients were satisfied with the way of NO administration. In view of the lack of systemic effects, its seems that the NO inhaled test proposed in this study may be used accurately to evaluate the HP of chronic lung disease patients.

Adult↗
PubMed1996

Surgical techniques for cardiac transplantation.

The surgical technique for cardiac transplantation was introduced by Lower and Shumway more than 30 years ago. It is known as "biatrial technique for cardiac transplantation" and has been used in more than 20,000 patients. However, since the early days of cardiac transplantation, atrial arrhythmias and atrioventricular conduction disturbances were noted so frequently that Dr. Barnard suggested a modification of the original technique to the present biatrial technique, in which the inferior vena cava orifice is enlarged with an atriotomy incision curving toward the base of the right atrial appendage, away from the sinus node. Atrial arrhythmias and other conduction abnormalities have, however, persisted and have resulted in the need for pacemaker insertion in a significant number of patients. Over the past years, with the more frequent use of transthoracic and transesophageal echocardiography, other abnormalities have been noted on follow-up of transplanted patients. These include tricuspid and mitral regurgitation, enlarged left and right atria with thrombus formation in the atrial suture line, asynchronous contraction of donor and recipient's atria, and right ventricular dysfunction in the early postoperative period. In the last 5 years, a new surgical technique for cardiac transplantation has been used in a few centers. This technique requires total excision of the recipient's heart and individual's caval and pulmonary vein anastomosis, "bicaval technique for cardiac transplantation." This technique seems to avoid the problems encountered with the biatrial technique. A comparison of the two surgical techniques, based on recently published surgical series, is presented.

Heart Diseases↗
PubMed1996

[2D and Doppler echocardiography after atrial switch operation for transposition of great arteries; a review].

Introduction of the atrial baffle procedure (Mustard, Senning) more than 30 years ago has dramatically improved the prognosis of patients with transposition of the great arteries. However, a range of late complications can occur even in clinically asymptomatic patients including: superior and inferior limb obstruction, pulmonary venous obstruction, residual baffle-leakage, left ventricular outflow tract obstruction, tricuspid valve regurgitation, right ventricular dysfunction and postoperative dysrhythmia. As an increasing number of patients has reached adulthood an accurate noninvasive technique is needed for routine follow-up studies. In most patients transthoracic two-dimensional (2D) and Doppler echocardiography allows a complete investigation of postoperative hemodynamic abnormalities -- in particular assessment of atrial baffle function. In adult patients with restricted echo-windows transoesophageal echocardiography may provide a more detailed assessment of atrial baffle morphology and function; TEE seems to be superior compared to angiography and magnetic resonance imaging. Furthermore TEE is a reliable guiding and monitoring technique during interventional cardiac catheterization procedures such as balloon dilatation or stent implantation and allows further surveillance. Even if compared to other noninvasive diagnostic procedures, 2D and Doppler echocardiography (transthoracic/transoesophageal) are still the most important and accurate diagnostic methods for routine investigation of the postoperative anatomy and potential late complications in patients who underwent an atrial baffle procedure.

Echocardiography↗
PubMed1996

[Cardiac adaptation to muscular exercise in children after complete repair of tetralogy of Fallot].

The aim of this study was to assess cardiac adaptation to muscular exercise in children operated for tetralogy of Fallot. Eight children with a history of tetralogy of Fallot were studied and compared with ten control children. The basal evaluation consisted of an electrocardiogram, spirometry in all cases. Chest X-ray and echocardiography in all operated children. A muscular exercise stress test with incremental load on a bicycle ergometer was carried out with measurement of the cardiac output by CO2 rebreathing (experimental method). Under resting conditions, the two groups were comparable with respect to anthropometrical parameters and respiratory function. The cardiovascular data confirmed the good postoperative results of the children with a history of tetralogy of Fallot; cardiothoracic index of 0.49 to 0.55; sinus rhythm on the electrocardiogram; right ventricular pressures within normal limits; residual instantaneous right ventricular-pulmonary artery pressure gradient less than 25 mmH. On exercise, there was no significant difference with respect to VO2max, maximal heart rate, maximal cardiac output and maximal ventilation. The relationship between cardiac output and oxygen consumption was linear in two groups: y = 8.17x + 1.95 in the control group, y = 8.57x + 2.82 in the operated children. The change in cardiac output on exercise was comparable in the two groups. These observations seemed to be related to the good postoperative haemodynamic result: absence of pulmonary sequellae and right ventricular dysfunction. Despite the normality of the results obtained in this series, exercise stress testing with analysis of cardiac and respiratory adaptation would seem to be necessary in the follow-up of children operated for tetralogy of Fallot to exclude a ventilatory or circulatory limitation.

Adaptation, Physiological↗
PubMed1996

Magnetic resonance imaging of acquired cardiac disease.

Over the last 15 years, advances in magnetic resonance imaging techniques have increased the accuracy and applicability of cardiovascular magnetic resonance imaging. These advances have improved the utility of magnetic resonance imaging in evaluating cardiac morphology, blood flow, and myocardial contractility, all significant diagnostic features in the evaluation of the patient with acquired heart disease. Utilization of cardiovascular magnetic resonance imaging has been limited, primarily due to clinical reliance upon nuclear scintigraphy and echocardiography. Recent developments in fast and ultrafast imaging should continue to enhance the significance of magnetic resonance imaging in this field. Widespread use of magnetic resonance imaging in the evaluation of the cardiovascular system will ultimately depend upon its maturation into a comprehensive, noninvasive imaging technique for the varying manifestations of acquired heart disease, including cardiomyopathy, ischemic heart disease, and acquired valvular disease.

Aorta, Thoracic↗
PubMed1996

Inhaled nitric oxide: effects on hemodynamics, myocardial contractility, and regional blood flow in dogs with mechanically induced pulmonary artery hypertension.

BACKGROUND: Pulmonary artery hypertension with right ventricular failure is a frequent complication that occurs immediately after heart transplantation in which the use of inhaled nitric oxide may be effective. METHODS: The effects of pulmonary artery hypertension and nitric oxide on myocardial function and on pulmonary and systemic hemodynamic parameters were evaluated in eight anesthetized dogs. Pulmonary artery hypertension was induced by successive microbead injections into the pulmonary circulation. RESULTS: Microbead injections resulted in overt pulmonary artery hypertension (pulmonary artery pressure, + 190%; pulmonary vascular resistance, + 389%; ratio of pulmonary vascular resistance to systemic vascular resistance, 0.41). RESULTS: The end-diastolic length of the right ventricular outflow tract increased significantly along with an increase in right ventricular contractility (peak first derivative of left ventricular pressure as a function of time, + 100%; outflow tract systolic shortening, + 19%). Despite this compensatory mechanism, the increased pulmonary barrier resulted in a decrease in stroke volume (-31%). Systemic effects were observed, such as an increase in heart rate that maintained the cardiac output despite a decrease in left ventricular end-diastolic length (end-diastolic length in region of left anterior descending artery, - 9%). Right myocardial and septal blood flows were also significantly increased. CONCLUSIONS: Nitric oxide administration restored the stroke volume with a decrease in pulmonary artery hypertension and an improvement of the pulmonary vascular resistance to systemic vascular resistance ratio. Systemic blood pressure and coronary perfusion remained unaffected. This selective effect on the pulmonary circulation should be considered a major advantage of nitric oxide inhalation in the treatment of right ventricular dysfunction in acute pulmonary hypertension.

Acute Disease↗
PubMed1995

The use of the right atrial free wall for reconstruction of the outflow tract in a patient with Fallot's tetralogy: a case report.

We report the use of the lateral wall of the right atrium, as a free graft, for the reconstruction of the narrow outflow tract in a patient with Fallot's tetralogy. Pericardium was used for closure of the ventricular septal defect, widening of the narrow pulmonary trunk and reconstruction of the right atrium. Postoperative echocardiographic studies showed cyclic shortening of the transplanted atrial tissue, a 40% increase in right ventricular ejection fraction and preserved (e) and (a) waves denoting normal blood flow pattern across the tricuspid value. Electrophysiological study carried out 6 months postoperatively recorded ventricular potential at the site of patch. The application of this technique may be considered, ona limited series of patients, for possible amelioration of the postoperative right ventricular dysfunction, whenever widening of its infundibulum is indicated.

Cardiac Surgical Procedures↗
PubMed1977

Respiratory distress syndrome: echocardiographic assessment of cardiovascular function and pulmonary vascular resistance.

Echocardiograms were performed for 82 preterm infants comprising 22 normal infants, 29 with mild respiratory distress syndrome (RDS), and 31 with severe RDS. Left ventricular systolic time intervals were measured from aortic valve echograms and right ventricular systolic time intervals from pulmonic valve echograms. Left ventricular performance seemed to be altered early in postnatal adaptation of preterm infants, but played no demonstrable role in the outcome of RDS. The right ventricular preejection period/right ventricular ejection time (RPEP/RVET) ratio was prolonged in 17 out of 31 patients with severe RDS, consistent with increased pulmonary vascular resistance or right ventricular dysfunction. Prolonged RPEP/RVET identified a subgroup with increased mortality and morbidity.

Echocardiography↗
PubMed1997

Hemodynamics and gas exchange after single lung transplantation and unilateral thoracoscopic lung reduction.

BACKGROUND: Single lung transplantation and recently thoracoscopic lung reduction (TLR) have become surgical alternatives to manage emphysema. We report here early outcomes of 10 single lung transplant (SLT) recipients with severe emphysema compared with 10 patients treated with unilateral TLR. METHODS: Ten consecutive recipients of (SLT) and 10 patients undergoing unilateral TLR were studied. Both groups had measurements of preoperative pulmonary function and arterial blood gases. Hemodynamic measurements were made by use of a right ventricular ejection fraction/volumetric pulmonary artery catheter during and immediately after surgery in both groups to compare hemodynamic and gas exchange response in each procedure. Pulmonary function tests were repeated 3 months and 1 year after surgery. Complications and functional outcome are reported. RESULTS: Both groups had the same severity of obstructive disease (mean forced expiratory volume in 1 second = 20% +/- 5% for the SLT group and 23% +/- 9% for the TLR group) and similar patterns of right ventricular dysfunction. During operation, SLT recipients showed worse hypercapnia and pulmonary hypertension than TLR subjects when ventilation and perfusion to the operative lung were interrupted. Patients undergoing TLR only had interrupted ventilation, which was transiently reversed when severe hypoventilation or hypoxemia occurred. All patients undergoing TLR were extubated immediately after surgery. SLT recipients were extubated an average of 42 hours later. Pulmonary function testing performed 3 months after surgery showed improvement in both groups. SLT recipients showed larger improvements in airflow but comparable improvements in forced vital capacity. Both groups achieved similar improvements in gas exchange. This trend continued a year after surgery. Patients undergoing TLR were not subjected to complications of immunosuppressive therapy or exposed to opportunistic infections. CONCLUSIONS: Early results show TLR as an acceptable alternative to SLT in carefully selected patients with the same severity of obstructive lung disease. Long-term follow-up studies are needed to establish long-term differences in functional outcome and development of complications. TLR may be an option for patients with severe dyspnea related to emphysema who do not meet criteria for transplantation.

Aged↗
PubMed1997

[Intracoronary stent in primary angioplasty in acute myocardial infarction].

INTRODUCTION AND OBJECTIVES: Stent implantation has been generally contraindicated during primary percutaneous transluminal balloon angioplasty in AMI, because of its possible trombogenicity. Report the early outcome of patients undergoing coronary stenting during primary PTCA. METHODS: From january 1995 to april 1996, 31 patients underwent stent implantation in primary. Mean age 62 +/- 11 years. Infarct location was anterior in 20 (65%), and inferior in 11 patients (35%). Four patients were in Killip class IV. Mean onset of chest pain was 129 +/- 29 minutes. Indications for stenting were suboptimal result (64%), dissection (29%) and elective (6%). All patients were treated with heparin during 72 hours and antiplatelet therapy with ticlopidine and aspirin. RESULTS: Coronary stenting restored vessel patency with TIMI 3 flow in 29 patients (94%) and TIMI 2 flow in 2 patients. Angiographic control was performed in 80% of the patients: no stent occlusion was observed and all patients showed a TIMI 3 flow. There were 3 deaths (9%): 2 patients died due to cardiogenic shock and 1 to severe right ventricular dysfunction. 2 patients (6%) had recurrent angina, due to other artery. One patient with left main coronary disease underwent elective coronary artery bypass graft surgery. CONCLUSIONS: Intracoronary stent can be used successfully during primary angioplasty with a low incidence of complications. The long term benefits remains to be established.

Adult↗
PubMed1997

Longstanding traumatic tricuspid regurgitation with severe right ventricular failure.

A very unusual case of traumatic tricuspid regurgitation is reported, with severe symptoms of right ventricular failure, extreme dilatation of the right heart, echocardiographic and angiographic criteria of major tricuspid regurgitation, and severe right ventricular systolic dysfunction. The patient was referred for heart transplantation, on the assumption that conventional surgery was not possible. After careful evaluation, as the patient had normal pulmonary artery pressure and resistance, a tricuspid valve was replaced with good surgical outcome.

Accidents, Traffic↗
PubMed2006

Biventricular diastolic filling patterns after coronary artery bypass graft surgery.

OBJECTIVE: We sought to study the evolution of biventricular filling properties after coronary artery bypass grafting. BACKGROUND: The evolution of diastolic function as defined with newer echocardiographic modalities after coronary artery bypass grafting surgery is unknown in patients with preoperative left ventricular diastolic dysfunction. METHODS: Transthoracic echocardiography was performed preoperatively and 48 hours and 6 months after coronary artery bypass grafting in 49 patients (randomized to milrinone [n = 25]) or placebo [n = 24]) with preoperative left ventricular diastolic dysfunction classified according to published criteria. Mild right ventricular diastolic dysfunction was defined as the ratio of early to atrial filling velocity of less than 1 in transtricuspid flow or the velocity of reversed atrial flow of greater than 50% of that of systolic flow in hepatic venous flow or the ratio of tricuspid annulus velocity during early and atrial filling of less than 1 if both the ratio of early to atrial filling velocity and the ratio of systolic to diastolic velocity was greater than 1 in hepatic venous flow. Moderate right ventricular diastolic dysfunction was diagnosed when there was a ratio of early to atrial filling velocity of greater than 1 with a ratio of systolic to diastolic velocity of less than 1. Severe right ventricular diastolic dysfunction was defined as a ratio of early to atrial filling velocity of greater than 1 associated with reversed systolic wave in hepatic venous flow. RESULTS: Moderate and severe left ventricular diastolic dysfunction increased from preoperatively to 48 hours after coronary artery bypass grafting from 8.2% to 53.7% and from 2.0% to 9.7%, respectively (P < .0001, 48 hours vs preoperatively for both), and the patterns at 6 months were similar to those observed preoperatively. Similar evolution over time was found for right ventricular diastolic dysfunction. CONCLUSIONS: In patients with preoperative left ventricular diastolic dysfunction, biventricular filling patterns are impaired initially but return to preoperative status 6 months after coronary artery bypass grafting.

Aged↗